- The purpose of these guides (below, by line of business) is to inform you of services that require prior authorization.
- If you do not find a specific service listed on these guides, it may be that the service is a non-covered benefit. If you need information related to covered services, please refer to our Billing Guidelines and Coverage Summaries or call Neighborhood Provider Services at 1-800-963-1001.
- All Acute and Post-Acute admissions require authorization.
- Neighborhood Health Plan of RI utilizes the following criteria to make medical review decisions:
- InterQual
- Clinical Medical Policies
- Access Prior Authorization Forms here. Forms can be completed online or submitted to the 24/7 fax line at 401-459-6023.If you have any questions about the authorization process, please call Utilization Management at 401-459-6060.
- For the following areas: Radiology, Oncology and Durable Medical Equipment please see our partnered vendor information below regarding authorization requirements
Radiology Authorization Information
Radiology Authorizations
Neighborhood has partnered with eviCore Healthcare for prior authorization of outpatient elective CT, MR, PET, CT Cardiac, MR Cardiac, PET Cardiac, Nuclear Cardiology and 3D Rendering Procedures. Out of Network Providers: Please see NHPRI auth guide for additional radiology codes that may require auth
Please note: Neighborhood and eviCore will accept authorizations from either the ordering or rendering provider prior to the service being rendered.
Additional resources:
For more information visit eviCore.
Oncology Authorization Information
Oncology Authorizations
Neighborhood has partnered with New Century Health – Program for oncology-related drugs and/or treatment.
ICD-10, CPT and HCPC code list for Genomic and Radiation Oncology
- New Century Health Portal: https://my.newcenturyhealth.com
- New Century Health Fax: 877-624-8602
- New Century Health Phone: 888-999-7713
Durable Medical Equipment (DME) Authorization Information
DME Authorizations
Neighborhood has partnered with Integra Partners- manages the DME vendor network and authorization process for DME delivered in the home. Please see NHPRI auth guide for DME HCPC codes rendered in POS other than 12(home).
- Integra Partners: https://accessintegra.com
- Integra Partners Fax: 248-844-3824
- Integra Partners Phone: (888) 729-8818
| Code | Code Description | Authorization Required | Comments | Form Link | INTERNAL USE ONLY- Authorization Type | INTERNAL USE ONLY - Referral Category |
|---|---|---|---|---|---|---|
| 10004 | Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10005 | Fine needle aspiration biopsy, including ultrasound guidance; first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10006 | Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10007 | Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10008 | Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10009 | Fine needle aspiration biopsy, including CT guidance; first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10010 | Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10011 | Fine needle aspiration biopsy, including MR guidance; first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10012 | Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10021 | Fine needle aspiration biopsy, without imaging guidance; first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10030 | Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10035 | Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10036 | Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10040 | Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10060 | Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10061 | Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10080 | Incision and drainage of pilonidal cyst; simple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10081 | Incision and drainage of pilonidal cyst; complicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10120 | Incision and removal of foreign body, subcutaneous tissues; simple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10121 | Incision and removal of foreign body, subcutaneous tissues; complicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10140 | Incision and drainage of hematoma, seroma or fluid collection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10160 | Puncture aspiration of abscess, hematoma, bulla, or cyst | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 10180 | Incision and drainage, complex, postoperative wound infection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11000 | Debridement of extensive eczematous or infected skin; up to 10% of body surface | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11001 | Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11004 | Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11005 | Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11006 | Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11008 | Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11010 | Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11011 | Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11012 | Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11042 | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11043 | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11044 | Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11045 | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11046 | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11047 | Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11055 | Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11056 | Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11057 | Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11102 | Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11103 | Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); each separate/additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11104 | Punch biopsy of skin (including simple closure, when performed); single lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11105 | Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11106 | Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11107 | Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11300 | Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11301 | Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11302 | Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11303 | Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11305 | Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11306 | Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11307 | Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11308 | Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11310 | Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11311 | Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11312 | Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11313 | Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11400 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less. (Complex or layered closure is reported separately, if required. Each lesion removed is reported separately.) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11401 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm. (Complex or layered closure is reported separately, if required. Each lesion removed is reported separately.) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11402 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11403 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11404 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11406 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11420 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11421 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11422 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11423 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11424 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11426 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11440 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11441 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11442 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11443 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11444 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11446 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11450 | Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11451 | Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11462 | Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11463 | Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11470 | Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11471 | Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11600 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11601 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11602 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11603 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11604 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11606 | Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11620 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11621 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11622 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11623 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11624 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11626 | Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11640 | Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11641 | Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11642 | Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11643 | Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11644 | Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11646 | Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11730 | Avulsion of nail plate, partial or complete, simple; single | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11732 | Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11740 | Evacuation of subungual hematoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11750 | Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11755 | Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11760 | Repair of nail bed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11762 | Reconstruction of nail bed with graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11765 | Wedge excision of skin of nail fold (eg, for ingrown toenail) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11770 | Excision of pilonidal cyst or sinus; simple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11771 | Excision of pilonidal cyst or sinus; extensive | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11772 | Excision of pilonidal cyst or sinus; complicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11900 | Injection, intralesional; up to and including 7 lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11901 | Injection, intralesional; more than 7 lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less | Yes | Outpatient Surgery e-form | |||
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm | Yes | Outpatient Surgery e-form | |||
| 11922 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure) | Yes | Outpatient Surgery e-form | |||
| 11950 | Subcutaneous injection of filling material (eg, collagen); 1 cc or less | Yes | Outpatient Surgery e-form | |||
| 11951 | Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc | Yes | Outpatient Surgery e-form | |||
| 11952 | Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc | Yes | Outpatient Surgery e-form | |||
| 11954 | Subcutaneous injection of filling material (eg, collagen); over 10.0 cc | Yes | Outpatient Surgery e-form | |||
| 11960 | Insertion of tissue expander(s) for other than breast, including subsequent expansion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11970 | Replacement of tissue expander with permanent prosthesis | Yes | Outpatient Surgery e-form | |||
| 11971 | Removal of tissue expander(s) without insertion of prosthesis | Yes | Outpatient Surgery e-form | |||
| 11976 | Removal, implantable contraceptive capsules | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11980 | Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11981 | Insertion, non-biodegradable drug delivery implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11982 | Removal, non-biodegradable drug delivery implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 11983 | Removal with reinsertion, non-biodegradable drug delivery implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12001 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12002 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12004 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12005 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12006 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12007 | Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12011 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12013 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12014 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12015 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12016 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12017 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12018 | Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12020 | Treatment of superficial wound dehiscence; simple closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12021 | Treatment of superficial wound dehiscence; with packing | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12031 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12032 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12034 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12035 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12036 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12037 | Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12041 | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12042 | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12044 | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12045 | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12046 | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12047 | Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12051 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12052 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12053 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12054 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12055 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12056 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 12057 | Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13100 | Repair, complex, trunk; 1.1 cm to 2.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13101 | Repair, complex, trunk; 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13102 | Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13120 | Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13121 | Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13122 | Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13131 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13132 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13133 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13150 | Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13151 | Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13152 | Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13153 | Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 13160 | Secondary closure of surgical wound or dehiscence, extensive or complicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14000 | Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14001 | Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14020 | Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14021 | Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14040 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14041 | Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14060 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14061 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14300 | Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14301 | Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14302 | Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 14350 | Filleted finger or toe flap, including preparation of recipient site | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15002 | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15003 | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15004 | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15005 | Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15040 | Harvest of skin for tissue cultured skin autograft, 100 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15050 | Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15100 | Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15101 | Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15110 | Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15111 | Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15115 | Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15116 | Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15120 | Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15121 | Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15130 | Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15131 | Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15135 | Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15136 | Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15151 | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15152 | Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15156 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15157 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15200 | Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15201 | Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15220 | Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15221 | Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15240 | Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15241 | Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15260 | Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15261 | Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15271 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15272 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15273 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15274 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15275 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15276 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15277 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15278 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15570 | Formation of direct or tubed pedicle, with or without transfer; trunk | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15572 | Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15574 | Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15576 | Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15600 | Delay of flap or sectioning of flap (division and inset); at trunk | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15610 | Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15620 | Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15630 | Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15650 | Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15730 | Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15731 | Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15733 | Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15734 | Muscle, myocutaneous, or fasciocutaneous flap; trunk | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15736 | Muscle, myocutaneous, or fasciocutaneous flap; upper extremity | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15738 | Muscle, myocutaneous, or fasciocutaneous flap; lower extremity | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15740 | Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15750 | Flap; neurovascular pedicle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15756 | Free muscle or myocutaneous flap with microvascular anastomosis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15757 | Free skin flap with microvascular anastomosis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15758 | Free fascial flap with microvascular anastomosis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15760 | Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15770 | Graft; derma-fat-fascia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15777 | Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15786 | Abrasion; single lesion (eg, keratosis, scar) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15787 | Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) | Yes | Outpatient Surgery e-form | |||
| 15819 | Cervicoplasty | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15820 | Blepharoplasty, lower eyelid | Yes | Outpatient Surgery e-form | |||
| 15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad | Yes | Outpatient Surgery e-form | |||
| 15822 | Blepharoplasty, upper eyelid; | Yes | Outpatient Surgery e-form | |||
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid | Yes | Outpatient Surgery e-form | |||
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy | Yes | Outpatient Surgery e-form | |||
| 15840 | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | Yes | Outpatient Surgery e-form | |||
