Appendix D: Authorization Guidelines for Dermatology Services Revised June 2011 1
Appendix D: Authorization Guidelines for Dermatology Dermatologists are limited to the CPT codes referenced in this Section. 10040 11000 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 1/1/2005 11001 11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS derm/surg 1/1/2005 11041 DEBRIDEMENT; SKIN, FULL THICKNESS derm/surg 1/1/2005 11042 DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE derm/surg 1/1/2005 11043 11044 11100 11101 11300 11301 11302 11303 11305 11306 11307 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 2011 2
11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 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 1/1/2005 11424 11426 derm/surg 1/1/2005 Revised June 2011 3
11440 11441 11442 11443 11444 11446 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 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 0.6-1.0 CM derm/surg 1/1/2005 TRUNK, ARMS, OR LEGS; EXCISED DIAMETER 1.1-2.0 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 2011 4
11626 11640 11641 11642 11643 11644 11646 11900 11901 16000 16020 16025 16030 17000 17003 17004 DIAMETER OVER 4.0 CM derm/surg 1/1/2005 0.5 CM OR LESS derm/surg 1/1/2005 0.6 TO 1.0 CM derm/surg 1/1/2005 1.1 TO 2.0 CM derm/surg 1/1/2005 2.1 TO 3.0 CM derm/surg 1/1/2005 3.1 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 2011 5
17110 17111 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 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 2011 6
17282 17283 17284 PRIMARY SPECIALTY CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, Revised June 2011 7 EFFECTIVE DATE 17286 17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE derm 1/1/2005 17360 CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID) derm 1/1/2005 46900 46916 54050 54055 54056 54057 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 1/1/2007 54060 VESICLE), SIMPLE; SURGICAL EXCISION derm 1/1/2007 67810 BIOPSY OF EYELID opth/derm 1/1/2005 69100 BIOPSY EXTERNAL EAR ent/derm 1/1/2005 96567 PHOTODYNAMIC THERAPY BY EXTERNAL APPLICATION OF LIGHT TO DESTROY PREMALIGNANT AND/OR MALIGNANT LESIONS OF THE SKIN AND ADJACENT MU derm 1/1/2005 96900 ACTINOTHERAPY (ULTRAVIOLET LIGHT) derm 1/1/2005 96902 96904 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
96913 96920 96921 96922 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 1/1/2005 97602 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 2011 8