Inpatient Procedures Requiring Precertification

CPT Codes Category Procedure/Description 15730 Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s) Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, 15733 Skin masseter,sternocleidomastoid, levator scapulae) 15830 Skin Excision. Excessive Skin and Subcutaneous Tissue (includes lipectomy); Abdomen, Infraumbilical Panniculectomy Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy), Abdomen (Eg, Abdominoplasty) (Includes Umbilical Transposition and 15847 Skin Fascial Plication) (List Separately In Addition To Code For Primary Procedure) 19300 Skin Mastectomy For Gynecomastia 19301 Skin Mastectomy, Partial (Eg, Lumpectomy, Tylectomy, Quadrantectomy, Segmentectomy); 19357 Skin Breast Reconstruction, Immediate or Delayed, With Tissue Expander, Including Subsequent Expansion 19361 Skin Breast Reconstruction With Latissimus Dorsi Flap, Without Prosthetic Implant (non-cosmetic) 19364 Skin Breast Reconstruction With Free Flap (non-cosmetic) Breast Reconstruction With Transverse Rectus Abdominis Myocutaneous Flap(Tram), Single Pedicle, Including Closure of Donor Site; (non- 19367 Skin cosmetic) Breast Reconstruction With Transverse Rectus Abdominis Myocutaneous Flap(Tram), Single Pedicle, Including Closure of Donor Site; With 19368 Skin Microvascular Anastomosis (Supercharging) (non-cosmetic) Breast Reconstruction With Transverse Rectus Abdominis Myocutaneous Flap(Tram), Double Pedicle, Including Closure of Donor Site (non- 19369 Skin cosmetic) 20975 Musculoskeletal Electrical Stimulation to Aid Healing; Invasive (Operative) 21120 Musculoskeletal Genioplasty; Augmentation (Autograft, Allograft, Prosthetic Material) 21121 Musculoskeletal Genioplasty; Sliding Osteotomy, Single Piece 21122 Musculoskeletal Genioplasty; Sliding Osteotomies, Two or more Osteotomies (EG, Wedge 1 Excision or Bone Wedge Reversal for Asymmetrical Chin 21123 Musculoskeletal Genioplasty; Sliding, Augmentation With Interpositional Bone Grafts (Includes Obtaining Autografts) 21141 Musculoskeletal Reconstruction Midface, Lefort I; Single Piece, Segment Movement in Any Direction (EG, for Long Face Syndrome), Without Bone 21142 Musculoskeletal Reconstruction Midface, Lefort I; Two Pieces, Segment Movement in Any Direction, Without Bone Graft 21143 Musculoskeletal Reconstruction Midface, Lefort I; Three or More Pieces, Segment Movement in Any Direction, Without Bone Graft 21145 Musculoskeletal Reconstruction Midface, Lefort I; Single Piece, Segment Movement in Any Direction, Requiring Bone Grafts (Includes Obtaining Autografts) Reconstruction Midface, Lefort I; Two Pieces, Segment Movement in Any Direction, Requiring Bone Grafts (Includes Obtaining Autografts) (EG, 21146 Musculoskeletal Ungrafted Unilateral Alveolar Cleft) Reconstruction Midface, Lefort I; Three or More Pieces, Segment Movement in Any Direction, Requiring Bone Grafts (Includes Obtaining 21147 Musculoskeletal Autografts) (EG, Ungrafted Bilateral Alveolar Cleft or Multiple Osteotomies) 21150 Musculoskeletal Reconstruction Midface, Lefort II; Anterior Intrusion (EG, Treacher-Collins Syndrome) 21151 Musculoskeletal Reconstruction Midface, Lefort II; Any Direction, Requiring Bone Grafts (Includes Obtaining Autografts) 21154 Musculoskeletal Reconstruction Midface, Lefort III (Extracranial), Any Type, Requiring Bone Grafts (Includes Obtaining Autografts); Without Lefort I 21155 Musculoskeletal Reconstruction Midface, Lefort III (Extracranial), Any Type, Requiring Bone Grafts (Includes Obtaining Autografts); With Lefort I Reconstruction Midface, Lefort III (Extra and Intracranial) With Forehead Advancement (EG, Mono Bloc), Requiring Bone Grafts (Includes Obtaining 21159 Musculoskeletal Autografts); Without Lefort I Reconstruction Midface, Lefort III (Extra and Intracranial) With Forehead Advancement (EG, Mono Bloc), Requiring Bone Grafts (Includes Obtaining 21160 Musculoskeletal Autografts); With Lefort I 21179 Musculoskeletal Reconstruction, Entire or Majority of Forehead and/or Supraorbital Rims; With Grafts (Allograft or Prosthetic Material) 21180 Musculoskeletal Reconstruction, Entire or Majority of Forehead and/or Supraorbital Rims; With Autograft (Includes Obtaining Grafts) Reconstruction of Orbital Walls, Rims, Forehead, Nasoethmoid Complex Following Intra and Extracranial Excision of Benign Tumor of Cranial Bone 21182 Musculoskeletal (EG, Fibrous Dysplasia), With Multiple Autografts (Includes Obtaining Grafts); Total Area of Less Than 40 CM2 Reconstruction of Orbital Walls, Rims, Forehead, Nasoethmoid Complex Following Intra and Extracranial Excision of Benign Tumor of Cranial Bone (EG, 21183 Musculoskeletal Fibrous Dysplasia), With Multiple Autografts (Includes Obtaining Grafts); Total Area of Bone Grafting