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CPT Codes RequiringPrior AuthorizationNOTE: To validate coverage by site of service, please reference the appropriate Appendices below. Services notdesignated as a covered service in the applicable Appendix, based on the location and type of service, are notreimbursable in accordance with the Ohio Administrative Code rules, unless prior authorization is obtained.Prior authorization is always required for non-covered or non-grouper surgical codes (codes not listed in theAppendices designated for the site of service).Site of ServicePhysician Services:AppendixAppendix DDOhio AdministrativeCode (OAC)5160-1-60Ambulatory Surgical Centers:Appendix DD(These codes are noted in the “Current ASC Group” column of theMedicaid Fee Schedule, Appendix DD. Please reference ASC FacilityPayment Rates for the ASC grouper assigned in Appendix DD.)5160-22-03Outpatient Hospital Surgical Services:Appendix C5160-2-21Outpatient Hospital Clinic Services:Appendix D5160-2-21Hospital Emergency Room Visits:Appendix E5160-2-21Outpatient Hospital Ancillary Services:Appendix F5160-2-21Outpatient Hospital Radiology Services:Appendix G5160-2-21Outpatient Hospital Laboratory Services:Appendix H5160-2-21Prior Authorization is NOT required for office-based surgical services performed in an office setting, except forthe following: Cosmetic, Plastic, and Reconstructive procedures Experimental/investigational procedures Services performed by Podiatrists Pain Management procedures Unlisted/Miscellaneous proceduresMHO-105945790OH101445790 OH Medicaid CPT Codes Requiring PA WEB.indd 110/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationAs of Oct. 1, 2014CodeDescription of Code11960Insert tissue expander(s)11970Replacement tissue expander w permanent prosthesis11971Remove tissue expander(s)11983Remove rein drug deliv implant device12001Repair superficial wound(s)12002Repair superficial wound(s)12004Repair superficial wound(s)12041Layer closure of wound(s)12042Layer closure of wound(s)13150Repair, complex eyelids; 1.0 cm14000Skin tissue rearrangement14001Skin tissue rearrangement14020Skin tissue rearrangement14021Skin tissue rearrangement14040Skin tissue rearrangement14041Skin tissue rearrangement14060Skin tissue rearrangement14061Skin tissue rearrangement14301Skin tissue rearrangement14302Skin tissue rearrange add-on14350Skin tissue rearrangement15002Wnd prep, ch/inf, trk/arm/lg15003Wnd prep, ch/inf addl 100 cm15004Wnd prep ch/inf, f/n/hf/g15005Wnd prep, f/n/hf/g, addl cm15050Skin pinch graft procedure15100Skin split graft procedure15101Skin split graft procedure15120Skin split graft procedure15121Skin split graft procedure15200Skin full graft procedure15201Skin full graft procedure15220Skin full graft procedure15221Skin full graft procedure15240Skin full graft procedure15241Skin full graft procedure15260Skin full graft procedureCommentsNon-covered effective 01/01/14MHO-105945790OH101445790 OH Medicaid CPT Codes Requiring PA WEB.indd 210/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code15261Skin full graft procedure15271Skin sub graft trnk/arm/leg15272Skin sub graft t/a/l add-on15273Skin sub grft t/arm/lg child15274Skn sub grft t/a/l child add15275Skin sub graft face/nk/hf/g15276Skin sub graft f/n/hf/g addl15277Skn sub grft f/n/hf/g child15278Skn sub grft f/n/hf/g ch add15570Form skin pedicle flap15572Form skin pedicle flap15574Form skin pedicle flap15576Form skin pedicle flap15600Skin graft procedure15610Skin graft procedure15620Skin graft procedure15630Skin graft procedure15650Transfer skin pedicle flap15731Forehead flap w/vasc pedicle15732Muscle-skin graft, head/neck15734Muscle-skin