| 15841 | Graft for facial nerve paralysis; free muscle graft (including obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15842 | Graft for facial nerve paralysis; free muscle flap by microsurgical technique | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15845 | Graft for facial nerve paralysis; regional muscle transfer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15850 | Removal of sutures under anesthesia (other than local), same surgeon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15851 | Removal of sutures under anesthesia (other than local), other surgeon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15852 | Dressing change (for other than burns) under anesthesia (other than local) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15860 | Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15920 | Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15922 | Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15931 | Excision, sacral pressure ulcer, with primary suture; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15933 | Excision, sacral pressure ulcer, with primary suture; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15934 | Excision, sacral pressure ulcer, with skin flap closure; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15935 | Excision, sacral pressure ulcer, with skin flap closure; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15936 | Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15937 | Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15940 | Excision, ischial pressure ulcer, with primary suture; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15941 | Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15944 | Excision, ischial pressure ulcer, with skin flap closure; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15945 | Excision, ischial pressure ulcer, with skin flap closure; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15946 | Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15950 | Excision, trochanteric pressure ulcer, with primary suture; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15951 | Excision, trochanteric pressure ulcer, with primary suture; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15952 | Excision, trochanteric pressure ulcer, with skin flap closure; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15953 | Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15956 | Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15958 | Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 15999 | Unlisted procedure, excision pressure ulcer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 16000 | Initial treatment, first degree burn, when no more than local treatment is required | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 16020 | Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 16025 | Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 16030 | Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 16035 | Escharotomy; initial incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 16036 | Escharotomy; each additional incision (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17000 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17003 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17004 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17106 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17107 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17108 | Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17110 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17111 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17250 | Chemical cauterization of granulation tissue (ie, proud flesh) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17260 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17261 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17262 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17263 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17264 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17266 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17270 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17271 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17272 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17273 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17274 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17276 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17280 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17281 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17282 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17283 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17284 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17286 | Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17311 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17312 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17313 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17314 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 17315 | Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19000 | Puncture aspiration of cyst of breast; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19001 | Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19020 | Mastotomy with exploration or drainage of abscess, deep | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19030 | Injection procedure only for mammary ductogram or galactogram | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19081 | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19082 | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19083 | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19084 | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19085 | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19086 | Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19100 | Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19101 | Biopsy of breast; open, incisional | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19105 | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19110 | Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19112 | Excision of lactiferous duct fistula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19120 | Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19126 | Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19281 | Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19282 | Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19283 | Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19284 | Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19285 | Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19286 | Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19287 | Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19288 | Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19294 | Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19296 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19297 | Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19298 | Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 19301 | Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19302 | Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19303 | Mastectomy, simple, complete | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19305 | Mastectomy, radical, including pectoral muscles, axillary lymph nodes | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19306 | Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19307 | Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19316 | Mastopexy | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19318 | Breast reduction | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19325 | Breast augmentation with implant | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19328 | Removal of intact breast implant | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19330 | Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19350 | Nipple/areola reconstruction | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19355 | Correction of inverted nipples | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19361 | Breast reconstruction; with latissimus dorsi flap | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19364 | Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19370 | Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19371 | Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19396 | Preparation of moulage for custom breast implant | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 19499 | Unlisted procedure, breast | Yes | Breast Reduction e-form | Other Hospital Outpatient | Breast Reduction (Outpatient) Female (ARBR) | |
| 20100 | Exploration of penetrating wound (separate procedure); neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20101 | Exploration of penetrating wound (separate procedure); chest | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20102 | Exploration of penetrating wound (separate procedure); abdomen/flank/back | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20103 | Exploration of penetrating wound (separate procedure); extremity | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20150 | Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20200 | Biopsy, muscle; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20205 | Biopsy, muscle; deep | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20206 | Biopsy, muscle, percutaneous needle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20220 | Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20240 | Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20245 | Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20250 | Biopsy, vertebral body, open; thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20251 | Biopsy, vertebral body, open; lumbar or cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20500 | Injection of sinus tract; therapeutic (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20501 | Injection of sinus tract; diagnostic (sinogram) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20520 | Removal of foreign body in muscle or tendon sheath; simple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20525 | Removal of foreign body in muscle or tendon sheath; deep or complicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20526 | Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20527 | Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20550 | Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20551 | Injection(s); single tendon origin/insertion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20552 | Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20553 | Injection(s); single or multiple trigger point(s), 3 or more muscles | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20555 | Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20600 | Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20604 | Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20605 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20606 | Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20610 | Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20612 | Aspiration and/or injection of ganglion cyst(s) any location | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20615 | Aspiration and injection for treatment of bone cyst | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20650 | Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20660 | Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20661 | Application of halo, including removal; cranial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20662 | Application of halo, including removal; pelvic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20663 | Application of halo, including removal; femoral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20664 | Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20665 | Removal of tongs or halo applied by another individual | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20670 | Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20680 | Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20690 | Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20692 | Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20693 | Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or bar[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20694 | Removal, under anesthesia, of external fixation system | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20696 | Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20697 | Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; exchange (ie, removal and replacement) of strut, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20700 | Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20701 | Removal of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20702 | Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20703 | Removal of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20704 | Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20705 | Removal of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20802 | Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20805 | Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20808 | Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20816 | Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20822 | Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20824 | Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20827 | Replantation, thumb (includes distal tip to MP joint), complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20838 | Replantation, foot, complete amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20900 | Bone graft, any donor area; minor or small (eg, dowel or button) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20902 | Bone graft, any donor area; major or large | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20910 | Cartilage graft; costochondral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20912 | Cartilage graft; nasal septum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20920 | Fascia lata graft; by stripper | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20922 | Fascia lata graft; by incision and area exposure, complex or sheet | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20924 | Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20930 | Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20931 | Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20932 | Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20933 | Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20934 | Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20936 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20937 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20938 | Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20939 | Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20950 | Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20955 | Bone graft with microvascular anastomosis; fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20956 | Bone graft with microvascular anastomosis; iliac crest | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20957 | Bone graft with microvascular anastomosis; metatarsal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20962 | Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20969 | Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20970 | Free osteocutaneous flap with microvascular anastomosis; iliac crest | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20972 | Free osteocutaneous flap with microvascular anastomosis; metatarsal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20973 | Free osteocutaneous flap with microvascular anastomosis; great toe with web space | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20974 | Electrical stimulation to aid bone healing; noninvasive (nonoperative) | Yes | Outpatient Surgery e-form | |||
| 20975 | Electrical stimulation to aid bone healing; invasive (operative) | Yes | Outpatient Surgery e-form | |||
| 20979 | Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20982 | Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 20999 | Unlisted procedure, musculoskeletal system, general | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21010 | Arthrotomy, temporomandibular joint | Yes | Outpatient Surgery e-form | |||
| 21011 | Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21012 | Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21013 | Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21014 | Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21015 | Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21016 | Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21025 | Excision of bone (eg, for osteomyelitis or bone abscess); mandible | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21026 | Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21029 | Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21030 | Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21031 | Excision of torus mandibularis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21032 | Excision of maxillary torus palatinus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21034 | Excision of malignant tumor of maxilla or zygoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21040 | Excision of benign tumor or cyst of mandible, by enucleation and/or curettage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21044 | Excision of malignant tumor of mandible | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21045 | Excision of malignant tumor of mandible; radical resection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21046 | Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21047 | Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21048 | Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21049 | Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21050 | Condylectomy, temporomandibular joint (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21060 | Meniscectomy, partial or complete, temporomandibular joint (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21070 | Coronoidectomy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21073 | Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21076 | Impression and custom preparation; surgical obturator prosthesis | Yes | Outpatient Surgery e-form | |||
| 21077 | Impression and custom preparation; orbital prosthesis | Yes | Outpatient Surgery e-form | |||
| 21078 | Impression and custom preparation; interim obturator prosthesis | Yes | Outpatient Surgery e-form | |||
| 21079 | Impression and custom preparation; definitive obturator prosthesis | Yes | Outpatient Surgery e-form | |||
| 21080 | Impression and custom preparation; mandibular resection prosthesis | Yes | Outpatient Surgery e-form | |||
| 21081 | Impression and custom preparation; palatal augmentation prosthesis | Yes | Outpatient Surgery e-form | |||
| 21082 | Impression and custom preparation; palatal lift prosthesis | Yes | Outpatient Surgery e-form | |||
| 21083 | Impression and custom preparation; speech aid prosthesis | Yes | Outpatient Surgery e-form | |||
| 21084 | Impression and custom preparation; oral surgical splint | Yes | Outpatient Surgery e-form | |||
| 21085 | Impression and custom preparation; oral surgical splint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21086 | Impression and custom preparation; auricular prosthesis | Yes | Outpatient Surgery e-form | |||
| 21087 | Impression and custom preparation; nasal prosthesis | Yes | Outpatient Surgery e-form | |||
| 21088 | Impression and custom preparation; facial prosthesis | Yes | Outpatient Surgery e-form | |||
| 21089 | Unlisted maxillofacial prosthetic procedure | Yes | Outpatient Surgery e-form | |||
