BlueAdvantageSM 2018 CMS Inpatient Only List

1 1 This list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion. For up to date information, please check the CMS EHCPCS Codes That Would Be Paid only as Inpatient Procedures for CY 2018 CPT codes and descriptions only are copyright 2017 American Medical Association. All Rights Reserved. Applicable FARS/DFARS CodeShort Descriptor0 0176 Anesth pharyngeal surgery0 0192 Anesth facial bone surgery00211 Anesth cran surg hemotoma00214 Anesth skull drainage00215 Anesth skull repair/fract00474 Anesth surgery of rib00524 Anesth chest drainage00540 Anesth chest surgery00542 Anesthesia removal pleura00546 Anesth lung chest wall surg00560 Anesth heart surg w/o pump00561 Anesth heart surg <1 yr00562 Anesth hrt surg w/pmp age 1+00567 Anesth cabg w/pump00580 Anesth heart/lung transplnt00604 Anesth sitting procedure00632 Anesth removal of nerves00670 Anesth spine cord surgery0075 TPerq stent/chest vert art0076TS&i stent/chest vert art00792 Anesth hemorr/excise liver00794 Anesth pancreas removal00796 Anesth for liver transplant00802 Anesth fat layer removal00844 Anesth pelvis surgery00846 Anesth hysterectomy00848 Anesth pelvic organ surg00864 Anesth removal of bladder00865 Anesth removal of prostate00866 Anesth removal of adrenalHCPCS CodeShort Descriptor00868 Anesth

2 Kidney transplant00882 Anesth major vein ligation00904 Anesth perineal surgery00908 Anesth removal of prostate00932 Anesth amputation of penis00934 Anesth penis nodes removal00936 Anesth penis nodes removal00944 Anesth vaginal hysterectomy0095 TRmvl artific disc addl crvcl0098 TRev artific disc addl0114 0 Anesth amputation at pelvis0115 0 Anesth pelvic tumor surgery01212 Anesth hip disarticulation01214 Anesth hip arthroplasty01232 Anesth amputation of femur01234 Anesth radical femur surg01272 Anesth femoral artery surg01 2 74 Anesth femoral embolectomy01402 Anesth knee arthroplasty01404 Anesth amputation at knee01442 Anesth knee artery surg01444 Anesth knee artery repair01486 Anesth ankle replacement01502 Anesth lwr leg embolectomy01634 Anesth shoulder joint amput01636 Anesth forequarter amput01638 Anesth shoulder replacement0163 TLumb artif diskectomy addl0164 TRemove lumb artif disc addl01652 Anesth shoulder vessel surgBlueAdvantageSM2018 CMS Inpatient only List2 This list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

3 For up to date information, please check the CMS CodeShort Descriptor01654 Anesth shoulder vessel surg01656 Anesth arm-leg vessel surg0165 TRevise lumb artif disc addl01756 Anesth radical humerus surg0195 TPrescrl fuse w/o instr l5/s10196 TPrescrl fuse w/o instr l4/l501990 Support for organ donor0202 TPost vert arthrplst 1 lumbar0219 TPlmt post facet implt cerv0220 TPlmt post facet implt thor0235 TTrluml perip athrc visceral0254 TEvasc rpr iliac art bifur0266 TImplt/rpl crtd sns dev total0345 TTranscath mtral vlve repair0375 TTotal disc arthrp ant appr0451 TInsj/rplcmt aortic ventr sys0452 TInsj/rplcmt dev vasc seal0455 TRemvl aortic ventr cmpl sys0456 TRemvl aortic dev vasc seal0459 TRelocaj rplcmt aortic ventr0461 TRepos aortic contrpulsj dev0483 TTmvi percutaneous approach0484 TTmvi transthoracic exposure0494 TPrep & cannulj cdvr don lung0495 TMntr cdvr don lng 1st 2 hrs0496 TMntr cdvr don lng ea addl hr110 0 4 Debride genitalia & perineum110 0 5 Debride abdom wall110 0 6 Debride