Greater Than 40 CM2 But Less Than 80 CM2 Reconstruction of Orbital Walls, Rims, Forehead, Nasoethmoid Complex Following Intra and Extracranial Excision of Benign Tumor of Cranial Bone 21184 Musculoskeletal (EG, Fibrous Dysplasia), With Multiple Autografts (Includes Obtaining Grafts); Total Area of Bone Grafting Greater Than 80 CM2 21188 Musculoskeletal Reconstruction Midface, Osteotomies (Other Than Lefort Type) and Bone Grafts (Includes Obtaining Autografts) 21193 Musculoskeletal Reconstruction of Mandibular RAMI, Horizontal, Vertical, C, or L Osteotomy; Without Bone Graft 21194 Musculoskeletal Reconstruction of Mandibular RAMI, Horizontal, Vertical, C, or L Osteotomy; With Bone Graft (Includes Obtaining Graft) 21195 Musculoskeletal Reconstruction of Mandibular RAMI and/or Body, Sagittal Split; Without Internal Rigid Fixation 21196 Musculoskeletal Reconstruction of Mandibular RAMI and/or Body, Sagittal Split; With Internal Rigid Fixation 21198 Musculoskeletal Osteotomy, Mandible, Segmental

PRV20366-1907 CPT Codes Category Procedure/Description 21199 Musculoskeletal Osteotomy, Mandible, Segmental; With Genioglossus Advancement 21206 Musculoskeletal Osteotomy, Maxilla, Segmental (EG, Wassmund or Schuchard) 21208 Musculoskeletal Osteoplasty, Facial ; Augmentation (Autograft, Allograft, or Prosthetic Implant) 21209 Musculoskeletal Osteoplasty, Facial Bones; Reduction 21240 Musculoskeletal Arthroplasty, Temporomandibular Joint, With or Without Autograft (Includes Obtaining Graft) 21242 Musculoskeletal Arthroplasty, Temporomandibular Joint, With Allograft 21243 Musculoskeletal Arthroplasty, Temporomandibular Joint, With Prosthetic Joint Replacement 21245 Musculoskeletal Reconstruction of Mandible or Maxilla, Subperiosteal Implant; Partial 21246 Musculoskeletal Reconstruction of Mandible or Maxilla, Subperiosteal Implant; Complete 21247 Musculoskeletal Reconstruction of Mandibular Condyle With Bone and Cartilage Autografts (Includes Obtaining Grafts) (EG, for Hemifacial Microsomia) 21248 Musculoskeletal Reconstruction of Mandible or Maxilla, Endosteal Implant (EG, Blade, Cylinder); Partial 21249 Musculoskeletal Reconstruction of Mandible or Maxilla, Endosteal Implant (EG, Blade, Cylinder); Complete 21268 Musculoskeletal Orbital Repositioning, Periorbital Osteotomies, Unilateral, With Bone Grafts; Combined Intra- and Extracranial Approach , pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, 22586 Musculoskeletal includes bone graft when performed, L5-S1 interspace 22861 Musculoskeletal Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Cervical 22862 Musculoskeletal Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Lumbar 22865 Musculoskeletal Removal of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Single Interspace; Lumbar 30120 ENT Excision or Surgical Planing of Skin of Nose for Rhinophyma 30400 ENT Rhinoplasty, Primary; Lateral and ALAR Cartilages and/or Elevation of Nasal Tip 30410 ENT Rhinoplasty, Primary; Complete, External Parts Including Bony Pyramid, Lateral and ALAR Cartilages, and/or Elevation of Nasal Tip 30420 ENT Rhinoplasty, Primary; Including Major Septal Repair 30430 ENT Rhinoplasty, Secondary; Minor Revision (Small Amount of Nasal Tip Work) 30435 ENT Rhinoplasty, Secondary; Intermediate Revision (Bony Work With Osteotomies) 30450 ENT Rhinoplasty, Secondary; Major Revision (Nasal Tip Work and Osteotomies) 30460 ENT Rhinoplasty for Nasal Deformity Secondary to Congenital Cleft Lip and/or Palate, Including Columellar Lengthening; Tip Only 30462 ENT Rhinoplasty for Nasal Deformity Secondary to Congenital Cleft Lip and/or Palate, Including Columellar Lengthening; Tip, Septum, Osteotomies Removal of Lung, Other Than Total Pneumonectomy; Excision-Plication of Emphysematous Lung(s) (Bullous or Non-Bullous) for Lung Volume 32491 Respiratory Reduction, Sternal Split or Transthoracic Approach, With or Without Any Pleural Procedure 32850 Respiratory Donor Pneumonectomy(s) (Including Cold Preservation), From Cadaver Donor 32851 Respiratory Lung Transplant, Single; Without Cardiopulmonary Bypass 32852 Respiratory Lung Transplant, Single; With Cardiopulmonary Bypass 32853 Respiratory Lung Transplant, Double (Bilateral Sequential Or En Bloc); Without Cardiopulmonary Bypass 32854 Respiratory Lung Transplant, Double (Bilateral Sequential or En Bloc); With Cardiopulmonary Bypass Backbench Standard Preparation of Cadaver Donor Lung Allograft Prior To Transplantation, Including Dissection of Allograft From Surrounding 32855 Respiratory Soft Tissues To Prepare Pulmonary Venous/Atrial Cuff, Pulmonary Artery, and Bronchus; Unilateral Backbench Standard Preparation of Cadaver Donor Lung Allograft Prior To Transplantation, Including Dissection of Allograft From Surrounding 32856 Respiratory