graft, trunk15736Muscle-skin graft, arm15738Muscle-skin graft, leg15740Island pedicle flap graft15750Neurovascular pedicle graft15756Free muscle flap15757Free skin flap15758Free fascial flap15760Composite skin graft15770Derma-fat-fascia graft15777Acellular derm matrix implt15786Abrasion treatment of lesion15787Abrasion, added skin lesions15821Blepharoplasty, lower eyelid; with extensive herniated fat pad15839Excise excessive skin tissue15840Graft for face nerve palsy15841Graft for face nerve palsy15842Graft for face nerve palsy15845Skin and muscle repair, face45790 OH Medicaid CPT Codes Requiring PA WEB.indd 3CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code15847Xc skin abd add-on15850Removal sutures w anesthesia, same surgeon15851Removal of sutures15920Removal of tail bone ulcer15922Removal of tail bone ulcer15931Remove sacrum pressure sore15933Remove sacrum pressure sore15934Remove sacrum pressure sore15935Remove sacrum pressure sore15936Remove sacrum pressure sore15937Remove sacrum pressure sore15940Removal of pressure sore15941Removal of pressure sore15944Removal of pressure sore15945Removal of pressure sore15946Removal of pressure sore15950Remove thigh pressure sore15951Remove thigh pressure sore15952Remove thigh pressure sore15953Remove thigh pressure sore15956Remove thigh pressure sore15958Remove thigh pressure sore15999Removal of pressure sore16020Treatment of burn(s)16025Treatment of burn(s)16030Treatment of burn(s)17004Destruction of benign lesions; 15 or more17106Destruction of skin lesions17107Destruction of skin lesions17108Destruction of skin lesions17110Destruction of skin lesions17111Destruction of skin lesions17250Chemical cautery, tissue17270Destruction of skin lesions17271Destruction of skin lesions17272Destruction of skin lesions17273Destruction of skin lesions17274Destruction of skin lesions17276Destruction of skin lesions45790 OH Medicaid CPT Codes Requiring PA WEB.indd 4CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of CodeComments17340Cryotherapy of skin17360Skin peel therapy17999Skin tissue procedure19081Bx breast 1st lesion strtctcPA not required effective 01/01/1419082Bx breast add lesion strtctcPA not required effective 01/01/1419083Bx breast 1st lesion us imagPA not required effective 01/01/1419084Bx breast add lesion us imagPA not required effective 01/01/1419085Bx breast 1st lesion mr imagPA not required effective 01/01/1419086Bx breast add lesion mr imagPA not required effective 01/01/1419102Biopsy of breast; percutaneous, needle core, imaging guidanceNon-covered effective 01/01/1419103Biopsy of breast; percutaneous, automated vacuum assist, imagingNon-covered effective 01/01/1419105Cryosurg ablate fa, each19260Removal of chest wall lesion19271Revision of chest wall19272Extensive chest wall surgery19281Perq device breast 1st imagPA not required effective 01/01/1419282Perq device breast ea imagPA not required effective 01/01/1419283Perq dev breast 1st strtctcPA not required effective 01/01/1419284Perq dev breast add strtctcPA not required effective 01/01/1419285Perq dev breast 1st us imagPA not required effective 01/01/1419286Perq dev breast add us imagPA not required effective 01/01/1419287Perq dev breast 1st mr guidePA not required effective 01/01/1419288Perq dev breast add mr guidePA not required effective 01/01/1419290Preop plcmt needle local wire,breastNon-covered effective 01/01/1419291Preop plcmt, ea addl lesionNon-covered effective 01/01/1419295Image guided placement, metallic localizn clip, during breastbiopsyNon-covered effective 01/01/1419296Place po breast cath for rad19300Removal of breast tissue19301Partical mastectomy19302P-mastectomy w/ln