| 21100 | Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21110 | Application of interdental fixation device for conditions other than fracture or dislocation, includes removal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21116 | Injection procedure for temporomandibular joint arthrography | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21121 | Genioplasty; sliding osteotomy, single piece | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21125 | Augmentation, mandibular body or angle; prosthetic material | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21127 | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21137 | Reduction forehead; contouring only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21143 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21145 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21150 | Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21151 | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21154 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21155 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21159 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21160 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21172 | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21175 | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21179 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21180 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21181 | Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21182 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21183 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21184 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21193 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21194 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21195 | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21196 | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21198 | Osteotomy, mandible, segmental; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21199 | Osteotomy, mandible, segmental; with genioglossus advancement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21206 | Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21209 | Osteoplasty, facial bones; reduction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21210 | Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21215 | Graft, bone; mandible (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21230 | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21235 | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21240 | Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21242 | Arthroplasty, temporomandibular joint, with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21243 | Arthroplasty, temporomandibular joint, with prosthetic joint replacement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21246 | Reconstruction of mandible or maxilla, subperiosteal implant; complete | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21247 | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21248 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21249 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21256 | Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21260 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21261 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21263 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21267 | Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21268 | Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21270 | Malar augmentation, prosthetic material | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21275 | Secondary revision of orbitocraniofacial reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21280 | Medial canthopexy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21282 | Lateral canthopexy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21295 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21296 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21299 | Unlisted craniofacial and maxillofacial procedure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21310 | Closed treatment of nasal bone fracture without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21315 | Closed treatment of nasal bone fracture; without stabilization | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21320 | Closed treatment of nasal bone fracture; with stabilization | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21325 | Open treatment of nasal fracture; uncomplicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21330 | Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21335 | Open treatment of nasal fracture; with concomitant open treatment of fractured septum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21336 | Open treatment of nasal septal fracture, with or without stabilization | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21337 | Closed treatment of nasal septal fracture, with or without stabilization | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21338 | Open treatment of nasoethmoid fracture; without external fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21339 | Open treatment of nasoethmoid fracture; with external fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21340 | Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21343 | Open treatment of depressed frontal sinus fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21344 | Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21345 | Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21346 | Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21347 | Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21348 | Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21355 | Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21356 | Open treatment of depressed zygomatic arch fracture (eg, Gillies approach) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21360 | Open treatment of depressed malar fracture, including zygomatic arch and malar tripod | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21365 | Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21366 | Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21385 | Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21386 | Open treatment of orbital floor blowout fracture; periorbital approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21387 | Open treatment of orbital floor blowout fracture; combined approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21390 | Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21395 | Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21400 | Closed treatment of fracture of orbit, except blowout; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21401 | Closed treatment of fracture of orbit, except blowout; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21406 | Open treatment of fracture of orbit, except blowout; without implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21407 | Open treatment of fracture of orbit, except blowout; with implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21408 | Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21421 | Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21422 | Open treatment of palatal or maxillary fracture (LeFort I type); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21423 | Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21431 | Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21432 | Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21433 | Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21435 | Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21436 | Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21440 | Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21445 | Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21450 | Closed treatment of mandibular fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21451 | Closed treatment of mandibular fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21452 | Percutaneous treatment of mandibular fracture, with external fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21453 | Closed treatment of mandibular fracture with interdental fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21454 | Open treatment of mandibular fracture with external fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21462 | Open treatment of mandibular fracture; with interdental fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21465 | Open treatment of mandibular condylar fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21470 | Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21480 | Closed treatment of temporomandibular dislocation; initial or subsequent | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21485 | Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21497 | Interdental wiring, for condition other than fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21499 | Unlisted musculoskeletal procedure, head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21501 | Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21502 | Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21510 | Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21550 | Biopsy, soft tissue of neck or thorax | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21552 | Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21554 | Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21555 | Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21556 | Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21557 | Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21558 | Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21600 | Excision of rib, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21601 | Excision of chest wall tumor including rib(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21602 | Excision of chest wall tumor involving rib(s), with plastic reconstruction; without mediastinal lymphadenectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21603 | Excision of chest wall tumor involving rib(s), with plastic reconstruction; with mediastinal lymphadenectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21610 | Costotransversectomy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21615 | Excision first and/or cervical rib; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21616 | Excision first and/or cervical rib; with sympathectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21620 | Ostectomy of sternum, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21627 | Sternal debridement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21630 | Radical resection of sternum; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21632 | Radical resection of sternum; with mediastinal lymphadenectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21685 | Hyoid myotomy and suspension | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21700 | Division of scalenus anticus; without resection of cervical rib | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21705 | Division of scalenus anticus; with resection of cervical rib | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21720 | Division of sternocleidomastoid for torticollis, open operation; without cast application | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21725 | Division of sternocleidomastoid for torticollis, open operation; with cast application | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21740 | Reconstructive repair of pectus excavatum or carinatum; open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21742 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21743 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21750 | Closure of median sternotomy separation with or without debridement (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21811 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21812 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21813 | Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21820 | Closed treatment of sternum fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21825 | Open treatment of sternum fracture with or without skeletal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21899 | Unlisted procedure, neck or thorax | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21920 | Biopsy, soft tissue of back or flank; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21925 | Biopsy, soft tissue of back or flank; deep | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21930 | Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21931 | Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21932 | Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21933 | Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21935 | Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 21936 | Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22010 | Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22015 | Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22100 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22101 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22102 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22103 | Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22110 | Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22112 | Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22114 | Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22116 | Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22206 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22207 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22208 | Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22210 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22212 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22214 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22216 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22220 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22222 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22224 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22226 | Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22310 | Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22315 | Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22318 | Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22319 | Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with grafting | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22325 | Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22326 | Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22327 | Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22328 | Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22510 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22511 | Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22512 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22513 | 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; thoracic | Yes | Outpatient Surgery e-form | |||
| 22514 | 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; lumbar | Yes | Outpatient Surgery e-form | |||
| 22515 | 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) | Yes | Outpatient Surgery e-form | |||
| 22526 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22527 | Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) | Yes | Outpatient Surgery e-form | |||
| 22532 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22533 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22534 | Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22548 | Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22551 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22552 | Arthrodesis, anterior interbody, including disc space preparation, discectomy, 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22554 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2 | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22556 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22558 | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22585 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22590 | Arthrodesis, posterior technique, craniocervical (occiput-C2) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22595 | Arthrodesis, posterior technique, atlas-axis (C1-C2) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22600 | Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22610 | Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22612 | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22614 | Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22630 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22632 | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22633 | 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; lumbar | Yes | Outpatient Surgery e-form | |||
| 22634 | 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) | Yes | Outpatient Surgery e-form | |||
| 22800 | Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22802 | Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22804 | Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22808 | Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22810 | Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22812 | Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22818 | Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22819 | Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22830 | Exploration of spinal fusion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22840 | Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22841 | Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22842 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22843 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22844 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22845 | Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22846 | Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22847 | Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22848 | Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22849 | Reinsertion of spinal fixation device | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22850 | Removal of posterior nonsegmental instrumentation (eg, Harrington rod) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22852 | Removal of posterior segmental instrumentation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22853 | Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22854 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22855 | Removal of anterior instrumentation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22856 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22857 | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22858 | 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) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22859 | Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22861 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22862 | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22865 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22899 | Unlisted procedure, spine | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22900 | Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22901 | Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22902 | Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22903 | Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22904 | Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22905 | Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 22999 | Unlisted procedure, abdomen, musculoskeletal system | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23000 | Removal of subdeltoid calcareous deposits, open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23020 | Capsular contracture release (eg, Sever type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23030 | Incision and drainage, shoulder area; deep abscess or hematoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23031 | Incision and drainage, shoulder area; infected bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23035 | Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23040 | Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23044 | Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23065 | Biopsy, soft tissue of shoulder area; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23066 | Biopsy, soft tissue of shoulder area; deep | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23071 | Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23073 | Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23075 | Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23076 | Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23077 | Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23078 | Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23100 | Arthrotomy, glenohumeral joint, including biopsy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23101 | Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23105 | Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23106 | Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23107 | Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23120 | Claviculectomy; partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23125 | Claviculectomy; total | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23130 | Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23140 | Excision or curettage of bone cyst or benign tumor of clavicle or scapula; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23145 | Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23146 | Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23150 | Excision or curettage of bone cyst or benign tumor of proximal humerus; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23155 | Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23156 | Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23170 | Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23172 | Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23174 | Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23180 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23182 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23184 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23190 | Ostectomy of scapula, partial (eg, superior medial angle) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23195 | Resection, humeral head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23200 | Radical resection of tumor; clavicle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23210 | Radical resection of tumor; scapula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23220 | Radical resection of tumor, proximal humerus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23330 | Removal of foreign body, shoulder; subcutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23333 | Removal of foreign body, shoulder; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23334 | Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23335 | Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23350 | Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23395 | Muscle transfer, any type, shoulder or upper arm; single | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23397 | Muscle transfer, any type, shoulder or upper arm; multiple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23400 | Scapulopexy (eg, Sprengels deformity or for paralysis) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23405 | Tenotomy, shoulder area; single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23406 | Tenotomy, shoulder area; multiple tendons through same incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23410 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23412 | Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23415 | Coracoacromial ligament release, with or without acromioplasty | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23420 | Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23430 | Tenodesis of long tendon of biceps | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23440 | Resection or transplantation of long tendon of biceps | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23450 | Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23455 | Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23460 | Capsulorrhaphy, anterior, any type; with bone block | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23462 | Capsulorrhaphy, anterior, any type; with coracoid process transfer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23465 | Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23466 | Capsulorrhaphy, glenohumeral joint, any type multi-directional instability | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23470 | Arthroplasty, glenohumeral joint; hemiarthroplasty | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23472 | Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23473 | Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23474 | Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23480 | Osteotomy, clavicle, with or without internal fixation; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23485 | Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23490 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23491 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23500 | Closed treatment of clavicular fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23505 | Closed treatment of clavicular fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23515 | Open treatment of clavicular fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23520 | Closed treatment of sternoclavicular dislocation; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23525 | Closed treatment of sternoclavicular dislocation; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23530 | Open treatment of sternoclavicular dislocation, acute or chronic; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23532 | Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23540 | Closed treatment of acromioclavicular dislocation; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23545 | Closed treatment of acromioclavicular dislocation; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23550 | Open treatment of acromioclavicular dislocation, acute or chronic; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23552 | Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23570 | Closed treatment of scapular fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23575 | Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23585 | Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23600 | Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23605 | Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23615 | Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23616 | Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23620 | Closed treatment of greater humeral tuberosity fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23625 | Closed treatment of greater humeral tuberosity fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23630 | Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23650 | Closed treatment of shoulder dislocation, with manipulation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23655 | Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23660 | Open treatment of acute shoulder dislocation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23665 | Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23670 | Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23675 | Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23680 | Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23700 | Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23800 | Arthrodesis, glenohumeral joint; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23802 | Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23900 | Interthoracoscapular amputation (forequarter) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23920 | Disarticulation of shoulder; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23921 | Disarticulation of shoulder; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23929 | Unlisted procedure, shoulder | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23930 | Incision and drainage, upper arm or elbow area; deep abscess or hematoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23931 | Incision and drainage, upper arm or elbow area; bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 23935 | Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24000 | Arthrotomy, elbow, including exploration, drainage, or removal of foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24006 | Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24065 | Biopsy, soft tissue of upper arm or elbow area; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24066 | Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24071 | Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24073 | Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24075 | Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24076 | Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24077 | Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24079 | Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24100 | Arthrotomy, elbow; with synovial biopsy only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24101 | Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24102 | Arthrotomy, elbow; with synovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24105 | Excision, olecranon bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24110 | Excision or curettage of bone cyst or benign tumor, humerus; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24115 | Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24116 | Excision or curettage of bone cyst or benign tumor, humerus; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24120 | Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24125 | Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24126 | Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24130 | Excision, radial head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24134 | Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24136 | Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24138 | Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24140 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24145 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24147 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24149 | Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24150 | Radical resection of tumor, shaft or distal humerus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24152 | Radical resection of tumor, radial head or neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24155 | Resection of elbow joint (arthrectomy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24160 | Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24164 | Removal of prosthesis, includes debridement and synovectomy when performed; radial head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24200 | Removal of foreign body, upper arm or elbow area; subcutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24201 | Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24220 | Injection procedure for elbow arthrography | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24300 | Manipulation, elbow, under anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24301 | Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24305 | Tendon lengthening, upper arm or elbow, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24310 | Tenotomy, open, elbow to shoulder, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24320 | Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24330 | Flexor-plasty, elbow (eg, Steindler type advancement); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24331 | Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24332 | Tenolysis, triceps | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24340 | Tenodesis of biceps tendon at elbow (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24341 | Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24342 | Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24343 | Repair lateral collateral ligament, elbow, with local tissue | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24344 | Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24345 | Repair medial collateral ligament, elbow, with local tissue | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24346 | Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24357 | Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24358 | Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24359 | Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24360 | Arthroplasty, elbow; with membrane (eg, fascial) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24361 | Arthroplasty, elbow; with distal humeral prosthetic replacement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24362 | Arthroplasty, elbow; with implant and fascia lata ligament reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24363 | Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24365 | Arthroplasty, radial head; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24366 | Arthroplasty, radial head; with implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24370 | Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24371 | Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24400 | Osteotomy, humerus, with or without internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24410 | Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24420 | Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24430 | Repair of nonunion or malunion, humerus; without graft (eg, compression technique) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24435 | Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24470 | Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24495 | Decompression fasciotomy, forearm, with brachial artery exploration | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24498 | Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24500 | Closed treatment of humeral shaft fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24505 | Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24515 | Open treatment of humeral shaft fracture with plate/screws, with or without cerclage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24516 | Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24530 | Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24535 | Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24538 | Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24545 | Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24546 | Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extension | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24560 | Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24565 | Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24566 | Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24575 | Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24576 | Closed treatment of humeral condylar fracture, medial or lateral; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24577 | Closed treatment of humeral condylar fracture, medial or lateral; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24579 | Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24582 | Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24586 | Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24587 | Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24600 | Treatment of closed elbow dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24605 | Treatment of closed elbow dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24615 | Open treatment of acute or chronic elbow dislocation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24620 | Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24635 | Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24640 | Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24650 | Closed treatment of radial head or neck fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24655 | Closed treatment of radial head or neck fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24665 | Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24666 | Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24670 | Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24675 | Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24685 | Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24800 | Arthrodesis, elbow joint; local | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24802 | Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24900 | Amputation, arm through humerus; with primary closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24920 | Amputation, arm through humerus; open, circular (guillotine) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24925 | Amputation, arm through humerus; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24930 | Amputation, arm through humerus; re-amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24931 | Amputation, arm through humerus; with implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24935 | Stump elongation, upper extremity | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24940 | Cineplasty, upper extremity, complete procedure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 24999 | Unlisted procedure, humerus or elbow | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25000 | Incision, extensor tendon sheath, wrist (eg, deQuervains disease) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25001 | Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25020 | Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25023 | Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25024 | Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25025 | Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25028 | Incision and drainage, forearm and/or wrist; deep abscess or hematoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25031 | Incision and drainage, forearm and/or wrist; bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25035 | Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25040 | Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25065 | Biopsy, soft tissue of forearm and/or wrist; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25066 | Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25071 | Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25073 | Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25075 | Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25076 | Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25077 | Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25078 | Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25085 | Capsulotomy, wrist (eg, contracture) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25100 | Arthrotomy, wrist joint; with biopsy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25101 | Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25105 | Arthrotomy, wrist joint; with synovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25107 | Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25109 | Excision of tendon, forearm and/or wrist, flexor or extensor, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25110 | Excision, lesion of tendon sheath, forearm and/or wrist | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25111 | Excision of ganglion, wrist (dorsal or volar); primary | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25112 | Excision of ganglion, wrist (dorsal or volar); recurrent | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25115 | Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25116 | Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25118 | Synovectomy, extensor tendon sheath, wrist, single compartment; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25119 | Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25120 | Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25125 | Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25126 | Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25130 | Excision or curettage of bone cyst or benign tumor of carpal bones; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25135 | Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25136 | Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25145 | Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25150 | Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25151 | Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25170 | Radical resection of tumor, radius or ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25210 | Carpectomy; 1 bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25215 | Carpectomy; all bones of proximal row | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25230 | Radial styloidectomy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25240 | Excision distal ulna partial or complete (eg, Darrach type or matched resection) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25246 | Injection procedure for wrist arthrography | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25248 | Exploration with removal of deep foreign body, forearm or wrist | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25250 | Removal of wrist prosthesis; (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25251 | Removal of wrist prosthesis; complicated, including total wrist | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25259 | Manipulation, wrist, under anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25260 | Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25263 | Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25265 | Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25270 | Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25272 | Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25274 | Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25275 | Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25280 | Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25290 | Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25295 | Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25300 | Tenodesis at wrist; flexors of fingers | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25301 | Tenodesis at wrist; extensors of fingers | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25310 | Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25312 | Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25315 | Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25316 | Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25320 | Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25332 | Arthroplasty, wrist, with or without interposition, with or without external or internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25335 | Centralization of wrist on ulna (eg, radial club hand) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25337 | Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25350 | Osteotomy, radius; distal third | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25355 | Osteotomy, radius; middle or proximal third | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25360 | Osteotomy; ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25365 | Osteotomy; radius AND ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25370 | Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25375 | Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25390 | Osteoplasty, radius OR ulna; shortening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25391 | Osteoplasty, radius OR ulna; lengthening with autograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25392 | Osteoplasty, radius AND ulna; shortening (excluding 64876) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25393 | Osteoplasty, radius AND ulna; lengthening with autograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25394 | Osteoplasty, carpal bone, shortening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25400 | Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25405 | Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25415 | Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25420 | Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25425 | Repair of defect with autograft; radius OR ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25426 | Repair of defect with autograft; radius AND ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25430 | Insertion of vascular pedicle into carpal bone (eg, Hori procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25431 | Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25440 | Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25441 | Arthroplasty with prosthetic replacement; distal radius | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25442 | Arthroplasty with prosthetic replacement; distal ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25443 | Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25444 | Arthroplasty with prosthetic replacement; lunate | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25445 | Arthroplasty with prosthetic replacement; trapezium | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25446 | Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25447 | Arthroplasty, interposition, intercarpal or carpometacarpal joints | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25449 | Revision of arthroplasty, including removal of implant, wrist joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25450 | Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25455 | Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25490 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25491 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25492 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25500 | Closed treatment of radial shaft fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25505 | Closed treatment of radial shaft fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25515 | Open treatment of radial shaft fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25520 | Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25525 | Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25526 | Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25530 | Closed treatment of ulnar shaft fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25535 | Closed treatment of ulnar shaft fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25545 | Open treatment of ulnar shaft fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25560 | Closed treatment of radial and ulnar shaft fractures; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25565 | Closed treatment of radial and ulnar shaft fractures; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25574 | Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25575 | Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25600 | Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25605 | Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25606 | Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25607 | Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25608 | Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25609 | Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25622 | Closed treatment of carpal scaphoid (navicular) fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25624 | Closed treatment of carpal scaphoid (navicular) fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25628 | Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25630 | Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25635 | Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25645 | Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25650 | Closed treatment of ulnar styloid fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25651 | Percutaneous skeletal fixation of ulnar styloid fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25652 | Open treatment of ulnar styloid fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25660 | Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25670 | Open treatment of radiocarpal or intercarpal dislocation, 1 or more bones | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25671 | Percutaneous skeletal fixation of distal radioulnar dislocation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25675 | Closed treatment of distal radioulnar dislocation with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25676 | Open treatment of distal radioulnar dislocation, acute or chronic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25680 | Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25685 | Open treatment of trans-scaphoperilunar type of fracture dislocation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25690 | Closed treatment of lunate dislocation, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25695 | Open treatment of lunate dislocation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25800 | Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25805 | Arthrodesis, wrist; with sliding graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25810 | Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25820 | Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25825 | Arthrodesis, wrist; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25830 | Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25900 | Amputation, forearm, through radius and ulna; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25905 | Amputation, forearm, through radius and ulna; open, circular (guillotine) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25907 | Amputation, forearm, through radius and ulna; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25909 | Amputation, forearm, through radius and ulna; re-amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25915 | Krukenberg procedure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25920 | Disarticulation through wrist; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25922 | Disarticulation through wrist; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25924 | Disarticulation through wrist; re-amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25927 | Transmetacarpal amputation; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25929 | Transmetacarpal amputation; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25931 | Transmetacarpal amputation; re-amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 25999 | Unlisted procedure, forearm or wrist | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26010 | Drainage of finger abscess; simple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26011 | Drainage of finger abscess; complicated (eg, felon) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26020 | Drainage of tendon sheath, digit and/or palm, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26025 | Drainage of palmar bursa; single, bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26030 | Drainage of palmar bursa; multiple bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26034 | Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26035 | Decompression fingers and/or hand, injection injury (eg, grease gun) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26037 | Decompressive fasciotomy, hand (excludes 26035) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26040 | Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26045 | Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26055 | Tendon sheath incision (eg, for trigger finger) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26060 | Tenotomy, percutaneous, single, each digit | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26070 | Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26075 | Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26080 | Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26100 | Arthrotomy with biopsy; carpometacarpal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26105 | Arthrotomy with biopsy; metacarpophalangeal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26110 | Arthrotomy with biopsy; interphalangeal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26111 | Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26113 | Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); 1.5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26115 | Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26116 | Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); less than 1.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26117 | Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26118 | Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26121 | Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26123 | Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26125 | Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26130 | Synovectomy, carpometacarpal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26135 | Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26140 | Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26145 | Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26160 | Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26170 | Excision of tendon, palm, flexor or extensor, single, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26180 | Excision of tendon, finger, flexor or extensor, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26185 | Sesamoidectomy, thumb or finger (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26200 | Excision or curettage of bone cyst or benign tumor of metacarpal; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26205 | Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26210 | Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26215 | Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26230 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26235 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26236 | Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26250 | Radical resection of tumor, metacarpal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26260 | Radical resection of tumor, proximal or middle phalanx of finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26262 | Radical resection of tumor, distal phalanx of finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26320 | Removal of implant from finger or hand | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26340 | Manipulation, finger joint, under anesthesia, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26341 | Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, collagenase), single cord | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26350 | Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26352 | Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26356 | Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26357 | Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26358 | Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26370 | Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26372 | Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26373 | Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26390 | Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26392 | Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26410 | Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26412 | Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26415 | Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26416 | Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26418 | Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26420 | Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26426 | Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26428 | Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26432 | Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26433 | Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26434 | Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26437 | Realignment of extensor tendon, hand, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26440 | Tenolysis, flexor tendon; palm OR finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26442 | Tenolysis, flexor tendon; palm AND finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26445 | Tenolysis, extensor tendon, hand OR finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26449 | Tenolysis, complex, extensor tendon, finger, including forearm, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26450 | Tenotomy, flexor, palm, open, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26455 | Tenotomy, flexor, finger, open, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26460 | Tenotomy, extensor, hand or finger, open, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26471 | Tenodesis; of proximal interphalangeal joint, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26474 | Tenodesis; of distal joint, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26476 | Lengthening of tendon, extensor, hand or finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26477 | Shortening of tendon, extensor, hand or finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26478 | Lengthening of tendon, flexor, hand or finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26479 | Shortening of tendon, flexor, hand or finger, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26480 | Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26483 | Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26485 | Transfer or transplant of tendon, palmar; without free tendon graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26489 | Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26490 | Opponensplasty; superficialis tendon transfer type, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26492 | Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26494 | Opponensplasty; hypothenar muscle transfer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26496 | Opponensplasty; other methods | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26497 | Transfer of tendon to restore intrinsic function; ring and small finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26498 | Transfer of tendon to restore intrinsic function; all 4 fingers | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26499 | Correction claw finger, other methods | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26500 | Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26502 | Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26508 | Release of thenar muscle(s) (eg, thumb contracture) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26510 | Cross intrinsic transfer, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26516 | Capsulodesis, metacarpophalangeal joint; single digit | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26517 | Capsulodesis, metacarpophalangeal joint; 2 digits | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26518 | Capsulodesis, metacarpophalangeal joint; 3 or 4 digits | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26520 | Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26525 | Capsulectomy or capsulotomy; interphalangeal joint, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26530 | Arthroplasty, metacarpophalangeal joint; each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26531 | Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26535 | Arthroplasty, interphalangeal joint; each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26536 | Arthroplasty, interphalangeal joint; with prosthetic implant, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26540 | Repair of collateral ligament, metacarpophalangeal or interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26541 | Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26542 | Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26545 | Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26546 | Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26548 | Repair and reconstruction, finger, volar plate, interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26550 | Pollicization of a digit | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26551 | Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26553 | Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26554 | Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26555 | Transfer, finger to another position without microvascular anastomosis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26556 | Transfer, free toe joint, with microvascular anastomosis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26560 | Repair of syndactyly (web finger) each web space; with skin flaps | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26561 | Repair of syndactyly (web finger) each web space; with skin flaps and grafts | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26562 | Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26565 | Osteotomy; metacarpal, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26567 | Osteotomy; phalanx of finger, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26568 | Osteoplasty, lengthening, metacarpal or phalanx | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26580 | Repair cleft hand | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26587 | Reconstruction of polydactylous digit, soft tissue and bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26590 | Repair macrodactylia, each digit | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26591 | Repair, intrinsic muscles of hand, each muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26593 | Release, intrinsic muscles of hand, each muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26596 | Excision of constricting ring of finger, with multiple Z-plasties | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26600 | Closed treatment of metacarpal fracture, single; without manipulation, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26605 | Closed treatment of metacarpal fracture, single; with manipulation, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26607 | Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26608 | Percutaneous skeletal fixation of metacarpal fracture, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26615 | Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26641 | Closed treatment of carpometacarpal dislocation, thumb, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26645 | Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26650 | Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26665 | Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26670 | Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26675 | Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26676 | Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26685 | Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26686 | Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reduction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26700 | Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26705 | Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26706 | Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26715 | Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26720 | Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26725 | Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26727 | Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26735 | Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26740 | Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26742 | Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26746 | Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26750 | Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26755 | Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26756 | Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26765 | Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26770 | Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26775 | Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26776 | Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26785 | Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26820 | Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26841 | Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26842 | Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26843 | Arthrodesis, carpometacarpal joint, digit, other than thumb, each; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26844 | Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26850 | Arthrodesis, metacarpophalangeal joint, with or without internal fixation; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26852 | Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26860 | Arthrodesis, interphalangeal joint, with or without internal fixation; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26861 | Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26862 | Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26863 | Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26910 | Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26951 | Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26952 | Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26989 | Unlisted procedure, hands or fingers | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26990 | Incision and drainage, pelvis or hip joint area; deep abscess or hematoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26991 | Incision and drainage, pelvis or hip joint area; infected bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 26992 | Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27000 | Tenotomy, adductor of hip, percutaneous (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27001 | Tenotomy, adductor of hip, open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27003 | Tenotomy, adductor, subcutaneous, open, with obturator neurectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27005 | Tenotomy, hip flexor(s), open (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27006 | Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27025 | Fasciotomy, hip or thigh, any type | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27027 | Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27030 | Arthrotomy, hip, with drainage (eg, infection) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27033 | Arthrotomy, hip, including exploration or removal of loose or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27035 | Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27036 | Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27040 | Biopsy, soft tissue of pelvis and hip area; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27041 | Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27043 | Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27045 | Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27047 | Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27048 | Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27049 | Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27050 | Arthrotomy, with biopsy; sacroiliac joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27052 | Arthrotomy, with biopsy; hip joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27054 | Arthrotomy with synovectomy, hip joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27057 | Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27059 | Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27060 | Excision; ischial bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27062 | Excision; trochanteric bursa or calcification | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27065 | Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes autograft, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27066 | Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27067 | Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring separate incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27070 | Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27071 | Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27075 | Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27076 | Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27077 | Radical resection of tumor; innominate bone, total | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27078 | Radical resection of tumor; ischial tuberosity and greater trochanter of femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27080 | Coccygectomy, primary | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27086 | Removal of foreign body, pelvis or hip; subcutaneous tissue | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27087 | Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27090 | Removal of hip prosthesis; (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27091 | Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27093 | Injection procedure for hip arthrography; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27095 | Injection procedure for hip arthrography; with anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27096 | Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed | Yes | Pain Managament Request e-form | Outpatient Hospital:Other Hospital Outpatient, Amb Surg Center or Physician Office: Physician Services | Pain Management (Auth Required) (ARPM) | |
