Original Effective Date:
12/01/2010
Current Effective Date:
06/01/2015
When submitting claims for one of the following HCPCS or CPT procedure codes, please submit an operative report or other documentation with the claim. See Cosmetic and Reconstructive Surgery and Services for more information.
Note: The list below is not an exhaustive list of all possible procedures that may be considered cosmetic. If you are planning to perform a procedure that you believe may be considered cosmetic, please call HMSA at 808-948-6464 on Oahu to confirm whether the procedure may be considered cosmetic.
| CPT or HCPCS Code | Description |
|---|---|
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less |
| 11921 | 6.1 to 20.0 sq cm |
| 11922 | each additional 20.0 sq cm |
| 11960 | Insertion of tissue expander(s) for other than breast, including subsequent expansion |
| 11970 | Replacement of tissue expander with permanent prosthesis |
| 11971 | Removal of tissue expander(s) without insertion of prosthesis |
| 15750 | Flap; neurovascular pedicle |
| 15775 | Punch graft for hair transplant; 1 to 15 punch grafts |
| 15776 | more than 15 punch grafts |
| 15760 | Graft; composite (e.g., full thickness of ear or nasal ala), including primary closure; donor area |
| 15770 | derma-fat fascia |
| 15786 | Abrasion; single lesion (e.g., keratosis, scar) |
| 15787* | each additional four lesions or less |
| 15819 | Cervicoplasty |
| 15820 | Blepharoplasty, lower eyelid; |
| 15821 | with extensive herniated fat pad |
| 15822 | Blepharoplasty, upper eyelid; |
| 15823 | with excessive skin weighting down lid |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
| 15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) |
| 15879 | Suction assisted lipectomy; lower extremity |
| 19300 | Mastectomy for gynecomastia |
| 19316 | Mastopexy |
| 19324 | Mammoplasty, augmentation; without prosthetic implant |
| 19325 | with prosthetic implant |
| 19328 | Removal of intact mammary implant |
| 19330 | Removal of mammary implant material |
| 19340 | Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction |
| 19342 | Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction |
| 19350 | Nipple/areola reconstruction |
| 19355 | Correction of inverted nipples |
| 19357 | Breast reconstruction, immediate or delayed with tissue expander, including subsequent expansion |
| 19361 | Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant |
| 19364 | Breast reconstruction with free flap |
| 19366 | Breast reconstruction with other technique |
| 19367 | Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; |
| 19368 | with microvascular anastomosis (supercharging) |
| 19369 | Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site |
| 19370 | Open periprosthetic capsulotomy, breast |
| 19371 | Periprosthetic capsulectomy, breast |
| 19380 | Revision of reconstructed breast |
| 19396 | Preparation of moulage for custom breast implant |
| 20912 | Cartilage graft; nasal septum |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) |
| 21121 | sliding osteotomy, single piece |
| 21122 | sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) |
| 21123 | sliding, augmentation with interpositional bone grafts (including obtaining autografts) |
| 21125 | Augmentation, mandibular body or angle; prosthetic material |
| 21127 | with bone graft, onlay or interpositional (includes obtaining autograft) |
| 21137 | Reduction, forehead; contouring only |
| 21138 | contouring and application of prosthetic material or bone graft (includes obtaining autograft) |
| 21139 | contouring and set back of anterior frontal sinus wall |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), without bone graft |
| 21142 | two pieces, segment movement in any direction, without bone graft |
| 21143 | three or more pieces, segment movement in any direction, without bone graft |
| 21145 | single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) |
| 21146 | two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft) |
| 21147 | three or more pieces, segment movement in any direction requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies) |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome) |
| 21151 | any direction, requiring bone grafts (includes obtaining autografts) |
| 21154 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I |
| 21155 | with LeFort I |
| 21159 | Reconstruction midface, LeFort III (extra and intra-cranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I |
| 21160 | with LeFort I |
| 21172 | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) |
| 21175 | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) |
| 21179 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) |
| 21180 | with autograft (includes obtaining grafts) |
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) |
| 21193 | Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft |
| 21194 | with bone graft (includes obtaining graft) |
| 21195 | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation |
| 21196 | with internal rigid fixation |
| 21198 | Osteotomy, mandible, segmental; |
| 21199 | with genioglossus advancement |
| 21206 | Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) |
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) |
| 21210 | Graft, bone; nasal maxillary or malar areas (includes obtaining graft) |
| 21215 | mandible (includes obtaining graft) |
| 21230 | Graft, rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) |
| 21235 | ear cartilage, autogenous, to nose or ear (includes obtaining graft) |
| 21244 | Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate) |
| 21245 | Reconstruction of mandible or maxilla, subperiosteal implant; partial |
| 21246 | complete |
| 21247 | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia) |
| 21248 | Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial |
| 21249 | complete |
| 21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) |
| 21270 | Malar augmentation prosthetic material |
| 21275 | Secondary revision of orbitocraniofacial reconstruction |
| 21280 | Medial canthopexy (separate procedure) |
| 21282 | Lateral canthopexy |
| 21740 | Reconstructive repair of pectus excavatum or carinatum |
| 30150 | Rhinectomy; partial |
| 30160 | total |
| 30400 | Rhinoplasty; primary; lateral and alar cartilages and/or elevation of nasal tip |
| 30410 | complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip |
| 30420 | including major septal repair |
| 30430 | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) |
| 30435 | intermediate revision (bony work with osteotomies) |
| 30450 | major revision (nasal tip work and osteotomies) |
| 30620 | Septal or other intranasal dermatoplasty (does not include obtaining graft) |
| 36468 | Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk |
| 36469 | face |
| 36470 | Injection of sclerosing solution; single vein |
| 36471 | multiple veins, same leg |
| 37788 | Penile revascularization, artery, with or without vein graft |
| 37790 | Penile venous occlusive procedure |
| 40820 | Destruction of lesion or scar of vestibule of mouth by physical methods (e.g., laser, thermal, cryo, chemical) |
| 41510 | Suture of tongue to lip for micrognathia (Douglas type procedure) |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material |
| 67902 | frontalis muscle technique with fascial sling (includes obtaining fascia) |
| 67903 | (tarso) levator resection or advancement, internal approach |
| 67904 | (tarso) levator resection or advancement external approach |
| 67906 | superior rectus technique with fascial sling (includes obtaining fascia) |
| 67908 | conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type) |
| 67909 | Reduction of overcorrection of ptosis |
| 67911 | Correction of lid retraction |
| 69300 | Otoplasty, protruding ear, with or without size reduction |
| 96405 | Chemotherapy administration, intralesional; up to and including 7 lesions |
| 96406 | more than 7 lesions |
| HCPCS Code | Description |
|---|---|
| C1789 | Prosthesis, breast (Implantable) |
| L8600 | Implantable breast prosthesis, silicone or equal |
| S0196 | Injectable poly-l-lactic acid, restorative, implant, 1 ml, face (deep dermis, subcutaneous layers) |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|