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List of Procedures Requiring

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List of Procedures Requiring Appendix H: Procedures Requiring TARs The document begins on the next page. Medi-Cal Treatment Authorizations and Claims Processing, Appendices H1 tar and non TAR and Non-Benefit: Introduction to List 1 The TAR and Non-Benefit List: Codes (10000 – 99999) contains CPT-4 codes and descriptions with numbers indicating benefit restrictions. Any code in the CPT-4 book currently valid for Medi-Cal but not on the TAR and Non-Benefit List is a Medi-Cal benefit without the listed restrictions. If you are uncertain about the authorization requirements, or suspect that this list contains an error, contact the EDS Provider Support Center (PSC) at 1-800-541-5555. Note: Refer to the CPT-4 book for complete descriptions of the listed codes. Non-Benefit (1) Codes marked with a “1” either are not Medi-Cal benefits or are not reimbursable, even though the service is a benefit. For example, immunization injections are benefits of Medi-Cal, but CPT-4 codes 90700 – 90747 are marked a “1” because Medi-Cal requires providers to bill immunizations using the HCPCS codes in the Injections: List of Codes section in the appropriate Part 2 manual. Medi-Cal will not reimburse any provider for codes marked with a “1.” Requires TAR, Primary Codes marked with a “2” (Requires TAR, Primary Surgeon/Provider) Surgeon/Provider (2) require a Treatment Authorization Request (TAR) for the primary surgeon or provider whether performed on an inpatient or outpatient basis. Podiatrists should refer to the Podiatry Services section in the appropriate Part 2 manual for prior authorization requirements. Anesthesiologists and assistant surgeons do not need a TAR for services marked with a “2.” Non-Benefit, Medi-Cal will not reimburse assistant surgeon services for codes Assistant Surgeon (3) marked with a “3” (Non-Benefit, Assistant Surgeon). Do not bill the assistant surgeon modifier for codes marked with a “3.” Non-Benefit, Medi-Cal will not reimburse anesthesia services for codes marked with Anesthesiologist (4) a “4” (Non-Benefit, Anesthesiologist). Do not bill anesthesia modifiers with codes marked with a “4.” 2 – TAR and Non-Benefit: Introduction to List September 1999 tar and non 2 Ambulatory Surgical (5) Codes marked with a “5” (Ambulatory Surgical) are routinely performed on an outpatient basis. A TAR is required when a primary surgeon or provider performs these services in an inpatient setting. TAR approval will be granted only when there is documentation of a medical condition making an outpatient setting inappropriate. Anesthesiologists and assistant surgeons do not need a TAR for services marked with a “5.” Inpatient Hospitalization Authorization for an inpatient hospital stay must be obtained, even Stay: Prior Authorization if the procedure being performed does not require a TAR. Reminder Authorization may be requested by either the physician performing the procedure or the hospital providing the inpatient stay. 2 – TAR and Non-Benefit: Introduction to List September 1999 tar and non cd1 TAR and Non-Benefit List: Codes 10000 – 19999 1 Benefit Benefit Code Description Restrictions Code Description Restrictions ANESTHESIA Excision – Benign Lesions Anesthesia services should be billed using the appropriate five-digit 11200 Excision, skin tags, up to 15 ............................................3 CPT-4 anesthesia code (00100 – 01999) and the appropriate 11201 Excision, skin tags, each additional 10 lesions anesthesia modifier. Refer to the Anesthesia section in the (List separately in addition to code for primary appropriate Part 2 manual for more detailed information. procedure)..............................................................3, 4 11300 Shaving, epidermal or dermal lesion, 0.5 cm or less .......3 11301 Shaving, epidermal or dermal lesion, 0.6 or 1.0 cm.........3 11302 Shaving, epidermal or dermal lesion, 1.1 or 2.0 cm.........3 SURGERY 11303 Shaving, epidermal or dermal lesion, over 2.0 cm...........3 11305 Shaving, epidermal or dermal lesion, 0.5 cm or less .......3 INTEGUMENTARY SYSTEM 11306 Shaving, epidermal or dermal lesion, 0.6 to 1.0 cm.........3 11307 Shaving, epidermal or dermal lesion, 1.1 to 2.0 cm.........3 SKIN, SUBCUTANEOUS 11308 Shaving, epidermal or dermal lesion, over 2.0 cm ..........3 AND ACCESSORY STRUCTURES 11310 Shaving, epidermal or dermal lesion, 0.5 cm or less ......3 Incision and Drainage 11311 Shaving, epidermal or dermal lesion, 0.6 to 1.0 cm ........3 10040 Acne surgery................................................................2, 3 11312 Shaving, epidermal or dermal lesion, 1.1 to 2.0 cm ........3 10060 Incision/drainage abscess, simple or single ................3, 5 11313 Shaving, epidermal or dermal lesion, over 2.0 cm ..........3 10061 Incision/drainage