| 27097 | Release or recession, hamstring, proximal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27098 | Transfer, adductor to ischium | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27100 | Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27105 | Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27110 | Transfer iliopsoas; to greater trochanter of femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27111 | Transfer iliopsoas; to femoral neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27120 | Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27122 | Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27125 | Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27130 | Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27132 | Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27134 | Revision of total hip arthroplasty; both components, with or without autograft or allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27137 | Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27138 | Revision of total hip arthroplasty; femoral component only, with or without allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27140 | Osteotomy and transfer of greater trochanter of femur (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27146 | Osteotomy, iliac, acetabular or innominate bone; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27147 | Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27151 | Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27156 | Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27158 | Osteotomy, pelvis, bilateral (eg, congenital malformation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27161 | Osteotomy, femoral neck (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27165 | Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27170 | Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27175 | Treatment of slipped femoral epiphysis; by traction, without reduction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27176 | Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27177 | Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27178 | Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27179 | Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27181 | Open treatment of slipped femoral epiphysis; osteotomy and internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27185 | Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27187 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27197 | Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27198 | Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27200 | Closed treatment of coccygeal fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27202 | Open treatment of coccygeal fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27215 | Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27216 | Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27217 | Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral superior/inferior rami) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27218 | Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral ilium, sacroiliac joint and/or sacrum) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27220 | Closed treatment of acetabulum (hip socket) fracture(s); without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27222 | Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27226 | Open treatment of posterior or anterior acetabular wall fracture, with internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27227 | Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27228 | Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27230 | Closed treatment of femoral fracture, proximal end, neck; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27232 | Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27235 | Percutaneous skeletal fixation of femoral fracture, proximal end, neck | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27236 | Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27238 | Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27240 | Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27244 | Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27245 | Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27246 | Closed treatment of greater trochanteric fracture, without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27248 | Open treatment of greater trochanteric fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27250 | Closed treatment of hip dislocation, traumatic; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27252 | Closed treatment of hip dislocation, traumatic; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27253 | Open treatment of hip dislocation, traumatic, without internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27254 | Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27256 | Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27257 | Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27258 | Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27259 | Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27265 | Closed treatment of post hip arthroplasty dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27266 | Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27267 | Closed treatment of femoral fracture, proximal end, head; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27268 | Closed treatment of femoral fracture, proximal end, head; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27269 | Open treatment of femoral fracture, proximal end, head, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27275 | Manipulation, hip joint, requiring general anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27279 | Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27280 | Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27282 | Arthrodesis, symphysis pubis (including obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27284 | Arthrodesis, hip joint (including obtaining graft); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27286 | Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27290 | Interpelviabdominal amputation (hindquarter amputation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27295 | Disarticulation of hip | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27299 | Unlisted procedure, pelvis or hip joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27301 | Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27303 | Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27305 | Fasciotomy, iliotibial (tenotomy), open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27306 | Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27307 | Tenotomy, percutaneous, adductor or hamstring; multiple tendons | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27310 | Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27323 | Biopsy, soft tissue of thigh or knee area; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27324 | Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27325 | Neurectomy, hamstring muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27326 | Neurectomy, popliteal (gastrocnemius) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27327 | Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27328 | Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27329 | Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27330 | Arthrotomy, knee; with synovial biopsy only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27331 | Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27332 | Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27333 | Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27334 | Arthrotomy, with synovectomy, knee; anterior OR posterior | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27335 | Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27337 | Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27339 | Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27340 | Excision, prepatellar bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27345 | Excision of synovial cyst of popliteal space (eg, Baker's cyst) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27347 | Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27350 | Patellectomy or hemipatellectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27355 | Excision or curettage of bone cyst or benign tumor of femur; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27356 | Excision or curettage of bone cyst or benign tumor of femur; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27357 | Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27358 | Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27360 | Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone abscess) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27364 | Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27365 | Radical resection of tumor, femur or knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27369 | Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27372 | Removal of foreign body, deep, thigh region or knee area | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27380 | Suture of infrapatellar tendon; primary | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27381 | Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27385 | Suture of quadriceps or hamstring muscle rupture; primary | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27386 | Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27390 | Tenotomy, open, hamstring, knee to hip; single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27391 | Tenotomy, open, hamstring, knee to hip; multiple tendons, 1 leg | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27392 | Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27393 | Lengthening of hamstring tendon; single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27394 | Lengthening of hamstring tendon; multiple tendons, 1 leg | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27395 | Lengthening of hamstring tendon; multiple tendons, bilateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27396 | Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27397 | Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); multiple tendons | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27400 | Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27403 | Arthrotomy with meniscus repair, knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27405 | Repair, primary, torn ligament and/or capsule, knee; collateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27407 | Repair, primary, torn ligament and/or capsule, knee; cruciate | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27409 | Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27412 | Autologous chondrocyte implantation, knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27415 | Osteochondral allograft, knee, open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27416 | Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27418 | Anterior tibial tubercleplasty (eg, Maquet type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27420 | Reconstruction of dislocating patella; (eg, Hauser type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27422 | Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27424 | Reconstruction of dislocating patella; with patellectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27425 | Lateral retinacular release, open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27427 | Ligamentous reconstruction (augmentation), knee; extra-articular | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27428 | Ligamentous reconstruction (augmentation), knee; intra-articular (open) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27429 | Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27430 | Quadricepsplasty (eg, Bennett or Thompson type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27435 | Capsulotomy, posterior capsular release, knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27437 | Arthroplasty, patella; without prosthesis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27438 | Arthroplasty, patella; with prosthesis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27440 | Arthroplasty, knee, tibial plateau; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27441 | Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27442 | Arthroplasty, femoral condyles or tibial plateau(s), knee; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27443 | Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27445 | Arthroplasty, knee, hinge prosthesis (eg, Walldius type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27446 | Arthroplasty, knee, condyle and plateau; medial OR lateral compartment | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27448 | Osteotomy, femur, shaft or supracondylar; without fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27450 | Osteotomy, femur, shaft or supracondylar; with fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27454 | Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27455 | Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); before epiphyseal closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27457 | Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27465 | Osteoplasty, femur; shortening (excluding 64876) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27466 | Osteoplasty, femur; lengthening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27468 | Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27470 | Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27472 | Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27475 | Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27477 | Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, proximal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27479 | Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal femur, proximal tibia and fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27485 | Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, genu varus or valgus) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27486 | Revision of total knee arthroplasty, with or without allograft; 1 component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27487 | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27488 | Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27495 | Prophylactic treatment (nailing, pinning, plating, or wiring) with or without methylmethacrylate, femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27496 | Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27497 | Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27498 | Decompression fasciotomy, thigh and/or knee, multiple compartments; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27499 | Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27500 | Closed treatment of femoral shaft fracture, without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27501 | Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27502 | Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27503 | Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with manipulation, with or without skin or skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27506 | Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27507 | Open treatment of femoral shaft fracture with plate/screws, with or without cerclage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27508 | Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27509 | Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27510 | Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27511 | Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27513 | Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27514 | Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27516 | Closed treatment of distal femoral epiphyseal separation; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27517 | Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27519 | Open treatment of distal femoral epiphyseal separation, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27520 | Closed treatment of patellar fracture, without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27524 | Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27530 | Closed treatment of tibial fracture, proximal (plateau); without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27532 | Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27535 | Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27536 | Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27538 | Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27540 | Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27550 | Closed treatment of knee dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27552 | Closed treatment of knee dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27556 | Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or augmentation/reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27557 | Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27558 | Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair, with augmentation/reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27560 | Closed treatment of patellar dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27562 | Closed treatment of patellar dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27566 | Open treatment of patellar dislocation, with or without partial or total patellectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27570 | Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27580 | Arthrodesis, knee, any technique | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27590 | Amputation, thigh, through femur, any level; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27591 | Amputation, thigh, through femur, any level; immediate fitting technique including first cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27592 | Amputation, thigh, through femur, any level; open, circular (guillotine) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27594 | Amputation, thigh, through femur, any level; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27596 | Amputation, thigh, through femur, any level; re-amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27598 | Disarticulation at knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27599 | Unlisted procedure, femur or knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27600 | Decompression fasciotomy, leg; anterior and/or lateral compartments only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27601 | Decompression fasciotomy, leg; posterior compartment(s) only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27602 | Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27603 | Incision and drainage, leg or ankle; deep abscess or hematoma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27604 | Incision and drainage, leg or ankle; infected bursa | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27605 | Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27606 | Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27607 | Incision (eg, osteomyelitis or bone abscess), leg or ankle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27610 | Arthrotomy, ankle, including exploration, drainage, or removal of foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27612 | Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27613 | Biopsy, soft tissue of leg or ankle area; superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27614 | Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27615 | Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27616 | Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27618 | Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27619 | Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27620 | Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27625 | Arthrotomy, with synovectomy, ankle; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27626 | Arthrotomy, with synovectomy, ankle; including tenosynovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27630 | Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27632 | Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27634 | Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); 5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27635 | Excision or curettage of bone cyst or benign tumor, tibia or fibula; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27637 | Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27638 | Excision or curettage of bone cyst or benign tumor, tibia or fibula; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27640 | Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); tibia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27641 | Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27645 | Radical resection of tumor; tibia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27646 | Radical resection of tumor; fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27647 | Radical resection of tumor; talus or calcaneus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27648 | Injection procedure for ankle arthrography | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27650 | Repair, primary, open or percutaneous, ruptured Achilles tendon; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27652 | Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27654 | Repair, secondary, Achilles tendon, with or without graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27656 | Repair, fascial defect of leg | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27658 | Repair, flexor tendon, leg; primary, without graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27659 | Repair, flexor tendon, leg; secondary, with or without graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27664 | Repair, extensor tendon, leg; primary, without graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27665 | Repair, extensor tendon, leg; secondary, with or without graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27675 | Repair, dislocating peroneal tendons; without fibular osteotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27676 | Repair, dislocating peroneal tendons; with fibular osteotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27680 | Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27681 | Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incision[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27685 | Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27686 | Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27687 | Gastrocnemius recession (eg, Strayer procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27690 | Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial extensors into midfoot) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27691 | Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27692 | Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27695 | Repair, primary, disrupted ligament, ankle; collateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27696 | Repair, primary, disrupted ligament, ankle; both collateral ligaments | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27698 | Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27700 | Arthroplasty, ankle; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27702 | Arthroplasty, ankle; with implant (total ankle) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27703 | Arthroplasty, ankle; revision, total ankle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27704 | Removal of ankle implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27705 | Osteotomy; tibia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27707 | Osteotomy; fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27709 | Osteotomy; tibia and fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27712 | Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27715 | Osteoplasty, tibia and fibula, lengthening or shortening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27720 | Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27722 | Repair of nonunion or malunion, tibia; with sliding graft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27724 | Repair of nonunion or malunion, tibia; with iliac or other autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27725 | Repair of nonunion or malunion, tibia; by synostosis, with fibula, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27726 | Repair of fibula nonunion and/or malunion with internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27727 | Repair of congenital pseudarthrosis, tibia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27730 | Arrest, epiphyseal (epiphysiodesis), open; distal tibia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27732 | Arrest, epiphyseal (epiphysiodesis), open; distal fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27734 | Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27740 | Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27742 | Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal femur | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27745 | Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27750 | Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27752 | Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27756 | Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27758 | Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27759 | Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27760 | Closed treatment of medial malleolus fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27762 | Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27766 | Open treatment of medial malleolus fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27767 | Closed treatment of posterior malleolus fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27768 | Closed treatment of posterior malleolus fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27769 | Open treatment of posterior malleolus fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27780 | Closed treatment of proximal fibula or shaft fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27781 | Closed treatment of proximal fibula or shaft fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27784 | Open treatment of proximal fibula or shaft fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27786 | Closed treatment of distal fibular fracture (lateral malleolus); without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27788 | Closed treatment of distal fibular fracture (lateral malleolus); with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27792 | Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27808 | Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27810 | Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27814 | Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27816 | Closed treatment of trimalleolar ankle fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27818 | Closed treatment of trimalleolar ankle fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27822 | Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27823 | Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27824 | Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27825 | Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27826 | Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of fibula only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27827 | Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of tibia only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27828 | Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with internal fixation, when performed; of both tibia and fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27829 | Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27830 | Closed treatment of proximal tibiofibular joint dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27831 | Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27832 | Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibula | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27840 | Closed treatment of ankle dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27842 | Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27846 | Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27848 | Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or external fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27860 | Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27870 | Arthrodesis, ankle, open | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27871 | Arthrodesis, tibiofibular joint, proximal or distal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27880 | Amputation, leg, through tibia and fibula; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27881 | Amputation, leg, through tibia and fibula; with immediate fitting technique including application of first cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27882 | Amputation, leg, through tibia and fibula; open, circular (guillotine) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27884 | Amputation, leg, through tibia and fibula; secondary closure or scar revision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27886 | Amputation, leg, through tibia and fibula; re-amputation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27888 | Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nerves | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27889 | Ankle disarticulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27892 | Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27893 | Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27894 | Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerve | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 27899 | Unlisted procedure, leg or ankle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28001 | Incision and drainage, bursa, foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28002 | Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28003 | Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28005 | Incision, bone cortex (eg, osteomyelitis or bone abscess), foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28008 | Fasciotomy, foot and/or toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28010 | Tenotomy, percutaneous, toe; single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28011 | Tenotomy, percutaneous, toe; multiple tendons | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28020 | Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28022 | Arthrotomy, including exploration, drainage, or removal of loose or foreign body; metatarsophalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28024 | Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28035 | Release, tarsal tunnel (posterior tibial nerve decompression) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28039 | Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28041 | Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); 1.5 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28043 | Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28045 | Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); less than 1.5 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28046 | Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; less than 3 cm | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28047 | Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 cm or greater | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28050 | Arthrotomy with biopsy; intertarsal or tarsometatarsal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28052 | Arthrotomy with biopsy; metatarsophalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28054 | Arthrotomy with biopsy; interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28055 | Neurectomy, intrinsic musculature of foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28060 | Fasciectomy, plantar fascia; partial (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28062 | Fasciectomy, plantar fascia; radical (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28070 | Synovectomy; intertarsal or tarsometatarsal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28072 | Synovectomy; metatarsophalangeal joint, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28080 | Excision, interdigital (Morton) neuroma, single, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28086 | Synovectomy, tendon sheath, foot; flexor | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28088 | Synovectomy, tendon sheath, foot; extensor | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28090 | Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28092 | Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); toe(s), each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28100 | Excision or curettage of bone cyst or benign tumor, talus or calcaneus; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28102 | Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28103 | Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28104 | Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28106 | Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with iliac or other autograft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28107 | Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with allograft | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28108 | Excision or curettage of bone cyst or benign tumor, phalanges of foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28110 | Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28111 | Ostectomy, complete excision; first metatarsal head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28112 | Ostectomy, complete excision; other metatarsal head (second, third or fourth) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28113 | Ostectomy, complete excision; fifth metatarsal head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28114 | Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (eg, Clayton type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28116 | Ostectomy, excision of tarsal coalition | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28118 | Ostectomy, calcaneus; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28119 | Ostectomy, calcaneus; for spur, with or without plantar fascial release | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28120 | Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28122 | Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28124 | Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28126 | Resection, partial or complete, phalangeal base, each toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28130 | Talectomy (astragalectomy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28140 | Metatarsectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28150 | Phalangectomy, toe, each toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28153 | Resection, condyle(s), distal end of phalanx, each toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28160 | Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28171 | Radical resection of tumor; tarsal (except talus or calcaneus) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28173 | Radical resection of tumor; metatarsal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28175 | Radical resection of tumor; phalanx of toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28190 | Removal of foreign body, foot; subcutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28192 | Removal of foreign body, foot; deep | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28193 | Removal of foreign body, foot; complicated | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28200 | Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28202 | Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28208 | Repair, tendon, extensor, foot; primary or secondary, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28210 | Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28220 | Tenolysis, flexor, foot; single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28222 | Tenolysis, flexor, foot; multiple tendons | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28225 | Tenolysis, extensor, foot; single tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28226 | Tenolysis, extensor, foot; multiple tendons | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28230 | Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28232 | Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28234 | Tenotomy, open, extensor, foot or toe, each tendon | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28238 | Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (eg, Kidner type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28240 | Tenotomy, lengthening, or release, abductor hallucis muscle | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28250 | Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28260 | Capsulotomy, midfoot; medial release only (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28261 | Capsulotomy, midfoot; with tendon lengthening | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28262 | Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28264 | Capsulotomy, midtarsal (eg, Heyman type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28270 | Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28272 | Capsulotomy; interphalangeal joint, each joint (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28280 | Syndactylization, toes (eg, webbing or Kelikian type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28285 | Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28286 | Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28288 | Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28289 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28291 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28292 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with resection of proximal phalanx base, when performed, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28295 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal metatarsal osteotomy, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28296 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28297 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28298 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28299 | Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28300 | Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28302 | Osteotomy; talus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28304 | Osteotomy, tarsal bones, other than calcaneus or talus; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28305 | Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28306 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28307 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28308 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28309 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (eg, Swanson type cavus foot procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28310 | Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28312 | Osteotomy, shortening, angular or rotational correction; other phalanges, any toe | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28313 | Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28315 | Sesamoidectomy, first toe (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28320 | Repair, nonunion or malunion; tarsal bones | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28322 | Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28340 | Reconstruction, toe, macrodactyly; soft tissue resection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28341 | Reconstruction, toe, macrodactyly; requiring bone resection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28344 | Reconstruction, toe(s); polydactyly | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28345 | Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28360 | Reconstruction, cleft foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28400 | Closed treatment of calcaneal fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28405 | Closed treatment of calcaneal fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28406 | Percutaneous skeletal fixation of calcaneal fracture, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28415 | Open treatment of calcaneal fracture, includes internal fixation, when performed; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28420 | Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft (includes obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28430 | Closed treatment of talus fracture; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28435 | Closed treatment of talus fracture; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28436 | Percutaneous skeletal fixation of talus fracture, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28445 | Open treatment of talus fracture, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28446 | Open osteochondral autograft, talus (includes obtaining graft[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28450 | Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28455 | Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28456 | Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28465 | Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28470 | Closed treatment of metatarsal fracture; without manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28475 | Closed treatment of metatarsal fracture; with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28476 | Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28485 | Open treatment of metatarsal fracture, includes internal fixation, when performed, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28490 | Closed treatment of fracture great toe, phalanx or phalanges; without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28495 | Closed treatment of fracture great toe, phalanx or phalanges; with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28496 | Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28505 | Open treatment of fracture, great toe, phalanx or phalanges, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28510 | Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28515 | Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28525 | Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, each | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28530 | Closed treatment of sesamoid fracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28531 | Open treatment of sesamoid fracture, with or without internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28540 | Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28545 | Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28546 | Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28555 | Open treatment of tarsal bone dislocation, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28570 | Closed treatment of talotarsal joint dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28575 | Closed treatment of talotarsal joint dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28576 | Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28585 | Open treatment of talotarsal joint dislocation, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28600 | Closed treatment of tarsometatarsal joint dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28605 | Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28606 | Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28615 | Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28630 | Closed treatment of metatarsophalangeal joint dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28635 | Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28636 | Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28645 | Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28660 | Closed treatment of interphalangeal joint dislocation; without anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28665 | Closed treatment of interphalangeal joint dislocation; requiring anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28666 | Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28675 | Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28705 | Arthrodesis; pantalar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28715 | Arthrodesis; triple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28725 | Arthrodesis; subtalar | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28730 | Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28735 | Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28737 | Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform (eg, Miller type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28740 | Arthrodesis, midtarsal or tarsometatarsal, single joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28750 | Arthrodesis, great toe; metatarsophalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28755 | Arthrodesis, great toe; interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28760 | Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28800 | Amputation, foot; midtarsal (eg, Chopart type procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28805 | Amputation, foot; transmetatarsal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28810 | Amputation, metatarsal, with toe, single | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28820 | Amputation, toe; metatarsophalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28825 | Amputation, toe; interphalangeal joint | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28890 | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 28899 | Unlisted procedure, foot or toes | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29000 | Application of halo type body cast (see 20661-20663 for insertion) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29010 | Application of Risser jacket, localizer, body; only | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29015 | Application of Risser jacket, localizer, body; including head | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29035 | Application of body cast, shoulder to hips; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29040 | Application of body cast, shoulder to hips; including head, Minerva type | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29044 | Application of body cast, shoulder to hips; including 1 thigh | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29046 | Application of body cast, shoulder to hips; including both thighs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29049 | Application, cast; figure-of-eight | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29055 | Application, cast; shoulder spica | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29058 | Application, cast; plaster Velpeau | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29065 | Application, cast; shoulder to hand (long arm) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29075 | Application, cast; elbow to finger (short arm) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29085 | Application, cast; hand and lower forearm (gauntlet) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29086 | Application, cast; finger (eg, contracture) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29105 | Application of long arm splint (shoulder to hand) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29125 | Application of short arm splint (forearm to hand); static | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29126 | Application of short arm splint (forearm to hand); dynamic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29130 | Application of finger splint; static | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29131 | Application of finger splint; dynamic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29200 | Strapping; thorax | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29240 | Strapping; shoulder (eg, Velpeau) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29260 | Strapping; elbow or wrist | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29280 | Strapping; hand or finger | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29305 | Application of hip spica cast; 1 leg | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29325 | Application of hip spica cast; 1 and one-half spica or both legs | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29345 | Application of long leg cast (thigh to toes); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29355 | Application of long leg cast (thigh to toes); walker or ambulatory type | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29358 | Application of long leg cast brace | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29365 | Application of cylinder cast (thigh to ankle) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29405 | Application of short leg cast (below knee to toes); | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29425 | Application of short leg cast (below knee to toes); walking or ambulatory type | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29435 | Application of patellar tendon bearing (PTB) cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29440 | Adding walker to previously applied cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29445 | Application of rigid total contact leg cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29450 | Application of clubfoot cast with molding or manipulation, long or short leg | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29505 | Application of long leg splint (thigh to ankle or toes) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29515 | Application of short leg splint (calf to foot) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29520 | Strapping; hip | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29530 | Strapping; knee | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29540 | Strapping; ankle and/or foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29550 | Strapping; toes | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29580 | Strapping; Unna boot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29581 | Application of multi-layer compression system; leg (below knee), including ankle and foot | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29584 | Application of multi-layer compression system; upper arm, forearm, hand, and fingers | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29700 | Removal or bivalving; gauntlet, boot or body cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29705 | Removal or bivalving; full arm or full leg cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29710 | Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc. | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29720 | Repair of spica, body cast or jacket | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29730 | Windowing of cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29740 | Wedging of cast (except clubfoot casts) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29750 | Wedging of clubfoot cast | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29799 | Unlisted procedure, casting or strapping | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29800 | Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29804 | Arthroscopy, temporomandibular joint, surgical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29805 | Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29806 | Arthroscopy, shoulder, surgical; capsulorrhaphy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29807 | Arthroscopy, shoulder, surgical; repair of SLAP lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29819 | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29820 | Arthroscopy, shoulder, surgical; synovectomy, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29821 | Arthroscopy, shoulder, surgical; synovectomy, complete | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29822 | Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29823 | Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29824 | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29825 | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29826 | Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29827 | Arthroscopy, shoulder, surgical; with rotator cuff repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29828 | Arthroscopy, shoulder, surgical; biceps tenodesis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29830 | Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29834 | Arthroscopy, elbow, surgical; with removal of loose body or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29835 | Arthroscopy, elbow, surgical; synovectomy, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29836 | Arthroscopy, elbow, surgical; synovectomy, complete | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29837 | Arthroscopy, elbow, surgical; debridement, limited | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29838 | Arthroscopy, elbow, surgical; debridement, extensive | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29840 | Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29843 | Arthroscopy, wrist, surgical; for infection, lavage and drainage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29844 | Arthroscopy, wrist, surgical; synovectomy, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29845 | Arthroscopy, wrist, surgical; synovectomy, complete | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29846 | Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29847 | Arthroscopy, wrist, surgical; internal fixation for fracture or instability | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29848 | Endoscopy, wrist, surgical, with release of transverse carpal ligament | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29850 | Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29851 | Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29855 | Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29856 | Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29860 | Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29861 | Arthroscopy, hip, surgical; with removal of loose body or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29862 | Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29863 | Arthroscopy, hip, surgical; with synovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29867 | Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29868 | Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29870 | Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29871 | Arthroscopy, knee, surgical; for infection, lavage and drainage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29873 | Arthroscopy, knee, surgical; with lateral release | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29874 | Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29875 | Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29876 | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29877 | Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29879 | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29880 | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29881 | Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29882 | Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29883 | Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29884 | Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29885 | Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29886 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29887 | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29888 | Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29889 | Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29891 | Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29892 | Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29893 | Endoscopic plantar fasciotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29894 | Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29895 | Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29897 | Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29898 | Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29899 | Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29900 | Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29901 | Arthroscopy, metacarpophalangeal joint, surgical; with debridement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29902 | Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (eg, Stenar lesion) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29904 | Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29905 | Arthroscopy, subtalar joint, surgical; with synovectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29906 | Arthroscopy, subtalar joint, surgical; with debridement | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29907 | Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29914 | Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29915 | Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29916 | Arthroscopy, hip, surgical; with labral repair | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 29999 | Unlisted procedure, arthroscopy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30000 | Drainage abscess or hematoma, nasal, internal approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30020 | Drainage abscess or hematoma, nasal septum | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30100 | Biopsy, intranasal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30110 | Excision, nasal polyp(s), simple | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30115 | Excision, nasal polyp(s), extensive | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30117 | Excision or destruction (eg, laser), intranasal lesion; internal approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30118 | Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30120 | Excision or surgical planing of skin of nose for rhinophyma | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30124 | Excision dermoid cyst, nose; simple, skin, subcutaneous | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30125 | Excision dermoid cyst, nose; complex, under bone or cartilage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30130 | Excision inferior turbinate, partial or complete, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30140 | Submucous resection inferior turbinate, partial or complete, any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30150 | Rhinectomy; partial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30160 | Rhinectomy; total | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30200 | Injection into turbinate(s), therapeutic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30210 | Displacement therapy (Proetz type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30220 | Insertion, nasal septal prosthesis (button) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30300 | Removal foreign body, intranasal; office type procedure | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30310 | Removal foreign body, intranasal; requiring general anesthesia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30320 | Removal foreign body, intranasal; by lateral rhinotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip | Yes | Outpatient Surgery e-form | |||
| 30410 | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip | Yes | Outpatient Surgery e-form | |||
| 30420 | Rhinoplasty, primary; including major septal repair | Yes | Outpatient Surgery e-form | |||
| 30435 | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) | Yes | Outpatient Surgery e-form | |||
| 30450 | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) | Yes | Outpatient Surgery e-form | |||
| 30460 | Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only | Yes | Outpatient Surgery e-form | |||
| 30462 | Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies | Yes | Outpatient Surgery e-form | |||
| 30465 | Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) | Yes | Outpatient Surgery e-form | |||
| 30468 | Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) | Yes | Outpatient Surgery e-form | |||
| 30520 | Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft | Yes | Outpatient Surgery e-form | |||
| 30540 | Repair choanal atresia; intranasal | Yes | Outpatient Surgery e-form | |||
| 30545 | Repair choanal atresia; transpalatine | Yes | Outpatient Surgery e-form | |||
| 30560 | Lysis intranasal synechia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30580 | Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30600 | Repair fistula; oronasal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30620 | Septal or other intranasal dermatoplasty (does not include obtaining graft) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30630 | Repair nasal septal perforations | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30801 | Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30802 | Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30901 | Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30903 | Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30905 | Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30906 | Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30915 | Ligation arteries; ethmoidal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30920 | Ligation arteries; internal maxillary artery, transantral | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30930 | Fracture nasal inferior turbinate(s), therapeutic | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 30999 | Unlisted procedure, nose | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31000 | Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31002 | Lavage by cannulation; sphenoid sinus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31020 | Sinusotomy, maxillary (antrotomy); intranasal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31030 | Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31032 | Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31050 | Sinusotomy, sphenoid, with or without biopsy; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31051 | Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31070 | Sinusotomy frontal; external, simple (trephine operation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31075 | Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31080 | Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31081 | Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31084 | Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31085 | Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31086 | Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31087 | Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal incision | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31090 | Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31200 | Ethmoidectomy; intranasal, anterior | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31201 | Ethmoidectomy; intranasal, total | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31205 | Ethmoidectomy; extranasal, total | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31225 | Maxillectomy; without orbital exenteration | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31230 | Maxillectomy; with orbital exenteration (en bloc) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31231 | Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31233 | Nasal/sinus endoscopy, diagnostic; with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31235 | Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31237 | Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31238 | Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31239 | Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31240 | Nasal/sinus endoscopy, surgical; with concha bullosa resection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31241 | Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31253 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31254 | Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31255 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31256 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31257 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31259 | Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31267 | Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31276 | Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31287 | Nasal/sinus endoscopy, surgical, with sphenoidotomy; | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31288 | Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31290 | Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31291 | Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31292 | Nasal/sinus endoscopy, surgical, with orbital decompression; medial or inferior wall | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31293 | Nasal/sinus endoscopy, surgical, with orbital decompression; medial and inferior wall | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31294 | Nasal/sinus endoscopy, surgical, with optic nerve decompression | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31298 | Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31299 | Unlisted procedure, accessory sinuses | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31300 | Laryngotomy (thyrotomy, laryngofissure), with removal of tumor or laryngocele, cordectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31360 | Laryngectomy; total, without radical neck dissection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31365 | Laryngectomy; total, with radical neck dissection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31367 | Laryngectomy; subtotal supraglottic, without radical neck dissection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31368 | Laryngectomy; subtotal supraglottic, with radical neck dissection | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31370 | Partial laryngectomy (hemilaryngectomy); horizontal | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31375 | Partial laryngectomy (hemilaryngectomy); laterovertical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31380 | Partial laryngectomy (hemilaryngectomy); anterovertical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31382 | Partial laryngectomy (hemilaryngectomy); antero-latero-vertical | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31390 | Pharyngolaryngectomy, with radical neck dissection; without reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31395 | Pharyngolaryngectomy, with radical neck dissection; with reconstruction | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31400 | Arytenoidectomy or arytenoidopexy, external approach | See Comment | In Network: No authorization required.Out of Network:Authorization is required. | Out of Network e-form | ||
| 31420 | Epiglottidectomy | See Comment | In Network: No authorization required.Out of Network:Authorization is required. |