removal19303Mast, simple, complete19304Mast, subq19305Mast, radical19306Mast, rad, urban type19307Mast, mod rad19316Mastopexy19318Reduction of large breastMHO-105945790OH101445790 OH Medicaid CPT Codes Requiring PA WEB.indd 510/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code19328Removal of breast implant19330Removal of implant material19340Immediate breast prosthesis19342Delayed breast prosthesis19350Breast reconstruction19357Breast reconstruction19361Breast reconstruction19364Breast reconstruction19366Breast reconstruction19367Breast reconstruction19368Breast reconstruction19369Breast Reconstruction19370Surgery of breast capsule19371Removal of breast capsule19380Revision reconst breast19396Prep moulage;custom breast implant19499Breast surgery procedure20550Inj tendon/ligament/cyst20551Injection, tendon origin/insertion20552Trigger point injection, 1-2 muscle grps20553Trigger point injection, 3 muscle grps20555Place ndl musc/tis for rt20600Drain/inject joint/bursa20605Drain/inject joint/bursa20612Aspirate/inj ganglion cyst20615Treatment of bone cyst20696Comp multiplane ext fixation20697Comp ext fixate strut change20802Replantation, arm, complete20805Replant forearm, complete20808Replantation, hand, complete20816Replantation digit, complete20822Replantation digit, complete20824Replantation thumb, complete20827Replantation thumb, complete20838Replantation, foot, complete20900Removal of bone for graft20902Removal of bone for graft20910Remove cartilage for graft45790 OH Medicaid CPT Codes Requiring PA WEB.indd 6CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code20912Remove cartilage for graft20920Removal of fascia for graft20922Removal of fascia for graft20924Removal of tendon for graft20926Removal of tissue for graft20930Spinal bone allograft20931Spinal bone allograft20936Spinal bone autograft20937Spinal bone autograft20938Spinal bone autograft20950Record fluid pressure,muscle20955Microvascular fibula graft20956Microvascular bone graft, iliac crest20957Microvascular bone graft, metatarsal20962Microvascular bone graft20969Bone-skin graft20970Bone-skin graft, pelvis20972Bone-skin graft, metatarsal20973Bone-skin graft, great toe20974Electrical bone stimulation20975Electrical bone stimulation20976Electrical stimulation to aid bone healing;percutaneous20979Low intensity ultrasound stimulation20982Ablate, Bone Tumor(s) Perq20985Cptr-asst dir ms px20999Musculoskeletal surgery21010Incision of jaw joint21011Exc face les sc 2 cm21012Exc face les sc 2 cm21013Exc face tum deep 2 cm21014Exc face tum deep 2 cm21015Resect facial tumor 2 cm21016Resect face tum 2 cm21025Excision of bone, lower jaw21026Excision of facial bone(s)21029Contour of face bone lesion21030Removal of face bone lesion21031Remove exostosis, mandible21032Remove exostosis, maxilla45790 OH Medicaid CPT Codes Requiring PA WEB.indd 7CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code21034Removal of face bone lesion21040Removal of jaw bone lesion21044Removal of jaw bone lesion21045Extensive jaw surgery21046Remove mandible cyst complex21047Excise lwr jaw cyst w/repair21048Remove maxilla cyst complex21049Excis uppr jaw cyst w/repair21050Removal of jaw joint21060Remove jaw joint cartilage21070Remove coronoid process21076Surgical obturator prosthesis21077Orbital prosthesis21079Interim obturator prosthesis21080Definitive obturator prosthesis21081Mandibular resection prosthesis21082Palatal augmentation prosthesis21083Palatal left prosthesis21084Speech aid prosthesis21085Oral surgical splint21086Auricular prosthesis21087Nasal prosthesis21088Facial prosthesis21089Unlisted maxillofacial prosthesis21100Maxillofacial fixation21110Appl interdental fixation o.t. fx/dislocation21116Injection, jaw