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UnitedHealthcare Community PlanNetwork Bulletin AppendixOUTPATIENT SURGICAL PROCEDURES – SITE OF SERVICE:CPT/HCPCS CODESEffective Date: June 1, 2020This list of codes applies to the policy titled Outpatient Surgical Procedures – Site of Service.SITE OF SERVICE REVIEWWe’re expanding our notification/prior authorization requirements to include the procedure codes below in thefollowing states. We’ll only require notification/prior authorization if these procedure codes will be performed in anoutpatient hospital setting.Effective Date11/01/2019StateMaryland, Rhode Island, Washington01/01/2020Michigan, Missouri, Ohio03/01/2020Arizona, New PennsylvaniaRefer to the policy titled Outpatient Surgical Procedures – Site of Service.CPT/HCPCS Code10121Codes Subject to Site of Service ReviewDescriptionIncision & removal foreign body subq tiss compl11440Exc b9 lesion mrgn xcp sk tg f/e/e/n/l/m 0.5cm/ 11450Excision hidradenitis axillary smpl/intrm rpr11624Excision malignant lesion s/n/h/f/g 3.1 - 4.0 cm11770Excision pilonidal cyst/sinus simple13101Repair of wound or lesion13121Repair complex scalp/arm/leg 2.6 - 7.5 cm13132Repair of wound or lesion14040Skin tissue rearrangement14060Skin tissue rearrangement14301Skin tissue rearrangement15100Split agrft t/a/l 1st 100 cm/&/1% bdy inft/chld15120Split agrft f/s/n/h/f/g/m/d gt 1st 100 cm/ /1 %15240Fth/gft fr w/dir clsr f/c/c/m/n/ax/g/h/f 20 cm/ 19020Mastotomy w/exploration/drainage abscess deep19120Exc cyst/aberrant breast tissue open 1/ lesion19125Exc breast les preop plmt rad marker open 1 les20552Injection single/mlt trigger point 1/2 muscles20553Injection single/mlt trigger point 3/ muscles20680Removal of support implant21012Excision tumor soft tiss face/scalp subq 2 cm/ 21013Exc tumor soft tiss face&scalp subfascial 2cmOutpatient Surgical Procedures – Site of Service: CPT/HCPCS CodesPage 1 of 6UnitedHealthcare Community Plan Network Bulletin AppendixEffective 06/01/2020Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.
CPT/HCPCS Code21320Codes Subject to Site of Service ReviewDescriptionTreatment of nose fracture21336Open tx nasal septal fracture w/wo stabilization21552Exc neck les sc 3 cm21554Exc tumor soft tissue neck/thorax subfasc 5 cm/ 21555Exc tumor soft tissue neck/ant thorax subq 3cm21556Exc tumor soft tiss neck/thorax subfascial 5cm21930Excision tumor soft tissue back/flank subq 3cm21931Exc back les sc 3 cm22514Perq vert agmntj cavity crtj uni/bi cannulj lmbr22902Exc tumor soft tissue abdominal wall subq 3cm22903Exc tumor soft tissue abdominal wall subq 3 cm/ 23071Excision tumor soft tissue shoulder subq 3 cm/ 23075Excision tumor soft tissue shoulder subq 3cm24071Exc tumor soft tissue upper arm/elbow subq 3cm/ 27327Excision tumor soft tissue thigh/knee subq 3cm27337Excison tumor soft tissue thigh/knee subq 3 cm/ 27632Excision tumor soft tissue leg/ankle subq 3 cm/ 28035Release tarsal tunnel28039Excision tumor soft tis foot/toe subq 1.5 cm/ 28041Exc tumor soft tissue foot/toe subfasc 1.5 cm/ 28060Fasciectomy plantar fascia partial spx28080Excision interdigital morton neuroma single each28090Exc lesion tendon sheath/capsule w/synvct foot28104Exc/curtg bone cyst/b9 tumortarsal/metatarsal28110Ostectomy prtl 5th metar head spx28118Ostectomy calcaneus28119Ostectomy calcaneus