Last year, we announced that Site of Service requirements would be extended to Medicare members. The COVID-19 pandemic delayed that launch but, with our region striving to get back to “normal,” we plan to apply new site of service rules for our Medicare members beginning April 1, 2021. Please see the list of applicable codes below; these are the same codes with existing Site of Service requirements for Commercial and Medicaid members.
We regularly update our preauthorization lists, so make sure to visit the preauthorization page to get the latest list. The page also has a lookup tool that provides an easy way to see if a CPT/HCPCS code requires preauthorization for a HIP or EmblemHealth Insurance Company (formerly HIPIC) member.
New Decision Tree for Varicose Vein procedures
For providers who have logged into our secure provider portal, we have added a decision tree to help you figure out if your varicose vein procedure requires an authorization or if you can proceed. By answering a few online questions, you can find out if your procedure falls into one of the 23 codes for which you can get immediate approval.
We will be rolling out additional online decision trees in the coming months, simplifying your office’s administrative burden.
Medicare Site of Service Codes Effective April 1, 2021.
CPT Code |
Description |
|---|---|
10120 |
Incision and removal of foreign body, subcutaneous tissues; simple |
10140 |
Incision and drainage of hematoma, seroma or fluid collection |
11400 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less |
11401 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm |
11402 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm |
11403 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm |
11404 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm |
11406 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm |
11420 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less |
11421 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm |
11422 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm |
11423 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm |
11424 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm |
11426 |
Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm |
11442 |
Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm |
13101 |
Repair, complex, trunk; 2.6 cm to 7.5 cm |
13132 |
Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm |
14040 |
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less |
14060 |
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less |
14301 |
Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm |
19000 |
Puncture aspiration of cyst of breast; |
20680 |
Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) |
21320 |
Closed treatment of nasal bone fracture; with stabilization |
21552 |
Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater |
21931 |
Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater |
27096 |
Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed |
30140 |
Submucous resection inferior turbinate, partial or complete, any method |
30520 |
Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft |
31579 |
Laryngoscopy, flexible or rigid telescopic, with stroboscopy |
42821 |
Tonsillectomy and adenoidectomy; age 12 or over |
42825 |
Tonsillectomy, primary or secondary; younger than age 12 |
42826 |
Tonsillectomy, primary or secondary; age 12 or over |
42830 |
Adenoidectomy, primary; younger than age 12 |
43235 |
Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
43239 |
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple |
43249 |
Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) |
45300 |
Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) |
45330 |
Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
45378 |
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) |
45380 |
Colonoscopy, flexible; with biopsy, single or multiple |
45384 |
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps |
45385 |
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique |
46922 |
Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision |
47000 |
Biopsy of liver, needle; percutaneous |
49505 |
Repair initial inguinal hernia, age 5 years or older; reducible |
49585 |
Repair umbilical hernia, age 5 years or older; reducible |
49587 |
Repair umbilical hernia, age 5 years or older; incarcerated or strangulated |
49650 |
Laparoscopy, surgical; repair initial inguinal hernia |
49651 |
Laparoscopy, surgical; repair recurrent inguinal hernia |
49652 |
Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible |
49653 |
Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated |
49654 |
Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible |
49655 |
Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated |
50590 |
Lithotripsy, extracorporeal shock wave |
52000 |
Cystourethroscopy (separate procedure) |
52005 |
Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; |
52204 |
Cystourethroscopy, with biopsy(s) |
52224 |
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy |
52234 |
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm) |
52235 |
Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) |
52260 |
Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia |
52281 |
Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female |
52310 |
Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple |
52332 |
Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) |
52351 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic |
52352 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) |
52353 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) |
52356 |
Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type) |
54161 |
Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age |
55040 |
Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) |
55250 |
Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) |
55700 |
Biopsy, prostate; needle or punch, single or multiple, any approach |
57288 |
Sling operation for stress incontinence (eg, fascia or synthetic) |
57460 |
Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix |
57522 |
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision |
58353 |
Endometrial ablation, thermal, without hysteroscopic guidance |
58558 |
Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C |
58563 |
Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) |
58565 |
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants |
64520 |
Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) |
64633 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint |
64635 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint |
64721 |
Neuroplasty and/or transposition; median nerve at carpal tunnel |
65426 |
Excision or transposition of pterygium; with graft |
65730 |
Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) Revised |
65855 |
Trabeculoplasty by laser surgery |
66170 |
Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae |
66761 |
Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) |
66821 |
Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages) |
66982 |
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage |
66984 |
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) |
67028 |
Intravitreal injection of a pharmacologic agent (separate procedure) |
67036 |
Vitrectomy, mechanical, pars plana approach; |
67040 |
Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation |
67228 |
Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation |
67311 |
Strabismus surgery, recession or resection procedure; 1 horizontal muscle |
67312 |
Strabismus surgery, recession or resection procedure; 2 horizontal muscles |
69436 |
Tympanostomy (requiring insertion of ventilating tube), general anesthesia |
69631 |
Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction |
