Enumerated CPT codes and increment rules (codes + add-on instructions)

Listed CPT procedure codes and billing increment rules are enumerated in the Limitations/Administrative Guidelines section; these include adjacent tissue transfer and graft codes (e.g., 15101, 15200, 15201, 15240, 15241), flap and flap-related codes (15738, 15750, 15757, 15769), autologous fat grafting codes with volume thresholds (15771, 15772, 15773, 15774), punch graft codes (15775, 15776), dermabrasion/abrasion/chemical peel codes (15780–15793), blepharoplasty (15820–15822), and multiple genital reconstructive codes (e.g., 55980, 56620, 57291, 57292, 57295, 57296, 57335). Increment rules requiring listing separately are specified for area (each additional 20 sq cm) and injectate (each additional 25 cc or 50 cc or part thereof) billable in addition to the primary procedure.

• Full-thickness graft area increment: each additional 20 sq cm, or part thereof (List separately).
• Autologous fat grafting (trunk/breast/limb): 15771 for ≤50 cc; 15772 each additional 50 cc (List separately).
• Autologous fat grafting (face/genitalia/hands/feet): 15773 for ≤25 cc; 15774 each additional 25 cc (List separately).
• Punch grafts: 15775 (1–15 grafts), 15776 (>15 grafts).
• Quantity-based add-ons (e.g., abrasion each additional 4 lesions — 15787) require listing separately in addition to the primary procedure.

Procedure codes to reference for authorization/coverage review

The policy identifies specific CPTs to reference when submitting services for review or authorization, including flap and graft codes (15738, 15750, 15757, 15769) and autologous fat grafting codes (15771–15774); these are the codes the payer uses to map procedures in the Limitations/Administrative Guidelines.

• Flap/graft: 15738, 15750, 15757, 15769.
• Autologous fat grafting: 15771, 15772, 15773, 15774.

Codes listed (no explicit prior authorization language in this section)

Sections list many CPT procedure codes (e.g., 15738, 15750, 15757, 15769, 15771–15774) without stating an explicit prior authorization rule in the provided text; providers should still submit the appropriate CPTs when requesting review because the policy enumerates them under Limitations/Administrative Guidelines.

• Codes listed: 15738, 15750, 15757, 15769, 15771, 15772, 15773, 15774.
• Text does not include explicit PA decision language for these codes in the provided chunks.

Procedure CPTs enumerated under Limitations/Administrative Guidelines

The Limitations/Administrative Guidelines section enumerates CPTs (15757, 15769, 15771–15776, 15780, etc.) that are treated as part of the policy's limitations and administrative review; prior authorization language is not present in these chunks but the listings indicate which codes fall under those sections.

• CPTs under Limitations/Administrative Guidelines include 15757, 15769, 15771–15776, 15780–15783.

Procedure codes enumerated (no PA rule stated in text)

Multiple CPTs are repeatedly listed across the Limitations section (e.g., autologous fat grafting, punch grafts, dermabrasion codes) but the provided text does not include an explicit prior authorization requirement for these codes; list of codes should be used for coding and claim submission.

• Repeated codes: 15771–15776, 15780–15789, 15792–15793.

CPT lists present (no PA instruction in excerpt)

The document lists numerous CPTs (e.g., 15772–15776, 15780–15783) in Limitations/Administrative Guidelines without attaching explicit prior authorization instructions in the excerpt; providers must code to these CPTs when billing the listed procedures.

• CPTs referenced include 15772, 15773, 15774, 15775, 15776, 15780–15783, 15786–15787.

CPT code list (no explicit PA stated)

The Limitations section enumerates autologous fat grafting codes and related add-on codes (15771–15774) and punch graft/dermabrasion codes (15775–15783) but does not include explicit prior authorization rules within these chunks; providers should reference these CPTs when submitting claims or prior authorization requests.

• Autologous fat grafting codes: 15771–15774.
• Dermabrasion/punch graft codes: 15775–15783.

Procedure CPTs with list‑separately/add-on instructions

The document lists CPTs (15773–15776, 15780–15789) and instructions to 'List separately in addition to code for primary procedure' for additional injectate or lesions; no explicit prior authorization directive appears in these chunks, but correct application of list-separately rules is required for claims.

• Examples: 15772/15774 each 'additional' injectate units are listed as 'List separately in addition to code for primary procedure.'
• 15787 (each additional 4 lesions) is 'List separately in addition to code for primary procedure.'

Dermabrasion/blepharoplasty and related CPT lists for administrative review

The policy enumerates extensive CPT lists (dermabrasion, chemical peels, abrasions, punch grafts, blepharoplasty) that providers should reference for coding and any coverage review; these code lists are the ones used in the Limitations/Administrative Guidelines mapping.