Soft Tissues To Prepare Pulmonary Venous/Atrial Cuff, Pulmonary Artery, and Bronchus; Bilateral 33140 Cardiovascular Transmyocardial Laser Revascularization, By Thoracotomy (Separate Procedure) Transmyocardial Laser Revascularization, By Thoracotomy; Performed at the Time of Other Open Cardiac Procedure(s) (List Separately in Addition 33141 Cardiovascular to Code for Primary Procedure) 33206 Cardiovascular Insertion or Replacement of Permanent Pacemaker With Transvenous Electrode(s); Atrial 33207 Cardiovascular Insertion or Replacement of Permanent Pacemaker With Transvenous Electrode(s); Ventricular 33208 Cardiovascular Insertion or Replacement of Permanent Pacemaker With Transvenous Electrode(s); Atrial and Ventricular 33230 Cardiovascular Pacing cardioverter-defibrillator pulse generator Insertion only; w/ existing dual leads 33231 Cardiovascular Pacing cardioverter-defibrillator pulse generator Insertion only; w/ existing multiple leads 33240 Cardiovascular Insertion of Single or Dual Chamber Pacing Cardioverter-Defibrillator Pulse Generator 33243 Cardiovascular Removal of Single or Dual Chamber Pacing Cardioverter-Defibrillator Electrode(s); By Thoracotomy 33244 Cardiovascular Removal of Single or Dual Chamber Pacing Cardioverter-Defibrillator Electrode(s); By Transvenous Extraction 33249 Cardiovascular Insertion or Repositioning of Electrode Lead(s) for Single or Dual Chamber Pacing Cardioverter-Defibrillator and Insertion of Pulse Generator Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation 33270 Cardiovascular threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed 33271 Cardiovascular Insertion of subcutaneous implantable defibrillator electrode 33272 Cardiovascular Removal of subcutaneous implantable defibrillator electrode CPT Codes Category Procedure/Description 33273 Cardiovascular Repositioning of previously implanted subcutaneous implantable defibrillator electrode Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter 33340 Cardiovascular placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation 33361 Cardiovascular Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach 33362 Cardiovascular Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach 33363 Cardiovascular Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach 33364 Cardiovascular Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery approach 33365 Cardiovascular Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; 33366 Cardiovascular Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure (eg, left thoracotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial 33367 Cardiovascular and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and 33368 Cardiovascular venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous 33369 Cardiovascular cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) 33418 Cardiovascular Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same 33419 Cardiovascular session (List separately in addition to code for primary procedure) Surgical Ventricular Restoration Procedure, Includes Prosthetic Patch, When Performed (Eg, Ventricular Remodeling, SVR, SAVER, Dor 33548 Cardiovascular Procedures) Endovascular Repair of Descending Thoracic Aorta (Eg, Aneurysm, Pseudoaneurysm, Dissection, Penetrating Ulcer, Intramural Hematoma, Or 33880 Cardiovascular Traumatic Disruption); Involving Coverage of Left Subclavian Artery Origin, Initial Endoprosthesis Plus Descending Thoracic Aortic Extension(s), If Required, To Level of Celiac Artery Origin Endovascular Repair of Descending Thoracic Aorta (Eg, Aneurysm, Pseudoaneurysm, Dissection, Penetrating Ulcer, Intramural Hematoma, 33881 Cardiovascular Or Traumatic Disruption); Not Involving Coverage of Left Subclavian Artery Origin, Initial Endoprosthesis Plus Descending Thoracic Aortic Extension(s), If Required, To Level of Celiac Artery Origin Placement of Proximal Extension Prosthesis For Endovascular Repair of Descending Thoracic Aorta (Eg, Aneurysm, Pseudoaneurysm, Dissection, 33883 Cardiovascular Penetrating Ulcer, Intramural Hematoma, Or Traumatic Disruption); Initial Extension Placement of Proximal Extension Prosthesis For Endovascular Repair of Descending Thoracic Aorta (Eg, Aneurysm, Pseudoaneurysm, Dissection, 33884 Cardiovascular Penetrating Ulcer, Intramural Hematoma, Or Traumatic Disruption); Each Additional Proximal Extension (List Separately In Addition To Code For Primary Procedure) 33886 Cardiovascular Placement of Distal Extension Prosthesis(s) Delayed After Endovascular Repair Of Descending Thoracic Aorta Open Subclavian To Carotid Artery Transposition Performed In Conjunction With Endovascular Repair of Descending Thoracic Aorta, By Neck 33889 Cardiovascular Incision, Unilateral Bypass Graft, With Other Than