spur w/wo plntar fascial rls28124Partical excision bone phalanx toe28285Correction hammertoe28289Hallux rigidus correct w/cheilectomy 1st mp jt28292Keller/mcbride/mayo procedure28296Corrj hallux valgus w/wo sesmdc w/metar osteot28297Corrj hallux valgus w/wo sesmdc lapidus - typ px28298Corrj hallux valgus w/wo sesmdc phalanx osteot28299Corrj hallux valgus w/wo sesmdc 2 osteot29806Arthroscopy shoulder surgical capsulorrhaphy29807Arthroscopy shoulder surgical repair slap lesion29819Arthroscopy shoulder surgical removal loose/fb29822Arthroscopy shoulder surg debridement limited29823Arthroscopy shoulder surg debridement extensive29824Arthroscopy shoulder distal claviculectomy29825Arthroscopy shoulder ahesiolysis w/wo manipj29826Arthroscopy shoulder w/coracoacrm ligmnt release29827Arthroscopy shoulder rotator cuff repair29828Arthroscopy shoulder biceps tenodesis29835Arthroscopy elbow surgical synovectomy partialOutpatient Surgical Procedures – Site of Service: CPT/HCPCS CodesPage 2 of 6UnitedHealthcare Community Plan Network Bulletin AppendixEffective 06/01/2020Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.
CPT/HCPCS Code29840Codes Subject to Site of Service ReviewDescriptionArthroscopy wrist diag w/wo synovial biopsy spx29845Arthroscopy wrist surgical synovectomy complete29846Arthrs wrst exc&/rpr triang fibrocart&/joint29848Ndsc wrst surg w/rls transvrs carpl ligm29861Arthroscopy hip surgical w/removal loose/fb29875Arthroscopy knee synovectomy limited spx29876Arthroscopy knee synovectomy 2/ compartments29877Arthrs knee debridement/shaving artclr crtlg29879Arthrs knee abrasion arthrp/mlt drlg/microfx29880Arthrs knee w/meniscectomy med&lat w/shaving29881Arthrs kne surg w/meniscectomy med/lat w/shvg29882Arthroscopy knee w/meniscus rpr medial/lateral29888Arthrs aided ant cruciate ligm rpr/agmntj/rcnstj29893Endoscopic plantar fasciotomy29916Arthroscopy hip w/labral repair30140Removal of turbinate bones30520Repair of nasal septum30802Abltj sof tiss inf turbs uni/bi supfc intramural30930Fracture nasal inferior turbinate therapeutic31240Nasal/sinus endoscopy, surg31254Revision of ethmoid sinus31255Removal of ethmoid sinus31256Exploration maxillary sinus31267Endoscopy, maxillary sinus31276Sinus endoscopy, surgical31287Nasal/sinus endoscopy, surg31288Nasal/sinus endoscopy, surg31525Laryngoscopy w/wo tracheoscopy dx except newborn31535Laryngoscopy direct operative w/biopsy31536Laryngoscopy w/biopsy microscope/telescope31541Largsc exc tum&/strpg cords/epigl mcrscp/tlscp31624Brnchsc w/brncl alveolar lavage36590Rmvl tun ctr vad w/subq port/pmp ctr/prph insj - av astula revision. Open38500Bx/exc lymph node open superficial38510Bx/exc lymph node open deep cervical node38525Bx/exc lymph node open deep axillary node42415Exc prtd tum/prtd glnd lat dsj&prsrv facial nr42440Excision submandibular submaxillary gland42820Remove tonsils and adenoids42821Remove tonsils and adenoids42825Removal of tonsils42826Removal of tonsils42830Removal of adenoids43200Esophagoscopy flexible transoral diagnostic43235Uppr gi endoscopy diagnosis43236Esophagogastroduodenoscopy submucosal injectionOutpatient Surgical Procedures – Site of Service: CPT/HCPCS CodesPage 3 of 6UnitedHealthcare Community Plan Network Bulletin AppendixEffective 06/01/2020Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.
