Appendix D: Authorization Guidelines for Dermatology Services
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1 Appendix D: Authorization Guidelines for Dermatology Services Revised June
2 Appendix D: Authorization Guidelines for Dermatology Dermatologists are limited to the CPT codes referenced in this Section PRIMARY SPECIALTY EFFECTIVE DATE ACNE SURGERY (EG, MARSUPIALIZATION, OPENING OR REMOVAL OF MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES) derm 1/1/2006 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE derm/surg 1/1/2005 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE derm/surg 1/1/ DEBRIDEMENT; SKIN, PARTIAL THICKNESS derm/surg 1/1/ DEBRIDEMENT; SKIN, FULL THICKNESS derm/surg 1/1/ DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE derm/surg 1/1/ DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE derm/surg 1/1/2005 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE derm/surg 1/1/2005 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; SINGLE LESION derm/surg 1/1/2005 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; EACH SEPARATE/ADDI derm/surg 1/1/2005 LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS derm/surg 1/1/2005 LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM derm/surg 1/1/2005 LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM derm/surg 1/1/2005 LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM derm/surg 1/1/2005 LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS derm/surg 1/1/2005 LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM derm/surg 1/1/2005 LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM derm/surg 1/1/2005 Revised June
3 LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM derm/surg 1/1/2005 LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR derm/surg 1/1/2005 LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 derm/surg 1/1/2005 LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 derm/surg 1/1/2005 LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 C derm/surg 1/1/2005 OR LEGS; EXCISED DIAMETER 0.5 CM derm/surg 1/1/2005 OR LEGS; EXCISED DIAMETER 0.6 TO derm/surg 1/1/2005 OR LEGS; EXCISED DIAMETER 1.1 TO derm/surg 1/1/2005 OR LEGS; EXCISED DIAMETER 2.1 TO derm/surg 1/1/2005 OR LEGS; EXCISED DIAMETER 3.1 TO derm/surg 1/1/2005 OR LEGS; EXCISED DIAMETER OVER 4 derm/surg 1/1/ derm/surg 1/1/2005 Revised June
4 HANDS, FEET, GENITALIA; EXCISED TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS derm/surg 1/1/2005 TRUNK, ARMS, OR LEGS; EXCISED DIAMETER CM derm/surg 1/1/2005 TRUNK, ARMS, OR LEGS; EXCISED DIAMETER CM derm/surg 1/1/2005 TRUNK, ARMS, LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM derm/surg 1/1/2005 TRUNK, ARMS, LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM derm/surg 1/1/2005 TRUNK, ARMS, LEGS; EXCISED DIAMETER OVER 4.0 CM derm/surg 1/1/2005 DIAMETER 0.5 CM OR LESS derm/surg 1/1/2005 DIAMETER 0.6 TO 1.0 CM derm/surg 1/1/2005 DIAMETER 1.1 TO 2.0 CM derm/surg 1/1/2005 DIAMETER 2.1 TO 3.0 CM derm/surg 1/1/2005 DIAMETER 3.1 TO 4.0 CM derm/surg 1/1/2005 Revised June
5 DIAMETER OVER 4.0 CM derm/surg 1/1/ CM OR LESS derm/surg 1/1/ TO 1.0 CM derm/surg 1/1/ TO 2.0 CM derm/surg 1/1/ TO 3.0 CM derm/surg 1/1/ TO 4.0 CM derm/surg 1/1/2005 OVER 4.0 CM derm/surg 1/1/2005 INJECTION, INTRALESIONAL; UP TO AND INCLUDING SEVEN LESIONS derm/surg 1/1/2005 INJECTION, INTRALESIONAL; MORE THAN SEVEN LESIONS derm/surg 1/1/2005 INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS REQUIRED derm/surg 1/1/2005 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL- THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA) derm/surg 1/1/2005 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL- THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% T derm/surg 1/1/2005 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL- THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN ONE EXTREMITY, OR GREATER THA derm/surg 1/1/2005 SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIO derm/surg 1/1/2005 SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIO derm/surg 1/1/2005 SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIO derm/surg 1/1/2005 Revised June
6 SURGICAL CURETTEMENT), OF FLAT WARTS, MOLLUSCUM CONTAGI derm/surg 1/1/2005 SURGICAL CURETTEMENT), OF FLAT WARTS, MOLLUSCUM CONTAGI derm/surg 1/1/2005 derm/surg 1/1/2005 Revised June
7 PRIMARY SPECIALTY CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, Revised June EFFECTIVE DATE CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE derm 1/1/ CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID) derm 1/1/ DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, VESICLE), SIMPLE; CHEMICAL derm 1/1/2005 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, VESICLE), SIMPLE; CRYOSURGERY derm 1/1/2006 VESICLE), SIMPLE; CHEMICAL derm 1/1/2005 VESICLE), SIMPLE; ELECTRODESICCATION derm 1/1/2005 VESICLE), SIMPLE; CRYOSURGERY derm 1/1/2005 VESICLE), SIMPLE; LASER SURGERY derm 1/1/ VESICLE), SIMPLE; SURGICAL EXCISION derm 1/1/ BIOPSY OF EYELID opth/derm 1/1/ BIOPSY EXTERNAL EAR ent/derm 1/1/ PHOTODYNAMIC THERAPY BY EXTERNAL APPLICATION OF LIGHT TO DESTROY PREMALIGNANT AND/OR MALIGNANT LESIONS OF THE SKIN AND ADJACENT MU derm 1/1/ ACTINOTHERAPY (ULTRAVIOLET LIGHT) derm 1/1/ MICROSCOPIC EXAMINATION OF HAIRS PLUCKED OR CLIPPED BY THE EXAMINER (EXCLUDING HAIR COLLECTED BY THE PATIENT) TO DETERMINE TELOGEN derm 1/1/2005 WHOLE BODY INTEGUMENTARY PHOTOGRAPHY, FOR MONITORING OF HIGH RISK PATIENTS WITH DYSPLASTIC NEVUS SYNDROME OR A HISTORY OF DYSPLAST derm 1/1/2007
8 PHOTOCHEMOTHERAPY (GOECKERMAN AND/OR PUVA) FOR SEVERE PHOTORESPONSIVE DERMATOSES REQUIRING AT LEAST FOUR - EIGHT HOURS OF CARE UN derm 1/1/2005 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); TOTAL AREA LESS THAN 250 SQ CM derm 1/1/2005 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 250 SQ CM TO 500 SQ CM derm 1/1/2005 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); OVER 500 SQ CM derm 1/1/2005 REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, derm 1/1/ J0215 INJECTION, ALEFACEPT, 0.5 MG derm 1/1/2005 AMINOLEVULINIC ACID HCL FOR TOPICAL ADMIN 20%, J7308 SINGLE UNIT DOSAGE FORM (354 MG) derm 1/1/2007 Revised June
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