508C Medicare Advantage 2021 CMS Inpatient Only List

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 Advantage 2022 CMS Inpatient only ListAddendum EHCPCS Codes That Would Be Paid only as Inpatient Procedures for CY codes and descriptions only are copyright 2021 American Medical Association. Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2021 American Dental Association. All Rights CodeShort Desciptor00176 Anesth pharyngeal surgery00192 Anesth facial bone surgery0 0 211 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 nerves0075 TPerq stent/chest vert artHCPCS CodeShort Desciptor0076TS&i stent/chest vert art00792 Anesth hemorr/excise liver00794 Anesth pancreas removal00796 Anesth for liver transplant00844 Anesth pelvis surgery00846 Anesth hysterectomy00848 Anesth pelvic organ surg00864 Anesth removal of bladder00866

2 Anesth removal of adrenal00868 Anesth kidney transplant00882 Anesth major vein ligation00904 Anesth perineal surgery00908 Anesth removal of prostate00932 Anesth amputation of penis00934 Anesth penis nodes removal00936 Anesth penis nodes removal0095 TRmvl artific disc addl crvcl0098 TRev artific disc addlThis 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 CodeShort Desciptor0114 0 Anesth amputation at pelvis0115 0 Anesth pelvic tumor surgery01212 Anesth hip disarticulation01232 Anesth amputation of femur01234 Anesth radical femur surg01272 Anesth femoral artery surg01274 Anesth femoral embolectomy01404 Anesth amputation at knee014 42 Anesth knee artery surg01444 Anesth knee artery repair01502 Anesth lwr leg embolectomy01634 Anesth shoulder joint amput01636 Anesth forequarter amput0163 TTot disc arthrp ea addl lmbr0164 TRemove lumb artif disc addl01652 Anesth shoulder vessel surg01654 Anesth shoulder vessel surg01656 Anesth arm-leg vessel surg0165 TRevise lumb artif disc addl01756 Anesth radical humerus surg01990 Support for organ donor0202 TPost vert arthrplst 1 lumbar0219 TPlmt post facet implt cerv0220 TPlmt post facet implt thor0235 TTrluml perip athrc

3 Visceral0345 TTranscath mtral vlve repair0483 TTmvi percutaneous approach0484 TTmvi transthoracic exposure0494 TPrep & cannulj cdvr don lung0495 TMntr cdvr don lng 1st 2 hrsHCPCS CodeShort Desciptor0496 TMntr cdvr don lng ea addl hr0543 TTa mv rpr w/artif chord tend0544 TTcat mv annulus rcnstj0545 TTcat tv annulus rcnstj0569 TTtvr perq appr 1st prosth0570 TTtvr perq ea addl prosth0584 TPerq islet cell transplant0585 TLaps islet cell transplant0586 TOpen islet cell transplant0643 TTcat l ventr rstrj dev implt0656 TVrt bdy tethering ant <7 seg0657 TVrt bdy tethering ant 8+ seg0659 TTcat intra-c nfs supersat o211004 Debride genitalia & perineum110 0 5 Debride abdom wall110 0 6 Debride 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 incision19305 Mast radical19306 Mast rad urban type19361 Brst rcnstj latsms drsi flap19364 Brst rcnstj free flap19367 Brst rcnstj 1 pdcl tram flap19368 Brst rcnstj 1pdcl tram anast19369 Brst rcnstj 2 pdcl tram flap20661 Application of head brace20664 Application of haloThis list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

4 For up to date information, please check the CMS CodeShort Desciptor20802 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 graft2114 2 Lefort i-2 piece w/o graft2114 3 Lefort i-3/> piece w/o graft2114 5 Lefort i-1 piece w/ graft2114 6 Lefort i-2 piece w/ graft21147 Lefort i-3/> piece w/ graft21151 Lefort ii w/bone grafts2115 4 Lefort iii w/o lefort i2115 5 Lefort iii w/ lefort i2115 9 Lefort iii w/fhdw/o lefort i2116 0 Lefort iii w/fhd w/ lefort i2117

