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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

Excision, ischial pressure ulcer, with skin flap closure; with ostectomy

Service Code
15945 (CPT) Excision, ischial pressure ulcer, with skin flap closure; with ostectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure

Service Code
15946 (CPT) Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, trochanteric pressure ulcer, with primary suture;

Service Code
15950 (CPT) Excision, trochanteric pressure ulcer, with primary suture;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, trochanteric pressure ulcer, with primary suture; with ostectomy

Service Code
15951 (CPT) Excision, trochanteric pressure ulcer, with primary suture; with ostectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, trochanteric pressure ulcer, with skin flap closure;

Service Code
15952 (CPT) Excision, trochanteric pressure ulcer, with skin flap closure;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy

Service Code
15953 (CPT) Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;

Service Code
15956 (CPT) Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy

Service Code
15958 (CPT) Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted procedure, excision pressure ulcer

Service Code
15999 (CPT) Unlisted procedure, excision pressure ulcer
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

Initial treatment, first degree burn, when no more than local treatment is required

Service Code
16000 (CPT) Initial treatment, first degree burn, when no more than local treatment is required
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)

Service Code
16020 (CPT) Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)

Service Code
16025 (CPT) Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area)

Service Code
16030 (CPT) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Escharotomy; initial incision

Service Code
16035 (CPT) Escharotomy; initial incision
Prior Authorization Required
No
Telephonic Billable
No
Telehealth Billable
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Major advances in care of burn patients have resulted in marked decreases in mortality and morbidity, especially with massive burns. In addition to survival, the current focus in burn care is on improving the long-term function and appearance of the healed or replaced skin cover as well as quality of life. Burn care includes Monitoring of Interstitial Fluid Pressure, Escharotomy. Fasciotomy and Skin Grafting.

Place of Service

Inpatient Hospital, Outpatient Hospital, Ambulatory Surgery Center, Office.

How to Submit

N/A - No authorization is required

Resources

Escharotomy; each additional incision (List separately in addition to code for primary procedure)

Service Code
16036 (CPT) Escharotomy; each additional incision (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

1E-7 Family Planning Services

Service Code
17000 (CPT) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.

Limits

  • • For FP Medicaid beneficiaries, these services are limited to services described in the policy's covered family planning service set.
  • • Outpatient hospital registration is limited for FP Medicaid; the only allowed outpatient registered surgical procedure or service is sterilization, IUD removal, or ultrasound for IUD-related complications including missing strings.
  • • Ultrasound for IUD placement issues may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.
  • • Telehealth claims, when allowed under the policy, must be filed with the provider's usual place of service and not place of service 02.

Exclusions

Ultrasound is not covered to verify IUD placement at the time of insertion. Ultrasounds are not intended for routine checking of placement after IUD insertion. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services. For FP Medicaid, surgical procedures or hospital services requiring outpatient beneficiary registration are not covered other than medically necessary contraceptive device removal or sterilizations; the policy note also identifies ultrasound for an IUD complication or removal of an IUD as exceptions to hospital cost responsibility. Hospital emergency room or emergency department services, inpatient hospital services, and treatment for acute or chronic conditions discovered during screening are not covered under FP Medicaid.

Place of Service

Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.

Additional Service Specifics

FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.

How to Submit

N/A - No authorization is required

Resources

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion)

Service Code
17003 (CPT) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions

Service Code
17004 (CPT) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

Service Code
17106 (CPT) Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm

Service Code
17107 (CPT) Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required