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MAP Non-Covered Services and Plan Limitations MAP NON-COVERED SERVICES EFF: 01/1/2021 (03/4/2021) CPT, HCPCS Description Comment or Revenue Code 0112 Room and Board Private (one bed) - OB 0114 Room and Board Private (one bed) - Psychiatric 0116 Room and Board Private (one bed) - Detoxification 0118 Room and Board Private (one bed) - Rehab 0120 Long term acute care 0122 Room and Board Semiprivate (two beds) - OB 0124 Room and Board Semiprivate (two beds) - Psychiatric 0126 Room and Board Semiprivate (two beds) - Detoxification 0128 Level 1 Rehab 0129 Level 2 Rehab - acute complex 0132 Room & Board - Three and Four Beds Obstetrics (OB) 0136 Room & Board - Three and Four Beds Psychiatric 0138 Room & Board - Three and Four Beds Rehabilitation 0142 Room & Board - Deluxe Private Obstetrics (OB) 0144 Room & Board - Deluxe Private Psychiatric 0146 Room & Board - Deluxe Private Detoxification 0148 Room & Board - Deluxe Private Rehabilitation 0152 Room & Board - Ward Obstetrics (OB) 0154 Room & Board - Ward Psychiatric 0156 Room & Board - Ward Detoxification 0158 Room & Board - Ward Rehabilitation 0170 Nursery General Classification 0171 Nursery Newborn - Level I 0172 Nursery Newborn - Level II 0173 Nursery Newborn - Level III 0174 Nursery Newborn - Level IV 0179 Nursery Other 0362 Transplant 0413 Hyperbaric Oxygen Therapy outpatient revenue code 551 Private Duty Nursing and Home Health 0660 General Classification 0661 Hourly Charge/Nursing 0662 Hourly Charge/Aide/Homemaker/Companion 0663 Daily Respite Charge 0664 Reserved 0665 Reserved 0666 Reserved 0667 Reserved 0668 Reserved 0669 Other Respite Care 0681 Level I - Trauma Response 0682 Level II - Trauma Response 0683 Level III - Trauma Response 0684 Level IV - Trauma Response 0685 Reserved 0686 Reserved 0687 Reserved 0688 Reserved 0689 Other Trauma Response 0810 General Classification - acquisition of body components 0811 Living Donor - acquisition of body components 0812 Cadaver Donor - acquisition of body components 0813 Unknown Donor - acquisition of body components 0814 Unsuccessful Organ Search - Donor Bank Charges - 0815 Stem Cell Acquisition-Allogenic - 0816 Reserved - acquisition of body components 0817 Reserved - acquisition of body components 0818 Reserved - acquisition of body components 0819 Other Donor - acquisition of body components 0911 Behavioral Health Rehab 0912 Behavioral Health Partial Hospitalization - less intensive 0913 Behavioral Health Partial Hospitalization - intensive 0930 Medical Rehabilitation Day Program 0931 Medical Rehabilitation Day Program 0932 Medical Rehabilitation Day Program 0933 Medical Rehabilitation Day Program 0934 Medical Rehabilitation Day Program 0935 Medical Rehabilitation Day Program 0936 Medical Rehabilitation Day Program 0937 Medical Rehabilitation Day Program 0938 Medical Rehabilitation Day Program 0939 Medical Rehabilitation Day Program 0940 Other Therapeutic Services - General 0951 Athletic training 0990 General Classification 0991 Cafeteria/Guest Tray 0992 Private Linen Service 0993 Telephone/Telecom 0994 TV/Radio 0995 Nonpatient Room Rentals 0996 Late Discharge 0997 Admission Kits 0998 Beauty Shop/Barber 0999 Other Convenience Items 1001 Residential treatment - psychiatric 1002 Residential treatment - chemical dependency 01841 Retinal prosthesis, includes all internal and external components 2100 Alternative Therapy Services 2101 Alternative Therapy Services 2102 Alternative Therapy Services 2103 Alternative Therapy Services 2104 Alternative Therapy Services 2105 Alternative Therapy Services 2106 Alternative Therapy Services 2107 Alternative Therapy Services 2108 Alternative Therapy Services 2109 Alternative Therapy Services 3100 Reserved 3101 Adult Day Care, Medical and Social - Hourly 3102 Adult Day Care, Social - Hourly 3103 Adult Day Care, Medical and Social - Daily 3104 Adult Day Care, Social - Daily 3105 Adult Foster Care - Daily 3106 Reserved 3107 Reserved 3108 Reserved 3109 Other Adult Care 10040 Acne