Vein, Transcervical Retropharyngeal Carotid- Carotid, Performed In Conjunction With Endovascular Repair of 33891 Cardiovascular Descending Thoracic Aorta, By Neck Incision 33915 Cardiovascular Pulmonary Artery Embolectomy; Without Cardiopulmonary Bypass 33927 Cardiovascular Implantation of artificial heart 33928 Cardiovascular Replacement of artificial heart 33929 Cardiovascular Removal of artificial heart (List separately in addition to code for primary procedure) 33930 Cardiovascular Donor Cardiectomy-Pneumonectomy (Including Cold Preservation) Backbench Standard Preparation of Cadaver Donor Heart/Lung Allograft Prior To Transplantation, Including Dissection of Allograft From 33933 Cardiovascular Surrounding Soft Tissues To Prepare Aorta, Superior Vena Cava, Inferior Vena Cava, and Trachea For Implantation 33935 Cardiovascular Heart-Lung Transplant With Recipient Cardiectomy-Pneumonectomy 33940 Cardiovascular Donor Cardiectomy (Including Cold Preservation) Backbench Standard Preparation of Cadaver Donor Heart Allograft Prior To Transplantation, Including Dissection of Allograft From Surrounding 33944 Cardiovascular Soft Tissues To Prepare Aorta, Superior Vena Cava, Inferior Vena Cava, Pulmonary Artery, and Left Atrium For Implantation 33945 Cardiovascular Heart Transplant, With or Without Recipient Cardiectomy 33975 Cardiovascular Insertion of Ventricular Assist Device; Extracorporeal, Single Ventricle 33976 Cardiovascular Insertion of Ventricular Assist Device; Extracorporeal, Biventricular 33977 Cardiovascular Removal of Ventricular Assist Device; Single Ventricle Support 33978 Cardiovascular Removal of Ventricular Assist Device; Biventricular Support 33979 Cardiovascular Insertion of Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle 33980 Cardiovascular Removal of ventricular assist device, implantable intracorporeal, single ventricle 33981 Cardiovascular Replacement of Extracorporeal Ventricular Assist Device, Single Or Biventricular, Pump(s), Single Or Each Pump 33982 Cardiovascular Replacement of Ventricular Assist Device Pump(s); Implantable Intracorporeal, Single Ventricle, Without Cardiopulmonary Bypass 33983 Cardiovascular Replacement of Ventricular Assist Device Pump(s); Implantable Intracorporeal, Single Ventricle, With Cardiopulmonary Bypass 33990 Cardiovascular Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, 33991 Cardiovascular with transseptal puncture CPT Codes Category Procedure/Description 33992 Cardiovascular Removal of percutaneous ventricular assist device at separate and distinct session from insertion 33993 Cardiovascular Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion Insertion of Arterial and Venous Cannula(s) for Isolated Extracorporeal Circulation and Regional Chemotherapy Perfusion to An Extremity, 36823 Cardiovascular With or Without Hyperthermia, With Removal of Cannula(s) and Repair of Arteriotomy and Venotomy Sites Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, 37215 Cardiovascular and radiological supervision and interpretation; with distal embolic protection Intravascular Stent(s) transcatheter placement, cervical carotid artery, open or percutaneous, including angioplasty, when performed; w/o distal 37216 Cardiovascular embolic protection Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, open 37217 Cardiovascular ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous 37218 Cardiovascular antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging 37241 Cardiovascular guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and 37242 Cardiovascular imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging 37243 Cardiovascular guidance necessary to complete the intervention; for tumors, ischemia, or infarction Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging 37244 Cardiovascular guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation 38240 Cardiovascular Transplantation of donor bone marrow or blood-derived stem cells 38241 Cardiovascular Transplantation of patient's bone marrow or blood-derived stem cells 41874 Gastrointestinal Alveoloplasty, each quadrant (specify) 43644 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass and Roux-En-Y Gastroenterostomy (Roux Limb 150 cm Or Less) 43645 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass and Small Intestine Reconstruction To Limit Absorption Laparoscopy, Surgical, Gastric Restrictive Procedure; Placement of Adjustable Gastric Band (Gastric Band and Subcutaneous Port 43770 Gastrointestinal Components) 43771 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; Revision of Adjustable Gastric Band Component Only 43772 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; Removal of Adjustable Gastric Band Component Only 43773 