4 Genit/per/abdom wall110 0 8 Remove mesh from abd wall15756 Free myo/skin flap microvasc15757 Free skin flap microvasc15758 Free fascial flap microvasc16036 Escharotomy addl incision19271 Revision of chest wall19272 Extensive chest wall surgery19305 Mast radical19306 Mast rad urban type19361 Breast reconstr w/lat flap19364 Breast reconstructionHCPCS CodeShort Descriptor19367 Breast reconstruction19368 Breast reconstruction19369 Breast reconstruction20661 Application of head brace20664 Application of halo20802 Replantation arm complete20805 Replant forearm complete20808 Replantation hand complete20816 Replantation digit complete20824 Replantation thumb complete20827 Replantation thumb complete20838 Replantation foot complete20955 Fibula bone graft microvasc20956 Iliac bone graft microvasc20957Mt bone graft microvasc20962 Other bone graft microvasc20969 Bone/skin graft microvasc20970 Bone/skin graft iliac crest21045 Extensive jaw surgery21141 Lefort i-1 piece w/o graft21142 Lefort i-2 piece w/o graft21143 Lefort i-3/> piece w/o graft21145 Lefort i-1 piece w/ graft21146 Lefort i-2 piece w/ graft21147 Lefort i-3/> piece w/ graft21151 Lefort ii w/bone grafts21154 Lefort iii w/o lefort i21155 Lefort iii w/ lefort i21159 Lefort iii w/fhdw/o lefort i21160 Lefort iii w/fhd w/ lefort i21179 Reconstruct entire forehead21180 Reconstruct entire forehead21182 Reconstruct cranial bone21183 Reconstruct cranial bone21184 Reconstruct cranial bone21188 Reconstruction of midface21194 Reconst lwr jaw w/graft21196 Reconst lwr jaw w/fixation21247 Reconstruct lower jaw bone21255 Reconstruct lower jaw bone3 This list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

5 For up to date information, please check the CMS CodeShort Descriptor21268 Revise eye sockets21343 Open tx dprsd front sinus fx21344 Open tx compl front sinus fx21347 Opn tx nasomax fx multple21348 Opn tx nasomax fx w/graft21366 Opn tx complx malar w/grft21422 Treat mouth roof fracture21423 Treat mouth roof fracture21431 Treat craniofacial fracture21432 Treat craniofacial fracture21433 Treat craniofacial fracture21435 Treat craniofacial fracture21436 Treat craniofacial fracture21510 Drainage of bone lesion21615 Removal of rib21616 Removal of rib and nerves21620 Partial removal of sternum21627 Sternal debridement21630 Extensive sternum surgery21632 Extensive sternum surgery21705 Revision of neck muscle/rib21740 Reconstruction of sternum21750 Repair of sternum separation21825 Treat sternum fracture22010I&d p-spine c/t/cerv-thor22015I&d abscess p-spine l/s/ls22110 Remove part of neck vertebra22112 Remove part thorax vertebra22114 Remove part lumbar vertebra22116 Remove extra spine segment22206

6 Incis spine 3 column thorac22207 Incis spine 3 column lumbar22208 Incis spine 3 column adl seg22210 Incis 1 vertebral seg cerv22212 Incis 1 vertebral seg thorac22214 Incis 1 vertebral seg lumbar22216 Incis addl spine segment22220 Incis w/discectomy cervical22222 Incis w/discectomy thoracic22224 Incis w/discectomy lumbarHCPCS CodeShort Descriptor22226 Revise extra spine segment22318 Treat odontoid fx w/o graft22319 Treat odontoid fx w/graft22325 Treat spine fracture22326 Treat neck spine fracture22327 Treat thorax spine fracture22328 Treat each add spine fx22532 Lat thorax spine fusion22533 Lat lumbar spine fusion22534 Lat thor/lumb addl seg22548 Neck spine fusion22556 Thorax spine fusion22558 Lumbar spine fusion22586 Prescrl fuse w/ instr l5-s122590 Spine & skull spinal fusion22595 Neck spinal fusion22600 Neck spine fusion22610 Thorax spine fusion22630 Lumbar spine fusion22632 Spine fusion extra segment22633 Lumbar spine fusion combined22634 Spine fusion extra segment22800 Post fusion </6 vert seg22802 Post fusion 7-12 vert seg22804 Post fusion 13/> vert seg22808 Ant fusion 2-3 vert seg22810 Ant fusion 4-7 vert seg22812 Ant fusion 8/> vert seg22818 Kyphectomy 1-2 segments22819 Kyphectomy 3 or more22830 Exploration of spinal fusion22841 Insert spine fixation device22843 Insert spine fixation device22844 Insert spine fixation device22846 Insert spine fixation device22847 Insert spine fixation device22848 Insert pelv fixation device22849 Reinsert spinal fixation22850 Remove spine fixation device22852 Remove spine fixation device4 This list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

7 For up to date information, please check the CMS CodeShort Descriptor22855 Remove spine fixation device22857 Lumbar artif diskectomy22861 Revise cerv artific disc22862 Revise lumbar artif disc22864 Remove cerv artif disc22865 Remove lumb artif disc23200 Resect clavicle tumor23210 Resect scapula tumor23220 Resect prox humerus tumor23335 Shoulder prosthesis removal23472 Reconstruct shoulder joint23474 Revis reconst shoulder joint23900 Amputation of arm & girdle23920 Amputation at shoulder joint24900 Amputation of upper arm24920 Amputation of upper arm24930 Amputation follow-up surgery24931 Amputate upper arm & implant24940 Revision of upper arm25900 Amputation of forearm25905 Amputation of forearm25915 Amputation of forearm25920 Amputate hand at wrist25924 Amputation follow-up surgery25927 Amputation of hand26551 Great toe-hand transfer26553 Single transfer toe-hand26554 Double transfer toe-hand26556 Toe joint transfer26992 Drainage of bone lesion27005 Incision of hip tendon27025 Incision of