joint x-ray21120Reconstruction of chin21121Reconstruction of chin21122Reconstruction of chin21123Reconstruction of chin21125Augmentation lower jaw bone21127Augmentation lower jaw bone21137Reduction of forehead21138Reduction of forehead21139Reduction of forehead21141Reconstruct midface, LeFort21142Reconstruct midface, LeFort21143Reconstruct midface, LeFort45790 OH Medicaid CPT Codes Requiring PA WEB.indd 8CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code21145Reconstruct midface, lefort21146Reconstruct midface, lefort21147Reconstruct midface, lefort21150Reconstruct midface, lefort21151Reconstruct midface, lefort21154Reconstruct midface, lefort21155Reconstruct midface, lefort21159Reconstruct midface, lefort21160Reconstruct midface, lefort21172Reconstruct orbit/forehead21175Reconstruct orbit/forehead21179Reconstruct entire forehead21180Reconstruct entire forehead21181Contour cranial bone lesion21182Reconstruct cranial bone21183Reconstruct cranial bone21184Reconstruct cranial bone21188Reconstruction of midface21193Reconstruct lower jaw bone21194Reconstruct lower jaw bone21195Reconstruct lower jaw bone21196Reconstruct lower jaw bone21198Reconstruct lower jaw bone21199Reconstr lwr jaw w/advance21206Reconstruct upper jaw bone21208Augmentation of facial bones21209Reduction of facial bones21210Face bone graft21215Lower jaw bone graft21230Rib cartilage graft21235Ear cartilage graft21240Reconstruction of jaw joint21242Reconstruction of jaw joint21243Reconstruction of jaw joint21244Reconstruction of lower jaw21245Reconstruction of jaw21246Reconstruction of jaw21247Reconstruct lower jaw bone21248Reconstruction of jaw45790 OH Medicaid CPT Codes Requiring PA WEB.indd 9CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code21249Reconstruction of jaw21255Reconstruct lower jaw bone21256Reconstruction of orbit21260Revise eye sockets21261Revise eye sockets21263Revise eye sockets21267Revise eye sockets21268Revise eye sockets21270Augmentation cheek bone21275Revision orbitofacial bones21280Revision of eyelid21282Revision of eyelid21295Revision of jaw muscle/bone21296Revision of jaw muscle/bone21299Cranio/maxillofacial surgery21499Head surgery procedure21552Exc back less sc 3 cm21554Exc neck tum deep 5 cm21557Resect neck tum 5cm21558Resect neck tum 5 cm21600Partial removal of rib21610Partial removal of rib21615Removal of rib21616Removal of rib and nerves21620Partial removal of sternum21627Sternal debridement21630Extensive sternum surgery21632Extensive sternum surgery21685Hyoid Myotomy & Suspension21700Revision of neck muscle21705Revision of neck muscle/rib21720Revision of neck muscle21725Revision of neck muscle21740Reconstruction of sternum21742Repair stern/nuss w/o scope21743Repair sternum/nuss w/scope21899Neck/chest surgery procedure21931Exc back les sc 3 cmCommentsMHO-105945790OH101445790 OH Medicaid CPT Codes Requiring PA WEB.indd 1010/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code21932Exc back tum deep 5 cm21933Exc back tum deep 5 cm21935Resect back tum 5 cm21936Resect back tum 5 cm22100Remove part of neck vertebra22101Remove part, thorax vertebra22102Remove part, lumbar vertebra22103Remove extra spine segment22110Remove part of neck vertebra22112Remove part, thorax vertebra22114Remove part, lumbar vertebra22116Remove extra spine segment22206Cut spine 3 col, thor22207Cut spine 3 col, lumb22208Cut spine 3 col, addl seg22210Revision of neck spine22212Revision of thorax spine22214Revision of lumbar spine22216Revision of extra spine segment22220Revision of neck spine22222Revision of thorax spine22224Revision of lumbar spine22226Revision of extra spine segment22505Manipulation of spine22520Percut