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; Removal and Replacement Of Adjustable Gastric Band Component Only 43774 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; Removal of Adjustable Gastric Band and Subcutaneous Port Components 43775 Gastrointestinal Laparoscopy, Surgical, Gastric Restrictive Procedure; Longitudinal Gastrectomy (Ie, Sleeve Gastrectomy) 43842 Gastrointestinal Gastric Restrictive Procedure, Without Gastric Bypass, for Morbid Obesity; Vertical-Banded Gastroplasty 43843 Gastrointestinal Gastric Restrictive Procedure, Without Gastric Bypass, for Morbid Obesity; Other Than Vertical-Banded Gastroplasty Gastric Restrictive Procedure w/ partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy (50 to 100 cm common 43845 Gastrointestinal channel) to limit absorption (biliopancreatic diversion w/ duodenal switch- BPDDS) 43846 Gastrointestinal Gastric Restrictive Procedure, With Gastric Bypass For Morbid Obesity; With Short Limb (150 cm Or Less) Roux-En-Y Gastroenterostomy 43847 Gastrointestinal Gastric Restrictive Procedure, With Gastric Bypass For Morbid Obesity; With Small Intestine Reconstruction To Limit Absorption 43848 Gastrointestinal Revision, Open, of Gastric Restrictive Procedure For Morbid Obesity, Other Than Adjustable Gastric Band (Separate Procedure) Revision of Gastrojejunal Anastomosis (Gastrojejunostomy) With Reconstruction, With or Without Partial Gastrectomy or Bowel Resection; 43860 Gastrointestinal Without Vagotomy 44132 Gastrointestinal Donor Enterectomy (Including Cold Preservation), Open; From Cadaver Donor 44133 Gastrointestinal Donor Enterectomy (Including Cold Preservation), Open; Partial, From Living Donor 44135 Digestive Intestinal Allotransplantation; From Cadaver Donor 44136 Digestive Intestinal Allotransplantation; From Living Donor 44137 Digestive Removal of Transplanted Intestinal Allograft, Complete Backbench Standard Preparation of Cadaver Or Living Donor Intestine Allograft Prior To Transplantation, Including Mobilization and 44715 Digestive Fashioning of The Superior Mesenteric Artery and Vein 44720 Digestive Backbench Reconstruction of Cadaver Or Living Donor Intestine Allograft Prior To Transplantation; Venous Anastomosis, Each 44721 Digestive Backbench Reconstruction of Cadaver Or Living Donor Intestine Allograft Prior 47133 Digestive Donor Hepatectomy (Including Cold Preservation), From Cadaver Donor 47135 Digestive Allotransplantation; Orthotopic, Partial or Whole, From Cadaver or Living Donor, Any Age 47140 Digestive Donor Hepatectomy (Including Cold Preservation), From Living Donor; Left Lateral Segment Only (Segments II and III) 47141 Digestive Donor Hepatectomy (Including Cold Preservation), From Living Donor; Total Left Lobectomy (Segments II, III and Iv) 47142 Digestive Donor Hepatectomy (Including Cold Preservation), From Living Donor; Total Right Lobectomy (Segments V, Vi, Vii and Viii) CPT Codes Category Procedure/Description Backbench Standard Preparation of Cadaver Donor Whole Liver Graft Prior To Allotransplantation, Including Cholecystectomy, If Necessary, 47143 Digestive and Dissection and Removal of Surrounding Soft Tissues To Prepare The Vena Cava, Portal Vein, Hepatic Artery, and Common Bile Duct For Implantation; Without Trisegment Or Lobe Split Backbench Standard Preparation of Cadaver Donor Whole Liver Graft Prior To Allotransplantation, Including Cholecystectomy, If Necessary, and Dissection and Removal of Surrounding Soft Tissues To Prepare The Vena Cava, Portal Vein, Hepatic Artery, and Common Bile Duct 47144 Digestive For Implantation; With Trisegment Split of Whole Liver Graft Into 2 Partial Liver Grafts (Ie, Left Lateral Segment (Segments II and III) and Right Trisegment (Segments I and IV Through Viii) Backbench Standard Preparation of Cadaver Donor Whole Liver Graft Prior To Allotransplantation, Including Cholecystectomy, If Necessary, and Dissection and Removal of Surrounding Soft Tissues To Prepare The Vena Cava, Portal Vein, Hepatic Artery, and Common Bile Duct 47145 Digestive For Implantation; With Lobe Split of Whole Liver Graft Into 2 Partial Liver Grafts (Ie, Left Lobe (Segments II, III, and Iv) and Right Lobe (Segments I and V Through Viii) 47146 Digestive Backbench Reconstruction of Cadaver or Living Donor Liver Graft Prior to Allotransplantation; Venous Anastomosis, Each 47147 Digestive Backbench Reconstruction of Cadaver Or Living Donor Liver Graft Prior To Allotransplantation; Arterial Anastomosis, Each 47370 Digestive Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency 47380 Digestive Ablation, open, of 1 or more liver tumor(s); radiofrequency 47381 Digestive Ablation, open, of 1 or more liver tumor(s); cryosurgical 47382 Digestive Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency Backbench Standard