• Dermabrasion/chemical peel/abrasion codes: 15780–15793.
• Blepharoplasty: 15820–15822.

Procedure CPTs listed under Limitations

CPT procedure codes enumerated under 'Limitations' include punch grafts, dermabrasion, abrasion, chemical peel, and blepharoplasty codes; the excerpted text does not set explicit prior authorization conditions but lists which CPTs the policy treats in those sections.

• Codes included in Limitations: 15775–15776, 15780–15793, 15820.

Codes listed for authorization/coverage reference

The Limitations/Administrative Guidelines section lists dermabrasion, chemical peel, abrasion, punch graft, and blepharoplasty CPTs among others as the codes to reference when determining administrative handling or submitting for coverage review.

• Key codes for authorization/coverage reference: 15775–15776, 15780–15793, 15820–15822.

Numerous listed CPTs may require prior authorization

A broad set of surgical and reconstructive CPT codes (including many listed genital and reconstructive procedure codes such as 15830–15839, 19303–19350, 21120–21270, 30400–30450, and 53410–53430) are enumerated; while explicit PA rules are not in the provided chunks, these listed CPTs may be subject to prior authorization per payer administrative rules.

• Examples: excision/lipectomy/liposuction codes (15830–15839, 15876–15879), breast surgery codes (19303, 19316, 19318, 19325, 19340, 19342, 19350), facial bone/genioplasty (21120–21270), rhinoplasty (30400–30450), urethroplasty (53410–53430).

Genital reconstructive CPTs enumerated (admin/PA relevant)

Genital reconstructive CPTs are explicitly listed (e.g., 55980, 56620, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426); the policy's Limitations/Administrative Guidelines section maps these codes to descriptors and indicates they are the codes to submit for review, implying prior authorization may apply when billing these services.

• Example genital reconstructive codes: 57291 (construction of artificial vagina without graft), 57292 (with graft), 57295/57296 (revision/removal of prosthetic vaginal graft), 57335 (vaginoplasty).
• Intersex/gender‑affirming codes: 55980, 56620, 56625, 56800, 56805, 57106, 57110.

Prior authorization may be required for listed genital reconstructive CPTs

Where the policy lists reconstructive genital CPTs (e.g., 57291, 57292, 57295, 57296, 57335), prior authorization may be required for those procedures per the document's Limitations/Administrative Guidelines; providers should submit the exact CPT(s) for review.

• Submit exact CPT code(s) for genital reconstructive procedures (e.g., 57291 vs 57292 to denote without vs with graft).
• Codes for revision/removal of prosthetic vaginal grafts include 57295, 57296, and 57426 (laparoscopic revision).

No step‑therapy requirements in this section

There are no step‑therapy requirements or step‑therapy rules present in the provided Limitations/Administrative Guidelines chunks; the policy excerpt focuses on CPT listings, increments, and coding instructions rather than clinical step therapy pathways.

• No step‑therapy pathways or prior conservative‑therapy trials are stated in these chunks.
• Authorization/coverage guidance in the excerpt centers on coding and administrative rules.

Document procedure site and injected volume (25 cc vs 50 cc thresholds)

Document the anatomic site and injected fat volume when billing autologous fat grafting codes: use the 50 cc threshold for trunk/breasts/limbs (15771/15772) and the 25 cc threshold for face/genitalia/hands/feet (15773/15774); list separately for each additional increment as specified.

• Trunk/breast/limb injectate: 15771 = ≤50 cc; 15772 = each additional 50 cc (List separately).
• Face/genitalia/hands/feet injectate: 15773 = ≤25 cc; 15774 = each additional 25 cc (List separately).
• Record and report injected volume and recipient site to support billing of primary and additional units.

List‑separately instructions for quantity‑based add‑ons

Quantity‑based add‑on items (e.g., 'each additional 50 cc injectate' or 'each additional 25 cc injectate' and 'each additional 4 lesions or less') are identified and must be listed separately in addition to the primary procedure code when billed.

• 15772 — each additional 50 cc injectate (List separately in addition to primary procedure).
• 15774 — each additional 25 cc injectate (List separately in addition to primary procedure).
• 15787 — abrasion; each additional 4 lesions or less (List separately in addition to primary procedure).

Ensure correct add‑on/list‑separately coding to avoid denials

Providers must ensure coding accuracy for add‑on and list‑separately items; the policy lists 'List separately in addition to code for primary procedure' for multiple codes — incorrect reporting of these adjunct/add‑on codes may result in administrative or payment issues.

• Confirm primary procedure code is billed and that each additional injectate or lesion code is listed separately as required by the code descriptors.
• When combining procedures (e.g., abdominoplasty with umbilical transposition and fascial plication), follow 'List separately' direction as shown.