CPT/HCPCS Code43237Codes Subject to Site of Service ReviewDescriptionEsophagogastroduodenoscopy us scope w/adj strxrs43238Egd intrmural us needle aspirate/biopsy esophags43239Upper gi endoscopy biopsy43242Egd intrmural needle aspir/biop altered anatomy43245Egd dilation gastric/duodenal stricture43246Egd percutaneous placement gastrostomy tube43247Egd flexible foreign body removal43248Egd insert guide wire dilator passage esophagus43249Esoph endoscopy, dilation43251Egd removal tumor polyp/other lesion snare tech43254Egd transoral endoscopic mucosal resection43255Egd transoral control bleeding any method43259Edg us exam surgical alter stom duodenum/jejunum44360Endoscopy upper small intestine44361Endoscopy upper small intestine w/biopsy45171Exc rct tum not incl muscularis propria45334Sigmoidoscopy flx control bleeding45335Sgmdsc flx dired sbmcsl njx any sbst45378Diagnostic colonoscopy45380Colonoscopy and biopsy45381Colsc flx with directed submucosal njx any sbst45384Lesion remove colonoscopy45385Lesion removal colonoscopy45390Colonoscopy flx w/endoscopic mucosal resection45990Anrct xm surg req anes general spi/edrl dx46020Placement seton46040I&d ischiorectal&/perirectal abscess spx46050I&d perianal abscess superficial46200Fissurectomy incl sphincterotomy when performed46220Excision single external papilla or tag anus46221Hemorrhoidectomy internal rubber band ligations46250Hemorrhoidectomy xtrnl 2/ column/group46255Hemorrhoidectomy ntrnl & xtrnl 1 column/group46261Hrhc ntrnl & xtrnl 2/ column/group w/fissu46270Surg tx anal fistula subq46275Surg tx anal fistula intersphincteric46288Clsr anal fstl w/rct advmnt flap46505Chemodenervation internal anal sphincter46750Sphnctrop anal incontinence/prolapse adult46910Dstrj lesion anus smpl eltrdsiccation46946Hrhc ntrnl lig oth than rbbr band 2/ col/grp47000Needle biopsy of liver49505Repair inguinal hernia49585Rpr umbil hern reduc 5 yr49587Rpr umbil hern block 5 yr49650Lap ing hernia repair initOutpatient Surgical Procedures – Site of Service: CPT/HCPCS CodesPage 4 of 6UnitedHealthcare Community Plan Network Bulletin AppendixEffective 06/01/2020Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.
CPT/HCPCS Code49651Codes Subject to Site of Service ReviewDescriptionLap ing hernia repair recur49652Lap vent/abd hernia repair49653Lap vent/abd hern proc comp49654Lap inc hernia repair49655Lap inc hern repair comp50590Fragmenting of kidney stone52000Cystoscopy52005Cystoscopy & ureter catheter52204Cystoscopy w/biopsy(s)52224Cystoscopy and treatment52234Cystoscopy and treatment52235Cystoscopy and treatment52260Cystoscopy and treatment52276Cystourethroscopy w/internal urethrotomy male52281Cystoscopy and treatment52287Cystourethroscopy inj chemodenervation bladder52310Cystoscopy and treatment52320Cystourethroscopy w/rmvl ureteral calculus52332Cystoscopy and treatment52344Cysto w/urtroscopy w/tx ureteral stricture52351Cystouretero & or pyeloscope52352Cystouretero w/stone remove52353Cystouretero w/lithotripsy52356Cysto/uretero w/lithotripsy &indwell stent insrt54161Circumcision54840Excision spermatocele w/wo epididymectomy55040Removal of hydrocele55700Biopsy of prostate57240Ant colporrhaphy cystocele w/wo rpr urethrocele57250Post colporrhaphy rectocele w/wo perineorrhaphy57288Repair bladder defect57461Colposcopy cervix vag eltrd conization cervix57520Conization cervix w/wo d&c rpr knife/laser57522Conization of cervix58353Endometr ablate thermal58558Hysteroscopy biopsy58561Hysteroscopy removal leiomyomata58562Hysteroscopy removal impacted foreign body58563Hysteroscopy ablation58565Hysteroscopy sterilization64561Prq impltj neurostim eltrd sacral nrve w/imaging64640Dstrj neurolytic agent other peripheral nerve64721Carpal tunnel surgery65426Removal of eye lesion65710Keratoplasty anterior lamellar65730Corneal transplantOutpatient Surgical Procedures – Site of Service: CPT/HCPCS CodesPage 5 of 6UnitedHealthcare Community Plan Network Bulletin AppendixEffective 06/01/2020Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.