Preparation of Cadaver Donor Pancreas Allograft Prior To Transplantation, Including Dissection of Allograft From 48551 Digestive Surrounding Soft Tissues, Splenectomy, Duodenotomy, Ligation of Bile Duct, Ligation of Mesenteric Vessels, and Y-Graft Arterial Anastomoses From Iliac Artery To Superior Mesenteric Artery and To Splenic Artery 48552 Digestive Backbench Reconstruction of Cadaver Donor Pancreas Allograft Prior To Transplantation, Venous Anastomosis, Each 48554 Digestive Transplantation of Pancreatic Allograft 48556 Digestive Removal of Transplanted Pancreatic Allograft Percutaneous Nephrostolithotomy or Pyelostolithotomy, With or Without Dilation, Endoscopy, Lithotripsy, Stenting or Basket Extraction; Up 50080 Urinary to 2 CM Percutaneous Nephrostolithotomy or Pyelostolithotomy, With or Without Dilation, Endoscopy, Lithotripsy, Stenting or Basket Extraction; 50081 Urinary Over 2 CM 50250 Urinary Ablation, Open, One Or More Renal Mass Lesion(s), Cryosurgical, Including Intraoperative Ultrasound, If Performed 50300 Urinary Donor Nephrectomy (Including Cold Preservation); From Cadaver Donor, Unilateral Or Bilateral 50320 Urinary Donor Nephrectomy (Including Cold Preservation); Open, From Living Donor 50542 Urinary Laparoscopy, Surgical; Ablation of Renal Mass Lesion(s) 50547 Urinary Laparoscopy, Surgical; Donor Nephrectomy (Including Cold Preservation), From Living Donor 50592 Urinary Ablation, One Or More Renal Tumor(s), Percutaneous, Unilateral, Radiofrequency 50593 Urinary Ablation, Renal Tumor(s), Unilateral, Percutaneous, Cryotherapy 55970 Genitourinary Change in sex surgery male to female 55980 Genitourinary Change in sex surgery female to male 56805 Genitourinary Clitoroplasty for Intersex State 57335 Genitourinary Vaginoplasty for Intersex State Ligation or Transection of Fallopian Tube(s), Abdominal or Vaginal Approach, Postpartum, Unilateral or Bilateral, During Same 58605 OB/GYN/GU Hospitalization (Separate Procedure) Ligation or Transection of Fallopian Tube(s) When Done at the Time of Cesarean Section or Intra-Abdominal Surgery (Not a Separate 58611 OB/GYN/GU Procedure) (List Separately in Addition to Code for Primary Procedure) Induced Abortion, By One or More Intra-Amniotic Injections (Amniocentesis- Injections), Including Hospital Admission and Visits, Delivery 59850 OB/GYN/GU of Fetus and Secundines); Induced Abortion, By One or More Intra-Amniotic Injections (Amniocentesis- Injections), Including Hospital Admission and Visits, Delivery 59851 OB/GYN/GU of Fetus and Secundines); With Dilation and Curettage and/or Evacuation Induced Abortion, By One or More Intra-Amniotic Injections (Amniocentesis- Injections), Including Hospital Admission and Visits, Delivery 59852 OB/GYN/GU of Fetus and Secundines); With Hysterotomy (Failed Intra-Amniotic Injection) Induced Abortion, By One or More Vaginal Suppositories (EG, Prostaglandin) With or Without Cervical Dilation (EG, Laminaria), Including 59855 OB/GYN/GU Hospital Admission and Visits, Delivery of Fetus and Secundines; Induced Abortion, By One or More Vaginal Suppositories (EG, Prostaglandin) With or Without Cervical Dilation (EG, Laminaria), Including 59856 OB/GYN/GU Hospital Admission and Visits, Delivery of Fetus and Secundines; With Dilation and Curettage and/or Evacuation Induced Abortion, By One or More Vaginal Suppositories (EG, Prostaglandin) With or Without Cervical Dilation (EG, Laminaria), Including 59857 OB/GYN/GU Hospital Admission and Visits, Delivery of Fetus and Secundines; With Hysterotomy (Failed Medical Evacuation) 60600 Endocrine Excision of Carotid Body Tumor; Without Excision of Carotid Artery 60605 Endocrine Excision of Carotid Body Tumor; With Excision of Carotid Artery Transcatheter Occlusion or Embolization (EG, for Tumor Destruction, to Achieve Hemostasis, to Occlude a Vascular Malformation), 61624 Nervous System Percutaneous, Any Method; Central Nervous System (Intracranial, Spinal Cord) Transcatheter Occlusion or Embolization (EG, for Tumor Destruction, to Achieve Hemostasis, to Occlude a Vascular Malformation), 61626 Nervous System Percutaneous, Any Method; Non-Central Nervous System, Head or Neck (Extracranial, Brachiocephalic Branch) 61630 Nervous System Balloon Angioplasty, Intracranial (Eg, Atherosclerotic Stenosis), Percutaneous CPT Codes Category Procedure/Description 61635 Nervous System Transcatheter Placement of Intravascular Stent(s), Intracranial (Eg, Atherosclerotic Stenosis), Including Balloon Angioplasty, If Performed Laminotomy (Hemilaminectomy), With Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of 63020 Nervous System Herniated Intervertebral Disk; One Interspace, Cervical Laminotomy (Hemilaminectomy), With Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of 63035 