vertebroplasty thor22521Percut vertebroplasty lumb22522Percut vertebroplasty addl22523Percut kyphoplasty, thor22524Percut kyphoplasty, lumbar22525Percut kyphoplasty, add-on22526Idet, single level22527Idet, 1 or more levels22532Lat Thorax Spine Fusion22533Lat Lumbar Spine Fusion22534Lat Thor/Lumb, Addæl Seg22548Neck spine fusion22551Arthrd ant interbody decompr cervical below c222552Arthrd ant interdy cervcl belw c2 ea addl ntrspc22554Neck spine fusion45790 OH Medicaid CPT Codes Requiring PA WEB.indd 11CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code22556Thorax spine fusion22558Lumbar spine fusion22585Additional spinal fusion22586Prescrl fuse w/ instr l5/s122590Spine & skull spinal fusion22595Neck spinal fusion22600Neck spine fusion22610Thorax spine fusion22612Lumbar spine fusion22614Spine fusion, extra segment22630Lumbar spine fusion22632Spine fusion, extra segment22633Lumbar spine fusion combined22634Spine fusion extra segment22800Fusion of spine22802Fusion of spine22804Fusion of spine22808Fusion of spine22810Fusion of spine22812Fusion of n of spinal fusion22840Insert spine fixation device22841Insert spine fixation device22842Insert spine fixation device22843Insert spine fixation device22844Insert spine fixation device22845Insert spine fixation device22846Insert spine fixation device22847Insert spine fixation device22848Insert pelvic fixation device22849Reinsert spinal fixation22850Remove spine fixation device22851Apply prosthetic spine device22852Remove spine fixation device22855Remove spine fixation device22856Cerv artific diskectomy22861Revise cerv artific disc45790 OH Medicaid CPT Codes Requiring PA WEB.indd 12CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code22864Remove cerv artif disc22899Spine surgery procedure22900Exc Back Tumor Deep 5cm22901Exc back tum deep 5 cm22902Exc abd les sc 3 cm22903Exc abd les sc 3 cm22904Resect abd tum 5 cm22905Resect abd tum 5 cm22999Abdomen surgery procedure23020Release shoulder joint23035Drain shoulder bone lesion23040Exploratory shoulder surgery23044Exploratory shoulder surgery23071Exc shoulder les sc 3 cm23073Exc shoulder tum deep 5 cm23077Resect shoulder tumor 5 cm23078Resect shoulder tum 5 cm23100Biopsy of shoulder joint23101Shoulder joint surgery23105Remove shoulder joint lining23106Incision of collarbone joint23107Explore,treat shoulder joint23120Partial removal, collarbone23125Removal of collarbone23130Partial removal,shoulderbone23140Removal of bone lesion23145Removal of bone lesion23146Removal of bone lesion23150Removal of humerus lesion23155Removal of humerus lesion23156Removal of humerus lesion23170Remove collarbone lesion23172Remove shoulder blade lesion23174Remove humerus lesion23180Remove collarbone lesion23182Remove shoulderblade lesion23184Remove humerus lesion23190Partial removal of scapula23195Removal of head of humerus45790 OH Medicaid CPT Codes Requiring PA WEB.indd 13CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of CodeComments23200Resect clavicle tumor23210Resect scapula tumor23220Resect prox humerus tumor23331Removal of foreign body, shoulder; deepNon-covered effective 01/01/1423333Remove shoulder fb deepPA not required effective 01/01/1423334Shoulder prosthesis removal23335Shoulder prosthesis removal23350Injection for shoulder x-ray23395Muscle transfer,shoulder/arm23397Muscle transfers23400Fixation of shoulderblade23405Incision of tendon & muscle23406Incise tendon(s) & muscle(s)23410Repair of tendon(s)23412Repair of tendon(s)23415Release of shoulder ligament23420Repair of shoulder23430Repair biceps tendon rupture23440Removal/transplant tendon23450Repair shoulder capsule23455Repair shoulder capsule23460Repair shoulder capsule23462Repair