surgery, marsupialization 11950 Subcutan inj filling matl 11951 Subcutan inj filling matl (e.g., collagen); 1.1 to 5.0 cc 11952 Subcutans inj filling matl (e.g., collagen); 5.1 to 10.0 cc 11954 Subcutan inj filling matl (e.g., collagen); over 10.0 cc 15769 Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) 15771 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate 15772 Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) 15773 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate 15774 Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure) 15775 Punch graft for hair transplant 15776 Punch graft for hair transplant; more than 15 punch grafts 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (e.g., tattoo removal) 15786 Abrasion; single lesion (e.g., keratosis, scar) 15787 Abrasion, each additional four lesions or less 15788 Chemical peel, facial, epidermal 15789 Chemical peel/facial/dermal 15792 Chemical peel nonfacial/epidermal 15793 Chemical peel/nonfacial/dermal 15819 Cervicoplasty 15820 Blepharoplasty – lower eyelid 15821 Blepharoplasty – lower eyelid 15822 Blepharoplasty – upper eyelid 15823 Blepharoplasty – upper eyelid 15824 Rhytidectomy; forehead 15825 Rhytidectomy; neck with platysmal tightening 15826 Rhytidectomy; glabellar frown lines 15828 Rhytidectomy; cheek, chin and neck 15829 Rhytidectomy; subcutaneous musculoaponeurotic system (SMAS) flap 15830 Panniculectomy 15837 Excision, excessive skin and subcut tissue; forearm, hand 15838 Excision, excess skin and subcut tissue; submental fat pad 15847 Abdominoplasty 15850 Removal of sutures under anesthesia (other than local), same surgeon 15876 Suction assisted lipectomy; head and neck 15877 Lipectomy – suction assisted, trunk when performed in conjunction with abdominoplasty/panniculectomy 17360 Chemical exfoliation for acne (e.g., acne paste, acid) 17380 Electrolysis epilation, each 1/2 hour 19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 19300 Mastectomy for gynecomastia 19316 Mastopexy 19318 Breast Reduction 19325 Breast, augmentation with implant 19364 Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) 19367 Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap 19368 Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) 19369 Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap 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) 19396 Preparation of moulage for custom breast implant 20552 Trigger point injections 20553 Trigger point injections 20700 Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) 20702 Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in addition to code for primary procedure) 20704 Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure) 20930 Allograft for spine surgery only; morselized 20936 Allograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar frag- ments) obtained from same incision 20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures; image-less (list separately in addition to code for primary procedure) 21050 Condylectomy, temporomandibular joint (separate procedure) 21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) 21076 Oral Maxillofacial Prosthesis 21077 Oral Maxillofacial Prosthesis 21079 Oral Maxillofacial Prosthesis 21080 Oral Maxillofacial Prosthesis 21081 Oral Maxillofacial Prosthesis 21082 Oral Maxillofacial Prosthesis 21083 Oral Maxillofacial Prosthesis 21084 Oral Maxillofacial Prosthesis 21085 Oral Maxillofacial Prosthesis 21086 Oral Maxillofacial Prosthesis 21087 Oral Maxillofacial Prosthesis 21088 Oral Maxillofacial Prosthesis 21089 Unlisted maxillofacial prosthetic procedure 21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal 21120 Genioplasty; augmentation (autogrft, allogrft, prosthetic material) 21121 Genioplasty; sliding osteotomy, single piece 21122 Genioplasty; sliding ostetomies, two or more 21123 Genioplasty; sliding, augmentatn w interposit bone grafts 21125 Augmentation, mandibular body or angle; prosthetic material 21127
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