Nervous System Herniated Intervertebral Disk; Each Additional Interspace, Cervical or Lumbar (List Separately in Addition to Code for Primary Procedure) Laminotomy (Hemilaminectomy), With Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of 63040 Nervous System Herniated Intervertebral Disk, Reexploration, Single Interspace; Cervical Laminotomy (Hemilaminectomy), With Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of 63043 Nervous System Herniated Intervertebral Disk, Reexploration, Single Interspace; Each Additional Cervical Interspace (List Separately in Addition to Code for Primary Procedure) Laminectomy, Facetectomy and Foraminotomy (Unilateral or Bilateral With Decompression of Spinal Cord, Cauda Equina and/or Nerve 63045 Nervous System Root(s), (EG, Spinal or Lateral Recess Stenosis)), Single Vertebral Segment; Cervical Laminectomy, Facetectomy and Foraminotomy (Unilateral or Bilateral With Decompression of Spinal Cord, Cauda Equina and/or Nerve 63048 Nervous System Root(s), (EG, Spinal or Lateral Recess Stenosis)), Single Vertebral Segment; Each Additional Segment, Cervical, Thoracic, or Lumbar (List Separately in Addition to Code for Primary Procedure) 63050 Nervous System , Cervical, With Decompression of The Spinal Cord, Two Or More Vertebral Segments; 63075 Nervous System Diskectomy, Anterior, With Decompression of Spinal Cord and/or Nerve Root(s), Including Osteophytectomy; Cervical, Single Interspace Diskectomy, Anterior, With Decompression of Spinal Cord and/or Nerve Root(s), Including Osteophytectomy; Cervical, Each Additional 63076 Nervous System Interspace (List Separately in Addition to Code for Primary Procedure) Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach w/ decompression of spinal cord and/or nerve 63081 Nervous System root(s); cervical, single segment Vertebral Corpectomy (Vertebral Body Resection), Partial or Complete, Anterior Approach With Decompression of Spinal Cord and/or Nerve 63082 Nervous System Root(s); Cervical, Each Additional Segment (List Separately in Addition to Code for Primary Procedure) 63185 Nervous System Laminectomy With Rhizotomy; One or Two Segments 63190 Nervous System Laminectomy With Rhizotomy; More Than Two Segments 64568 Nervous System Incision For Implantation of Cranial Nerve (Eg, Vagus Nerve) Neurostimulator Electrode Array and Pulse Generator Revision Or Replacement of Cranial Nerve (Eg, Vagus Nerve) Neurostimulator Electrode Array, Including Connection To Existing Pulse 64569 Nervous System Generator 64570 Nervous System Removal of Cranial Nerve (Eg, Vagus Nerve) Neurostimulator Electrode Array and Pulse Generator 64581 Nervous System Incision for Implantation of Neurostimulator Electrodes; Sacral Nerve (Transforaminal Placement) 64585 Nervous System Revision or Removal of Peripheral Neurostimulator Electrodes 64590 Nervous System Insertion Or Replacement of Peripheral Neurostimulator Pulse Generator Or Receiver, Direct Or Inductive Coupling 64595 Nervous System Revision or Removal of Peripheral Neurostimulator Pulse Generator or Receiver 64802 Nervous System Sympathectomy, Cervical 64804 Nervous System Sympathectomy, Cervicothoracic 69300 Nervous System Otoplasty, Protruding Ear, With or Without Size Reduction 75894 Vascular Transcatheter Therapy, Embolization, Any Method, Radiological Supervision and Interpretation Aorta Repair - Descending Thoracic Endovascular(eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, 75956 Vascular or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin Aorta Repair - Descending Thoracic Endovascular(eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, 75957 Vascular or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin Aorta Repair - Descending Thoracic Endovascular Placement of proximal extension prosthesis (eg, aneurysm, pseudoaneurysm, 75958 Vascular dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) 75959 Vascular Aorta Repair - Descending Thoracic Endovascular Placement of distal extension prosthesis(s) (delayed) as needed, to level of celiac origin 92970 Cardiovascular Cardioassist-Method of Circulatory Assist; Internal 92971 Cardiovascular Cardioassist-Method of Circulatory Assist; External 92997 Cardiovascular PCI-Percutaneous Coronary Intervention: Thrombolysis, coronary by intravenous infusion 93580 Cardiovascular Percutaneous Transcatheter Closure of Congenital Interatrial Communication (IE, Fontan Fenestration, Atrial Septal Defect) With Implant 93581 Cardiovascular Percutaneous Transcatheter Closure of a Congenital Ventricular Septal Defect With Implant 93582 Cardiovascular Closure of congenital heart defect from pulmonary (lung) artery to aorta via catheter accessed through the skin The following procedural CPT codes do not have an assigned LOS and should not be entered in Jiva. Reference instructions at top of document. 