5 9 Reconstruct entire forehead2118 0 Reconstruct entire forehead2118 2 Reconstruct cranial bone2118 3 Reconstruct cranial bone2118 4 Reconstruct cranial boneHCPCS CodeShort Desciptor2118 8 Reconstruction of midface2119 4 Reconst lwr jaw w/graft2119 6 Reconst lwr jaw w/fixation21247 Reconstruct lower jaw bone21255 Reconstruct lower jaw bone21268 Revise eye sockets21343 Open tx dprsd front sinus fx2134 4 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 lesion21602 Exc ch wal tum w/o lymphadec21603 Exc ch wal tum w/lymphadec21615 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 separationThis list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

6 For up to date information, please check the CMS CodeShort Desciptor21825 Treat sternum fracture22010I&d p-spine c/t/cerv-thor22015I&d abscess p-spine l/s/ls2 2110 Remove part of neck vertebra2 2112 Remove part thorax vertebra2 2114 Remove part lumbar vertebra2 2116 Remove extra spine segment22206 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 Osteot dsc ant 1 vrt sgm crv22222 Osteot dsc ant 1vrt sgm thrc22224 Osteot dsc ant 1vrt sgm lmbr22226 Osteot dsc ant 1vrt sgm ea22318 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 Arthrd lat xtrcvtry

7 Tq thrc22533 Arthrd lat xtrcvtry tq lmbr22534 Arthrd lat xtrcvtry tq ea ad22548 Arthrd ant toral/xoral c1-c222556 Arthrd ant ntrbd min dsc thc22558 Arthrd ant ntrbd min dsc lumHCPCS CodeShort Desciptor22586 Arthrd pre-sac ntrbdy l5-s122590 Arthrd pst tq craniocervical22595 Arthrd pst tq atlas-axis22600 Arthrd pst tq 1ntrspc crv22610 Arthrd pst tq 1ntrspc thrc22632 Arthrd pst tq 1ntrspc lm ea22800 Arthrd pst dfrm<6 vrt sgm22802 Arthrd pst dfrm 7-12 vrt sgm22804 Arthrd pst dfrm 13+ vrt sgm22808 Arthrd ant dfrm 2-3 vrt sgm22810 Arthrd ant dfrm 4-7 vrt sgm22812 Arthrd ant dfrm 8+ vrt sgm22818 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 device22855 Remove spine fixation device22857 Tot disc arthrp ant lumbar22861 Revise cerv artific disc22862 Revise lumbar artif disc22864 Remove cerv artif disc22865 Remove lumb artif discThis list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

8 For up to date information, please check the CMS CodeShort Desciptor23200 Resect clavicle tumor23210 Resect scapula tumor23220 Resect prox humerus tumor23335 Shoulder prosthesis removal23474 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 hip/thigh fascia27030 Drainage of hip joint27036 Excision of hip

9 Joint/muscle27054 Removal of hip joint lining27070 Part remove hip bone superHCPCS CodeShort Desciptor27071 Part removal hip bone deep27075 Resect hip tumor27076 Resect hip tum incl acetabul27077 Resect hip tum w/innom bone27078 Rsect hip tum incl femur27090 Removal of hip prosthesis27091 Removal of hip prosthesis27120 Reconstruction of hip socket27122 Reconstruction of hip socket27125 Partial hip replacement27132 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 bonesThis list is produced by the Centers for Medicare and Medicaid Services and is subject to change at their discretion.

10 For up to date information, please check the CMS CodeShort Desciptor27222 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 dislocation27259 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 tumor274 45 Revision of knee joint274 4 8 Incision of thigh27450 Incision of thigh27454 Realignment of thigh bone27455 Realignment of knee27457 Realignment of kneeHCPCS CodeShort Desciptor27465 Shortening of thigh bone27466 Lengthening of thigh bone27468 Shorten/lengthen thighs27470 Repair of thigh27472