CPT/HCPCS Code65820Codes Subject to Site of Service ReviewDescriptionGoniotomy65855Laser surgery of eye66170Glaucoma surgery66250Revj/rpr oprative wound anterior segment66710Ciliary body dstrj cyclophotocoag transsceral66711Ciliary body dstrj cyclophotocoag endoscopic66761Revision of iris66821After cataract laser surgery66825Repositioning IO lens prosthesis req inc spx66982Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stageprocedure), manual or mechanical technique, complex, requiring devices ortechniques not generally used in routine cataract surgery (e.g., iris expansion device,suture support for intraocular lens, or primary posterior capsulorrhexis) or performedon patients in the amblyogenic developmental stage; without endoscopiccyclophotocoagulation66984Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stageprocedure), manual or mechanical technique (e.g., irrigation and aspiration orphacoemulsification); without endoscopic cyclophotocoagulation66986Exchange intraocular lens66987Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stageprocedure), manual or mechanical technique, complex, requiring devices ortechniques not generally used in routine cataract surgery (e.g., iris expansion device,suture support for intraocular lens, or primary posterior capsulorrhexis) or performedon patients in the amblyogenic developmental stage; with endoscopiccyclophotocoagulation66988Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stageprocedure), manual or mechanical technique; with endoscopic cyclophotocoagulation67010Rmvl vitreous ant appr subtot rmvl mech vitrect67028Injection eye drug67036Removal of inner eye fluid67040Laser treatment of retina67041Vitrectomy pars plana remove preretinal membrane67042Vitrectomy pars plana remove int memb retina67105Rpr retinal dtchmnt 1/ ses pc incl subreti drg67108Rpr retinal dtchmnt w/vitrectomy any meth67113Rpr complex retina detach vitrect &membrane peel67228Treatment of retinal lesion67311Revise eye muscle67312Revise two eye muscles67840Exc lesion eyelid w/o clsr/w/simple dir closure68110Excision lesion conjunctiva /1 cm68115Excision lesion conjunctiva 1 cm68320Conjunctivoplasty w/grf/xtnsv rearrangement68720Dacryocstorhinostomy68815Probe nasolacrimal duct w/wo irrg insj tube/stnt69205Rmvl fb xtrnl auditory canal anes69436Create eardrum opening69631Repair eardrum structuresG0260Inj proc si jnt;anes steroid&/tx agt&arthrogrphCPT is a registered trademark of the American Medical AssociationOutpatient Surgical Procedures – Site of Service: CPT/HCPCS CodesPage 6 of 6UnitedHealthcare Community Plan Network Bulletin AppendixEffective 06/01/2020Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.
CPT/HCPCS Code Description 49651 Lap ing hernia repair recur 49652 Lap vent/abd hernia repair 49653 Lap vent/abd hern proc comp 49654 Lap inc hernia repair 49655 Lap inc hern repair comp 50590 Fragmenting of kidney stone 52000 Cystoscopy 52005 Cystoscopy & ureter catheter 52204 Cystoscopy w/biopsy(s) 52224 Cystoscopy and treatment
