Documentation Information
It is recommended that PARs are submitted at least ten business days prior to the expected date of service to allow National Government Services the full standard timeframe to receive and review requests.
For more information on coverage and documentation requirements, refer to:
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Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair*
| Code |
Description |
| 15820 |
Blepharoplasty, lower eyelid |
| 15821 |
Blepharoplasty, lower eyelid; with extensive herniated fat pad |
| 15822 |
Blepharoplasty, upper eyelid |
| 15823 |
Blepharoplasty upper eyelid; with excessive skin weighting down lid |
| 67900 |
Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 67901 |
Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) |
| 67902 |
Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) |
| 67903 |
Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach |
| 67904 |
Repair of blepharoptosis; (tarso) levator resection or advancement, external approach |
| 67906 |
Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) |
| 67908 |
Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) |
*CPT 67911 (Correction of lid retraction) was removed on January 7, 2022
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Botulinum Toxin Injection
Please note: Botox paired codes other than what is listed below, do not require PA at this time.
| Code |
Description |
| 64612 |
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm) |
| 64615 |
Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) |
| J0585 |
Injection, onabotulinumtoxin A, 1 unit |
| J0586 |
Injection, abobotulinumtoxin A, 5 units |
| J0587 |
Injection, rimabotulinumtoxin B, 100 units |
| J0588 |
Injection, incobotulinumtoxin A, 1 unit |
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Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
| Code |
Description |
| 15830 |
Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
| 15847 |
Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) |
| 15877 |
Suction assisted lipectomy; trunk |
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Rhinoplasty and Related Services
| Code |
Description |
| 20912 |
Cartilage graft; nasal septum |
| 21210 |
Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) |
| 30400 |
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
| 30410 |
Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip |
| 30420 |
Rhinoplasty, primary; including major septal repair |
| 30430 |
Rhinoplasty, secondary; minor revision (small amount of nasal tip work) |
| 30435 |
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) |
| 30450 |
Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) |
| 30460 |
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only |
| 30462 |
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies |
| 30465 |
Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) |
| 30520 |
Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft |
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Vein Ablation and Related Services
| Code |
Description |
| 36473 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated |
| 36474 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
| 36475 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated |
| 36476 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
| 36478 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated |
| 36479 |
Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
| 36482 |
Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated |
| 36483 |
Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) |
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Cervical Fusion with Disc Removal
| Code |
Cervical Fusion with Disc Removal |
| 22551 |
Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 |
| 22552 |
Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure) |
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Implanted Spinal Neurostimulators
| Code |
Implanted Spinal Neurostimulators |
| 63650 |
Percutaneous implantation of neurostimulator electrode array, epidural |
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Facet Joint Interventions
| Code |
Facet Joint Interventions |
| 64490 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level |
| 64491 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level |
| 64493 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level |
| 64494 |
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level |
| 64633 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint |
| 64634 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint |
| 64635 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint |
| 64636 |
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint |
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Revised 8/9/2024