8 Hip/thigh fascia27030 Drainage of hip joint27036 Excision of hip joint/muscle27054 Removal of hip joint lining27070 Part remove hip bone super27071 Part removal hip bone deep27075 Resect hip tumor27076 Resect hip tum incl acetabul27077 Resect hip tum w/innom boneHCPCS CodeShort Descriptor27078 Rsect hip tum incl femur27090 Removal of hip prosthesis27091 Removal of hip prosthesis27120 Reconstruction of hip socket27122 Reconstruction of hip socket27125 Partial hip replacement27130 Total hip arthroplasty27132 Total hip arthroplasty27134 Revise hip joint replacement27137 Revise hip joint replacement27138 Revise hip joint replacement27140 Transplant femur ridge27146 Incision of hip bone27147 Revision of hip bone27151 Incision of hip bones27156 Revision of hip bones27158 Revision of pelvis27161 Incision of neck of femur27165 Incision/fixation of femur27170 Repair/graft femur head/neck27175 Treat slipped epiphysis27176 Treat slipped epiphysis27177 Treat slipped epiphysis27178 Treat slipped epiphysis27181 Treat slipped epiphysis27185 Revision of femur epiphysis27187 Reinforce hip bones27222 Treat hip socket fracture27226 Treat hip wall fracture27227 Treat hip fracture(s)27228 Treat hip fracture(s)27232 Treat thigh fracture27236 Treat thigh fracture27240 Treat thigh fracture27244 Treat thigh fracture27245 Treat thigh fracture27248 Treat thigh fracture27253 Treat hip dislocation27254 Treat hip dislocation27258 Treat hip dislocation5 This list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

9 For up to date information, please check the CMS CodeShort Descriptor27259 Treat hip dislocation27268 Cltx thigh fx w/mnpj27269 Optx thigh fx27280 Fusion of sacroiliac joint27282 Fusion of pubic bones27284 Fusion of hip joint27286 Fusion of hip joint27290 Amputation of leg at hip27295 Amputation of leg at hip27303 Drainage of bone lesion27365 Resect femur/knee tumor27445 Revision of knee joint27448 Incision of thigh27450 Incision of thigh27454 Realignment of thigh bone27455 Realignment of knee27457 Realignment of knee27465 Shortening of thigh bone27466 Lengthening of thigh bone27468 Shorten/lengthen thighs27470 Repair of thigh27472 Repair/graft of thigh27486 Revise/replace knee joint27487 Revise/replace knee joint27488 Removal of knee prosthesis27495 Reinforce thigh27506 Treatment of thigh fracture27507 Treatment of thigh fracture27511 Treatment of thigh fracture27513 Treatment of thigh fracture27514 Treatment of thigh fracture27519 Treat thigh fx growth plate27535 Treat knee fracture27536 Treat

10 Knee fracture27540 Treat knee fracture27556 Treat knee dislocation27557 Treat knee dislocation27558 Treat knee dislocation27580 Fusion of knee27590 Amputate leg at thighHCPCS CodeShort Descriptor27591 Amputate leg at thigh27592 Amputate leg at thigh27596 Amputation follow-up surgery27598 Amputate lower leg at knee27645 Resect tibia tumor27646 Resect fibula tumor27702 Reconstruct ankle joint27703 Reconstruction ankle joint27712 Realignment of lower leg27715 Revision of lower leg27724 Repair/graft of tibia27725 Repair of lower leg27727 Repair of lower leg27880 Amputation of lower leg27881 Amputation of lower leg27882 Amputation of lower leg27886 Amputation follow-up surgery27888 Amputation of foot at ankle28800 Amputation of midfoot31225 Removal of upper jaw31230 Removal of upper ndsc w/artery lig31290 Nasal/sinus endoscopy surg31291 Nasal/sinus endoscopy surg31360 Removal of larynx31365 Removal of larynx31367 Partial removal of larynx31368 Partial removal of larynx31370 Partial removal of larynx31375 Partial removal of larynx31380 Partial removal of larynx31382 Partial removal of larynx31390 Removal of larynx & pharynx31395 Reconstruct larynx & pharynx31725 Clearance of airways31760 Repair of windpipe31766 Reconstruction of windpipe31770 Repair/graft of bronchus31775 Reconstruct bronchus31780 Reconstruct windpipe6 This list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.