once
Once-in-a-Lifetime Procedure Codes1
The following is a list of surgical procedures the Department of Health Care Services (DHCS) considers
to be once-in-a-lifetime. Claims submitted for any of these procedures a second time for the same recipient must include a full explanation and medical justification to avoid being denied. (For a full definition of these codes, please refer to the Physician’s Current Procedural Terminology – 4th Edition [CPT-4] published by the American Medical Association.)
Denied claims may be submitted for reconsideration through the normal claims inquiry process. (See the CIF Overview section in the Part 1 manual and the CIF Completion section in this manualfor instructions.)
HCPCS CodeDescription
S2078Hysterectomy
S3620Newborn metabolic screening panel
CPT-4 CodeDescription
15920Removal of tail bone ulcer
15922Removal of tail bone ulcer
27080Coccygectomy, primary
30160Removal of nose
31360Removal of larynx
31365Removal of larynx
31390Removal of larynx & pharynx
31395Reconstruct larynx & pharynx
31420Epiglottidectomy
31560Laryngoscopy with arytenoidectomy
31561Laryngoscopy with arytenoidectomy; with operating microscope
32440Pneumonectomy, total
38100Removal of spleen, total
38102Removal of spleen, total
38571Laparoscopy
38572Laparoscopy
38780Retroperitoneal transabdominal lymphadenectomy, extensive
41140Removal of tongue
41145Tongue removal; neck surgery
41150Tongue, mouth, jaw surgery
41153Tongue, mouth, neck surgery
41155Tongue, jaw, & neck surgery
42140Excision of uvula
42820Tonsillectomy and adenoidectomy; under age 12
42821Tonsillectomy and adenoidectomy; age 12 or over
42825Tonsillectomy, primary or secondary; under age 12
42826Tonsillectomy, primary or secondary; age 12 or over
42830Adenoidectomy, primary; under age 12
42831Adenoidectomy, primary; age 12 or over
42835Adenoidectomy, secondary; under age 12
42836Adenoidectomy, secondary; age 12 or over
2 – Once-in-a-Lifetime Procedure Codes
October2007
CPT-4 CodeDescription
43107Esophagectomy
43108Esophagectomy
43112Esophagectomy
43113Esophagectomy
43620Removal of stomach
43621Removal of stomach
43622Removal of stomach
44150Removal of colon
44151Removal of colon/ileostomy
44155Removal of colon
44156Removal of colon/ileostomy
44157Colectomy with ileoanal anastomosis
44158Colectomy with ileoanal anastomosis
44800Excision of bowel pouch
44950Appendectomy
44955Appendectomy
44960Appendectomy
45110Removal of rectum
45112Removal of rectum
45120Removal of rectum
45121Proctectomy, complete; with subtotal or total colectomy
45126Pelvic extenteration
45395Removal of rectum
45397Removal of rectum
47125Partial removal of liver
47130Partial removal of liver
47600Removal of gallbladder
47605Removal of gallbladder
47610Removal of gallbladder
47612Removal of gallbladder
47620Removal of gallbladder
48155Removal of pancreas
48160Pancreas removal, transplant
51500Removal of bladder cyst
51570Removal of bladder
51575Removal of bladder & nodes
51580Remove bladder; revise tract
51585Removal bladder & nodes
51590Remove bladder; revise tract
51595Remove bladder; revise tract
51596Cystectomy, complete
51597Removal of pelvic structures
*Effective December 12, 1994
**Effective August 1, 1995
once
3
CPT-4
CodeDescription
51925Hysterectomy/bladder repair
52601Transurethral prostatectomy (TURP)
53210Removal of urethra
53215Removal of urethra
54125Removal of penis
54130Remove penis & nodes
54135Remove penis & nodes
54161Circumcision, older than 28 days of age
54164Frenulotomy of penis
54861Removal of epididymes
55810Extensive prostate surgery
55812Extensive prostate surgery
55815Extensive prostate surgery
55840Extensive prostate surgery
55842Extensive prostate surgery
55845Extensive prostate surgery
55866Laparascopy, radical
56625Removal of vulva
56630Extensive vulva surgery
56634Vulvectomy, radical, complete
56637Vulvectomy, radical, complete
57110Remove vaginal wall, complete
57120Colpocleisis
57130Excision of vaginal septum
57530Removal of cervix
57540Removal of residual cervix
57545Removal of cervix, repair pelvis
57550Removal of residual cervix
57555Remove cervix, repair vagina
57556Remove cervix, repair bowel
58150Total abdominal hysterectomy
58152Total abdominal hysterectomy
58180Partial abdominal hysterectomy
58200Extensive abdominal hysterectomy
58210Extensive abdominal hysterectomy
58240Removal of pelvis contents
58260Vaginal hysterectomy
58262Vaginal hysterectomy
58263Vaginal hysterectomy
58267Vaginal hysterectomy with urinary repair
58270Hysterectomy & enterocele repair
58275Hysterectomy, revise vagina
58280Hysterectomy, revise vagina
58285Extensive hysterectomy
2 – Once-in-a-Lifetime Procedure Codes
July 2007
once
3
CPT-4
CodeDescription
58290Vaginal hysterectomy, complex
58291Vaginal hysterectomy, including tube(s) and/or ovary(s), complex
58292Vaginal hysterectomy, including tube(s) and/or ovary(s) and enterocele, complex
58293Vaginal hysterectomy with urinary repair, complex
58294Vaginal hysterectomy, with enterocele, complex
58541Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less
58542Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
58543Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
58544Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s)
58548Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed
58550Laparoscopy surgical, with vaginal hysterectomy
58552Laparoscopy surgical, with vaginal hysterectomy, including tube(s) and/or ovary(s)
58553Laparoscopy surgical, with vaginal hysterectomy, complex
58554Laparoscopy surgical, with vaginal hysterectomy, including tube(s) and/or ovary(s), complex
58950Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy
58951Resect ovarian, tubal or primary peritoneal malignancy
58952Resect ovarian, tubal or primary peritoneal malignancy
58954Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy
58956Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy
59135Treat ectopic pregnancy
59525Subtotal or total hysterectomy after cesarean delivery
60240Removal of thyroid
60270Removal of thyroid
60271Removal of thyroid
61542Removal of brain tissue
62292Injection into intervertebral disk lesion
87902Genotype, hepatitis C
90989Dialysis training, completed course
2 – Once-in-a-Lifetime Procedure Codes
July 2007