abscess, complicated or multiple.........5 11400 Excision, benign lesion, 0.5 cm or less............................3 10080 Incision/drainage pilonidal cyst, simple........................3, 5 11401 Excision, benign lesion, 0.6 to 1.0 cm..............................3 10081 Incision/drainage pilonidal cyst, complicated...................5 11402 Excision, benign lesion, 1.1 to 2.0 cm..............................3 10120 Incision/removal foreign body, simple..........................3, 5 11403 Excision, benign lesion, 2.1 to 3.0 cm..............................3 10121 Incision/removal foreign body, complicated.....................5 11404 Excision, benign lesion, 3.1 to 4.0 cm..............................3 10140 Incision/drainage hematoma, simple ...........................3, 5 11406 Excision, benign lesion, over 4.0 cm................................3 10160 Puncture aspiration......................................................3, 5 11420 Excision, benign lesion, 0.5 cm or less............................3 11421 Excision, benign lesion, 0.6 to 1.0 cm..............................3 Excision – Debridement 11422 Excision, benign lesion, 1.1 to 2.0 cm..............................3 11000 Debridement of extensive eczematous 11423 Excision, benign lesion, 2.1 to 3.0 cm..............................3 or infected skin ...........................................................3 11424 Excision, benign lesion, 3.1 to 4.0 cm..............................3 11001 Debridement of extensive eczematous 11426 Excision, benign lesion, over 4.0 cm................................3 or infected skin; each additional 10% of the body 11440 Excision, benign lesion, 0.5 cm or less............................3 surface (List separately in addition to code for 11441 Excision, benign lesion, 0.6 to 1.0 cm..............................3 primary procedure).....................................................3 11442 Excision, benign lesion, 1.1 to 2.0 cm..............................3 11443 Excision, benign lesion, 2.1 to 3.0 cm..............................3 Paring or Cutting 11444 Excision, benign lesion, 3.1 to 4.0 cm..............................3 11055 Paring or cutting of benign hyperkeratotic lesion 11446 Excision, benign lesion, over 4.0 cm................................3 (e.g., corn or callus); single lesion..............................3 11450 Excision, skin, hidradenitis, axillary, 11056 Paring or cutting of benign hyperkeratotic lesion primary suture.........................................................3, 5 (e.g., corn or callus); two to four lesions.....................3 11451 Excision, skin, hidradenitis, axillary, other ...................3, 5 11057 Paring or cutting of benign hyperkeratotic lesion 11462 Excision, skin, hidradenitis, inguinal, primary ..............3, 5 (e.g., corn or callus); four or more lesions..................3 11463 Excision, skin, hidradenitis, inguinal, other ..................3, 5 11470 Excision, skin, hidradenitis, perianal, Biopsy perineal, primary.....................................................3, 5 11100 Biopsy skin, subcutaneous tissue, 11471 Excision, skin, hidradenitis, perianal, mucous membrane.................................................3, 5 perineal, other.........................................................3, 5 11101 Biopsy skin, subcutaneous tissue, mucous membrane; each separate/additional lesion (List separately in addition to code for primary procedure) .............................................3, 4, 5 Benefit Restriction Descriptions: 1 Non-Benefit 3 Assistant Surgeon services not payable 2 Requires TAR, 4 Anesthesiology services not payable Primary Surgeon/Provider 5 Ambulatory Surgical 2 – TAR and Non-Benefit List: Codes 10000 – 19999 October 1999 tar and non cd1 2 Benefit Benefit Code Description Restrictions Code Description Restrictions Excision – Malignant Lesions Introduction (continued) 11600 Excision, malignant lesion, 0.5 cm or less ...................3, 5 11970 Replacement, tissue expander 11601 Excision, malignant lesion, 0.6 to 1.0 cm.....................3, 5 with permanent prosthesis..........................................2 11602 Excision, malignant lesion, 1.1 to 2.0 cm.....................3, 5 11971 Removal, tissue expander(s) 11603 Excision, malignant lesion, 2.1 to 3.0 cm.........................5 without prosthesis insertion ........................................2 11604 Excision, malignant lesion, 3.1 to 4.0 cm.........................5 11975 Insertion, implantable contraceptive capsules .........3, 4, 5 11606 Excision, malignant lesion, over 4.0 cm...........................5 11976 Removal without reinsertion, 11620 Excision, malignant lesion, 0.5 cm or less ..................3, 5 implantable contraceptive capsules....................3, 4, 5 11621 Excision, malignant lesion, 0.6 to 1.0 cm.....................3,
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