shoulder capsule23465Repair shoulder capsule23466Repair shoulder capsule23470Reconstruct shoulder joint23472Reconstruct shoulder joint23473Revis reconst shoulder joint23474Revis reconst shoulder joint23480Revision of collarbone23485Revision of collarbone23490Reinforce clavicle23491Reinforce shoulder bones23800Fusion of shoulder joint23802Fusion of shoulder joint23900Amputation of arm & girdle23920Amputation at shoulder joint23921Amputation follow-up surgery23929Shoulder surgery procedure45790 OH Medicaid CPT Codes Requiring PA WEB.indd 14MHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code24000Exploratory elbow surgery24071Exc arm/elbow les sc 3 cm24073Ex arm/elbow tum deep 5 cm24079Resect arm/elbow tum 5 cm24100Biopsy elbow joint lining24101Explore/treat elbow joint24102Remove elbow joint lining24105Removal of elbow bursa24110Remove humerus lesion24115Remove/graft bone lesion24116Remove/graft bone lesion24120Remove elbow lesion24125Remove/graft bone lesion24126Remove/graft bone lesion24130Removal of head of radius24134Removal of arm bone lesion24136Remove radius bone lesion24138Remove elbow bone lesion24140Partial removal of arm bone24145Partial removal of radius24147Partial removal of elbow24149Radical resection, elbow24150Resect distal humerus tumor24152Resect radius tumor24155Removal of elbow joint24160Remove elbow joint implant24164Remove radius head implant24200Removal of arm foreign body24201Removal of arm foreign body24220Injection for elbow x-ray24300Manipulate elbow, under anesthesia24301Muscle/tendon transfer24305Arm tendon lengthening24310Revision of arm tendon24320Repair of arm tendon24330Revision of arm muscles24331Revision of arm muscles24332Tenolysis of triceps24340Repair of ruptured tendon24341Repair tendon/muscle, upper arm or elbow45790 OH Medicaid CPT Codes Requiring PA WEB.indd 15CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code24342Repair of ruptured tendon24343Repair, elbow ligament, w. local tissue24344Repair, elbow ligament, w tendon graft24345Repair, medial ligament, w local tissue24346Reconstruct elbow ligament24357Repair elbow, perc24358Repair elbow w/deb, open24359Repair elbow deb/attch open24360Reconstruct elbow joint24361Reconstruct elbow joint24362Reconstruct elbow joint24363Replace elbow joint24365Reconstruct head of radius24366Reconstruct head of radius24370Revise reconst elbow joint24371Revise reconst elbow joint24400Revision of humerus24410Revision of humerus24420Revision of humerus24430Repair of humerus24435Repair humerus with graft24470Revision of elbow joint24495Decompression of forearm24498Reinforce humerus24800Fusion of elbow joint24802Fusion/graft of elbow joint24900Amputation of upper arm24920Amputation of upper arm24925Amputation follow-up surgery24930Amputation follow-up surgery24931Amputate upper arm & implant24935Revision of amputation24940Revision of upper arm24999Upper arm/elbow surgery25000Incision of tendon sheath25001Incision flexor tendon sheath, wrist25020Decompression of forearm25023Decompression of forearm25024Decompress fasciotomy, forea/wrist,25025Decompress fasciotomy, forea/wrist, w debr45790 OH Medicaid CPT Codes Requiring PA WEB.indd 16CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code25028Drainage of forearm lesion25031Drainage of forearm bursa25035Treat forearm bone lesion25071Exc forearm les sc 3cm25073Exc forearm tum deep 3 cm25075Exc forearm les sc 3 cm25076Exc forearm tum deep 3 cm25077Resect forearm/wrist tum 3cm25078Resect forearm/wrist tum 3 cm25085Incision of wrist capsule25100Biopsy of wrist joint25101Explore/treat wrist joint25105Remove wrist joint lining25107Remove wrist joint cartilage25109Excise tendon