Appendix B: Authorization Guidelines for Outpatient Services (Auto Auth List) See the Following Page
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KAISER PERMANENTE OF OHIO Appendix B: Authorization Guidelines for Outpatient Services (Auto Auth List) See the following page. Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 1 KAISER PERMANENTE OF OHIO KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; NOT 00630 OTHERWISE SPECIFIED anes/rad 1/1/2007 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO 00740 DUODENUM gastro 1/1/2007 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES, ENDOSCOPE INTRODUCED DISTAL TO 00810 DUODENUM gastro 1/1/2006 ANESTHESIA FOR MYELOGRAPHY, DISKOGRAPHY, 01905 VERTEBROPLASTY radiology 1/1/2007 01916 ANESTHESIA FOR DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPHY radiology 1/1/2007 ANESTHESIA FOR NON-INVASIVE IMAGING OR RADIATION 01922 THERAPY radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE ARTERIAL SYSTEM; NOT 01924 OTHERWISE SPECIFIED radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE ARTERIAL SYSTEM; CAROTID OR 01925 CORONARY radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE ARTERIAL SYSTEM; 01926 INTRACRANIAL, INTRACARDIAC, OR AORT radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE VENOUS/LYMPHATIC SYSTEM 01930 (NOT TO INCLUDE ACCESS TO TH radiology 1/1/2006 REGIONAL INTRAVENOUS ADMINISTRATION OF LOCAL ANESTHETIC AGENT OR OTHER MEDICATION (UPPER OR 01995 LOWER EXTREMITY) general 1/1/2006 10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE general 1/1/2005 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS 10060 ABSCESS, CYST, FURUNCLE, OR P general 1/1/2005 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS 10061 ABSCESS, CYST, FURUNCLE, OR P general 1/1/2005 10080 INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE general 1/1/2006 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS 10120 TISSUES; SIMPLE general 1/1/2005 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR 10160 CYST general 1/1/2005 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED 11000 SKIN; UP TO 10% OF BODY SURFACE surg 1/1/2005 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST 11001 SEPARATELY IN ADDITION TO CODE surg 1/1/2005 11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS surg 1/1/2005 11041 DEBRIDEMENT; SKIN, FULL THICKNESS surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 2 KAISER PERMANENTE OF OHIO KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE 11042 DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE surg 1/1/2005 11043 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE surg 1/1/2005 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND 11044 BONE surg 1/1/2005 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS 11100 OTHERWISE LISTED; SINGLE LESION surg 1/1/2005 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS 11101 OTHERWISE LISTED; EACH SEPARATE/ADDI surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11300 TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11301 TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11302 TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11303 TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 11305 CM OR LESS surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 11306 TO 1.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 11307 TO 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 11308 OVER 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11310 LESION DIAMETER 0.5 CM OR surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11311 LESION DIAMETER 0.6 TO 1.0 surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11312 LESION DIAMETER 1.1 TO 2.0 surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11313 LESION DIAMETER OVER 2.0 C surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11400 EXCISED DIAMETER 0.5 CM surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11401 EXCISED DIAMETER 0.6 TO surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 11402 TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 3 KAISER PERMANENTE OF OHIO KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE EXCISED DIAMETER 1.1 TO EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11403 EXCISED DIAMETER 2.1 TO surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11404 EXCISED DIAMETER 3.1 TO surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11406 EXCISED DIAMETER OVER 4 surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11420 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11421 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11422 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11423 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11424 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11426 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11440 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11441 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11442 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11443 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11444 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11446 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11600 ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11601 ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 4 KAISER PERMANENTE OF OHIO KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11602 ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11603 ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11604 ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11606 ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR 11620 LESS surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 11621 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 11622 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 11623 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 11624 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 11626 CM surg 1/1/2005 EXCISION, MALIGNANT LESION