01990 Physiological Support for Harvesting of Organ(s) From Brain-Dead Patient 0075T Insertion of stents into vertebral artery via catheter, open or accessed through the skin including radiologic supervision and interpretation Insertion of stents into vertebral artery via catheter, open or accessed through the skin including radiologic supervision and interpretation 0076T each additional vessel (List separately in addition to code for primary procedure) 0095T Removal of upper spine artificial disc Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Each Additional Interspace, Cervical (List 0098T Separately In Addition To Code For Primary Procedure) CPT Codes Category Procedure/Description Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Including Discectomy To Prepare Interspace (Other Than For Decompression), 0163T Each Additional Interspace, Lumbar (List Separately In Addition To Code For Primary Procedure) Removal of Total Disc Arthroplasty, (Artificial Disc), Anterior Approach, Each Additional Interspace, Lumbar (List Separately In Addition To 0164T Code For Primary Procedure) Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Each Additional Interspace, Lumbar (List 0165T Separately In Addition To Code For Primary Procedure) Posterior vertebral joint(s) arthroplasty (e.g., facet joint(s) replacement) including facetectomy, laminectomy, foraminotomy and vertebral 0202T column fixation, with or without injection of bone cement, including fluroscopy, single level, lumbar spine 0219T Placement of A Posterior Intrafacet Implant(s), Unilateral Or Bilateral, Including Placement of A Posterior Intrafacet Implant(s), Unilateral Or Bilateral, Including Imaging and Placement of Bone Graft(s) Or Synthetic 0220T Device(s), Single Level; Thoracic Catheter removal of plaque from organ artery, accessed through the skin or open procedure including radiological supervision and 0235T interpretation Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or 0266T bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) 0345T Transcatheter mitral valve repair percutaneous approach via the coronary sinus 0375T Insertion of artificial upper spine discs anterior approach 0451T Insertion or replacement of complete lower heart chamber assist system 0452T Insertion or replacement of lower heart chamber assist system part 0455T Removal of complete lower heart chamber assist system 0456T Removal of lower heart chamber assist system part 0459T Replacement of skin interface and electrodes of lower heart chamber assist system into new skin pocket 0461T Repositioning of lower heart chamber assist system part 0483T Insertion of artificial valve between left heart chambers, accessed through theskin 0484T Insertion of artificial valve between left heart chambers, open chest procedure 0494T Preparation and storage of donor lung 0495T Initiation and monitoring of circulation in donor lung 0496T Initiation and monitoring of circulation in donor lung Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or C9606 coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel G0341 Percutaneous Islet Cell Transplant, Includes Portal Vein Catheterization and Infusion G0342 Laparoscopy For Islet Cell Transplant, Includes Portal Vein Catheterization and Infusion G0343 Laparotomy For Islet Cell Transplant, Includes Portal Vein Catheterization and Infusion Follow-Up Inpatient Telehealth Consultation, Limited, Physicians Typically Spend 15 Minutes Communicating with the Patient via G0406 Telehealth Follow-Up Inpatient Telehealth Consultation, Intermediate, Physicians Typically Spend 25 Minutes Communicating with the Patient via G0407 Telehealth Follow-Up Inpatient Telehealth Consultation, Complex, Physicians Typically Spend 35 Minutes or More Communicating with the Patient via G0408 Telehealth Insertion Or Replacement of A Permanent Pacing Cardioverter-Defibrillator System With Transvenous Lead(s), Single Or Dual Chamber G0448 With Insertion of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal G0459 medical psychotherapy. Initiation of selective head or total body hypothermia in the critically ill neonate, includes appropriate patient selection by review of 99184 clinical, imaging and laboratory data, confirmation of esophageal temperature probe location, evaluation of amplitude EEG, supervision of controlled hypothermia, and assessment of patient tolerance of cooling Updated: July 15, 2019

Blue Cross and Blue Shield of Alabama is an independent licensee of the Blue Cross and Blue Shield Association. Blue Advantage (PPO) is a Medicare-approved PPO plan. Enrollment in Blue Advantage (PPO) depends on Centers for Medicare & Medicaid Services contract renewal.

PRV20366-1907