forearm/wrist25110Remove wrist tendon lesion25115Remove wrist/forearm lesion25116Remove wrist/forearm lesion25118Excise wrist tendon sheath25119Partial removal of ulna25120Removal of forearm lesion25125Remove/graft forearm lesion25126Remove/graft forearm lesion25130Removal of wrist lesion25135Remove & graft wrist lesion25136Remove & graft wrist lesion25145Remove forearm bone lesion25150Partial removal of ulna25151Partial removal of radius25170Resect radius/ulnar tumor25210Removal of wrist bone25215Removal of wrist bones25230Partial removal of radius25240Partial removal of ulna25246Injection for wrist x-ray25248Remove forearm foreign body25250Removal of wrist prosthesis25251Removal of wrist prosthesis25260Repair forearm tendon/muscleCommentsMHO-105945790OH101445790 OH Medicaid CPT Codes Requiring PA WEB.indd 1710/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code25263Repair forearm tendon/muscle25265Repair forearm tendon/muscle25270Repair forearm tendon/muscle25272Repair forearm tendon/muscle25274Repair forearm tendon/muscle25275Repair tendon sheath, forearm/wrist25280Revise wrist/forearm tendon25290Incise wrist/forearm tendon25295Release wrist/forearm tendon25300Fusion of tendons at wrist25301Fusion of tendons at wrist25310Transplant forearm tendon25312Transplant forearm tendon25315Revise palsy hand tendon(s)25316Revise palsy hand tendon(s)25320Repair/revise wrist joint25332Revise wrist joint25335Realignment of hand25337Reconstruct ulna/radioulnar25350Revision of radius25355Revision of radius25360Revision of ulna25365Revise radius & ulna25370Revise radius or ulna25375Revise radius & ulna25390Shorten radius/ulna25391Lengthen radius/ulna25392Shorten radius & ulna25393Lengthen radius & ulna25394Osteoplasty of carpal bone25400Repair radius or ulna25405Repair/graft radius or ulna25415Repair radius & ulna25420Repair/graft radius & ulna25425Repair/graft radius or ulna25426Repair/graft radius & ulna25430Vascular pedicle graft for carpal bone25431Repair nonunion carpal bone25440Repair/graft wrist bone25441Reconstruct wrist joint45790 OH Medicaid CPT Codes Requiring PA WEB.indd 18CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code25442Reconstruct wrist joint25443Reconstruct wrist joint25444Reconstruct wrist joint25445Reconstruct wrist joint25446Wrist replacement25447Repair wrist joint(s)25449Remove wrist joint implant25450Revision of wrist joint25455Revision of wrist joint25490Reinforce radius25491Reinforce ulna25492Reinforce radius and ulna25800Fusion of wrist joint25805Fusion/graft of wrist joint25810Fusion/graft of wrist joint25820Fusion of hand bones25825Fusion hand bones with graft25830Fusion radioulnar joint/ulna25900Amputation of forearm25905Amputation of forearm25907Amputation follow-up surgery25909Amputation follow-up surgery25915Amputation of forearm25920Amputate hand at wrist25922Amputate hand at wrist25924Amputation follow-up surgery25927Amputation of hand25929Amputation follow-up surgery25931Amputation follow-up surgery25999Forearm or wrist surgery26040Release palm contracture26045Release palm contracture26055Incise finger tendon sheath26060Incision of finger tendon26100Biopsy hand joint lining26105Biopsy finger joint lining26110Biopsy finger joint lining26111Exc hand les sc 1.5 cmCommentsMHO-105945790OH101445790 OH Medicaid CPT Codes Requiring PA WEB.indd 1910/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code26113Exc hand tum deep 5 cm26115Exc hand les sc 1.5 cm26116Exc hand tum deep 1.5 cm26117Exc hand tum ra 3 cm26118Exc hand tum ra 3cm26121Release palm contracture26123Release palm contracture26125Release palm contracture26130Remove wrist joint lining26135Revise finger joint, each26140Revise finger joint, each26145Tendon excision, palm/finger26170Removal of palm tendon, each26180Removal of finger tendon26185Sesamoidectomy, thumb or finger26200Remove hand bone lesion26205Remove/graft bone lesion26210Removal of finger lesion26215Remove/graft finger lesion26230Partial removal of hand bone26235Partial removal, finger bone26236Partial removal, finger bone26250Extensive hand surgery26260Resect prox finger tumor26262Resect distal finger tumor26341Manipulat palm (Dupuytren) cord post inj26350Repair finger/hand tendon26352Repair/graft hand tendon26356Repair finger/hand tendon26357Repair finger/hand tendon26358Repair/graft hand tendon26370Repair finger/hand tendon26372Repair/graft hand tendon26373Repair finger/hand tendon26390Revise hand/finger tendon26392Repair/graft hand tendon26410Repair hand tendon26412Repair/graft hand tendon26415Excision, hand/finger tendon45790 OH Medicaid CPT Codes Requiring PA WEB.indd 20CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code26416Graft hand or finger tendon26418Repair finger tendon26420Repair/graft finger tendon26426Repair finger/hand tendon26428Repair/graft finger tendon26432Repair finger tendon26433Repair finger tendon26434Repair/graft finger tendon26437Realignment of tendons26440Release palm/finger tendon26442Release palm & finger tendon26445Release hand/finger tendon26449Release forearm/hand tendon26450Incision of palm tendon26455Incision of finger tendon26460Incise hand/finger tendon26471Fusion of finger tendons26474Fusion of finger tendons26476Tendon lengthening26477Tendon shortening26478Lengthening of hand tendon26479Shortening of hand tendon26480Transplant hand tendon26483Transplant/graft hand tendon26485Transplant palm tendon26489Transplant/graft palm tendon26490Revise thumb tendon26492Tendon transfer with graft26494Hand tendon/muscle transfer26496Revise thumb tendon26497Finger tendon transfer26498Finger tendon transfer26499Revision of finger26500Hand tendon reconstruction26502Hand tendon reconstruction26508Release thumb contracture26510Thumb tendon transfer26516Fusion of knuckle joint26517Fusion of knuckle joints45790 OH Medicaid CPT Codes Requiring PA WEB.indd 21CommentsMHO-105945790OH101410/9/14 2:44 PM
CPT Codes RequiringPrior AuthorizationCodeDescription of Code26518Fusion of knuckle joints26520Release knuckle contracture26525Release finger contracture26530Revise knuckle joint26531Revise knuckle with implant26535Revise finger joint26536Revise/implant finger joint26540Repair hand joint26541Repair hand joint with graft26542Repair hand joint with graft26545Reconstruct finger joint26546Repair non-union metacarpal or phalanx26548Reconstruct finger joint26550Construct thumb replacement26551Microvascular toe-to-hand transfer26553Microvascular toe-to-hand transfer26554Microvascular toe-to-hand transfer26555Positional change of finger26556Microvascular free toe joint transfer26560Repair of web finger26561Repair of web finger26562Repair of web finger26565Correct metacarpal flaw26567Correct finger deformity26568Lengthen metacarpal/finger26580Repair hand deformity26587Reconstruct extra finger26590Repair finger deformity26591Repair muscles of hand26593Release muscles of hand26596Excision constricting tissue26820Thumb fusion with graft26841Fusion of thumb26842Thumb fusion with graft26843Fusion of hand joint26844Fusion/graft o
20976 Electrical stimulation to aid bone healing;percutaneous 20979 Low intensity ultrasound stimulation 20982 Ablate, Bone Tumor(s) Perq 20985 Cptr-asst dir ms px 20999 Musculoskeletal surgery . 45790 OH Medicaid CPT Codes Requiring PA WEB.indd 8 10/9/14 2:44 PM. MHO10 40O1014 CPT Codes Requiring Prior Authorization Code Description of Code .
