Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-027 - DMS-2005-W-1: 2004 HCPCS Final Procedure Code Conversion

Universal Citation: AR Admin Rules 016.06.05-027

Current through Register Vol. 49, No. 9, September, 2024

I. General Information

A final review of the HCPCS procedure codes has been completed and the Arkansas Medicaid Program will begin accepting updated HCPCS procedure codes on claims with dates of service on and after July 1, 2005.

II. 2004 HCPCS Payable Procedure Code Tables Information

Payable procedures codes have been broken into separate tables. Tables have been created for each payable provider type (e.g.: physician, hospital, etc.)

The tables are designed with nine columns of information. All columns may not be applicable for each covered program, but have been devised for ease of reference.

The first column contains the HCPCS procedure code. In some instances, the procedure code will be shown in multiples, depending on the number of types of service for which it can be used by a provider.

The second column is the procedure code description.

The third column is the type of service (TOS) code that may be used in conjunction with the procedure code. Type of service codes are used when billing on paper.

The fourth and fifth columns indicate any modifiers that need to be used in conjunction with the procedure code, when billing, either electronically or on paper. The columns are titled "Ml" and "M2". This information is used in the prosthetics program.

The sixth column indicates the diagnosis list, and is titled "Diag. List". The information is used by physicians, hospitals, independent radiology, ambulatory surgical centers, area health education centers and nurse practitioners. Applicable lists will be discussed in each provider's section.

The seventh column indicates whether a review must be completed when providing a service. The column is titled "Review Y/N". A "Y" in a column means that a review is necessary; an "N" indicates that a review is not necessary. Providers should consult their program manual to obtain the information that is needed for a review.

The eighth column shows procedure codes that require prior authorization (PA) before payment. The column is titled PA, Y/N". An alpha "Y" in the column indicates that a procedure code requires prior authorization and an "N" means that the code does not require prior authorization. Providers should consult their program manual to ascertain what information should be provided for the prior authorization process.

The ninth column shows procedure codes that require manual pricing and is titled "MP Y/N". An alpha "Y" in the column indicates that an item is manually priced and an "N" shows that an item is not manually priced. Providers should consult their program manual to review the process involved in manual pricing.

III. Diagnosis Lists

The following are the diagnosis lists referred to in column six which are used by physicians, hospitals, independent radiology, ambulatory surgical centers, area health education centers and nurse practitioners. The diagnosis list refers to specific ICD-9 codes and certain procedure codes are limited by the diagnosis lists. Not all providers use all the lists, but they are shown for clarity of information.

Diagnosis List 003

ICD 9 Codes

042

1400 through 20891

Diagnosis List 006:

ICD-9 Codes: 41010 through 41092 4110 through 41189 4130 through 4139 41400 through 4149

Diagnosis List 007

ICD-9 Codes:

1622 through 1629

7931

Diagnosis List 008

ICD-9 Codes

1530 through 1539

1540 through 1541

Diagnosis List 009

ICD-9 Codes

20000 through 20008

20010 through 20018

20020 through 20028

20100 through 20198

20200 through 20298

Diagnosis List 010

ICD-9 Codes

1400 through 1409

1410 through 1419

1420 through 1429

1430 through 1439

1440 through 1449

1450 through 1459

1460 through 1469

1470 through 1479

1480 through 1489

1490 through 1499

1600 through 1609

1610 through 1619

1950

1960

Diagnosis List 011

ICD-9 Codes

1500 through 1509

1510

Diagnosis List 012

ICD-9 Codes

34501

34511

Diagnosis List 013

ICD-9 Codes

41000 through 41092

4110 through 41189

4130 through 4139

41400 through 41405

41410 through 41419

Diagnosis List 014

ICD-9 Codes

1740 through 1749

1750

2330

Diagnosis List 015

ICD-9 Codes

193

2374

V1087

IV. HCPCS Codes Payable for Physicians

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review Y/N	PA Y/N	MP Y/N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	C	00	00	006	N	N	N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	P	00	00	006	N	N	N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	T	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	C	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	P	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	T	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	C	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	P	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	T	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	C	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	P	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	T	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	C	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	P	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	T	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	C	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	P	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	T	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	C	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	P	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	T	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	C	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	P	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	T	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	C	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	P	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	T	00	00	006	N	N	N

G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	C	006	N	N	N
G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	P	006	N	N	N
G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	T	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	C	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	P	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	T	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	C	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	P	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	T	006	N	N	N
G0042	PET myocard perf imag, (after 78481/78483) single study, rest/stress	C	006	N	N	N
G0042	PET myocard perf imag, (after 78481/78483) single study, rest/stress	P	006	N	N	N
G0042	PET myocard perf imag, (after 78481/78483) single study, rest/stress	T	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	C	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	P	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	T	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	C	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	P	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	T	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	C	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	P	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	T	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	C	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	P	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	T	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	C	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	P	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	T	006	N	N	N

G0125	PET imag regional/whole body; single pulmonary nodule	C	007	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	P	007	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	T	007	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites; appendicular skeleton	C	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites; appendicular skeleton	P	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites; appendicular skeleton	T	N	N	N
G0166	External counterpulsation, per treatment session	C	N	N	N
G0166	External counterpulsation, per treatment session	P	N	N	N
G0166	External counterpulsation, per treatment session	T	N	N	N
G0173	Linear accelerator based stereotactic radiosurgery, complete course of therapy/1 session	2	N	N	Y
G0173	Linear accelerator based stereotactic radiosurgery, complete course of therapy/1 session	8	N	N	Y
G0186	Destruction localized lesion of choroid, feeder vessel tech, 1 or [GREATER THAN] sess	2	N	N	Y
G0186	Destruction localized lesion of choroid, feeder vessel tech, 1 or [GREATER THAN] sess	8	N	N	Y
G0202	Screening mammography, producing direct digital image, bilateral, all views	C	N	N	N
G0202	Screening mammography, producing direct digital image, bilateral, all views	P	N	N	N
G0202	Screening mammography, producing direct digital image, bilateral, all views	T	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	C	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	P	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	T	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	C	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	P	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	T	N	N	N
G0210	PET imaging whole body; diagnosis; lung cancer, non-small cell	C	007	N	N	N
G0210	PET imaging whole body; diagnosis; lung cancer, non-small cell	P	007	N	N	N
G0210	PET imaging whole body; diagnosis; lung cancer, non-small cell	T	007	N	N	N
G0211	PET imaging whole body; initial staging; lung cancer; non-small cell	C	007	N	N	N
G0211	PET imaging whole body; initial staging; lung cancer; non-small cell	P	007	N	N	N
G0211	PET imaging whole body; initial staging; lung cancer; non-small cell	T	007	N	N	N
G0212	PET imaging whole body; restaging; lung cancer; non-small	C	007	N	N	N
G0212	PET imaging whole body; restaging; lung cancer; non-small	P	007	N	N	N
G0212	PET imaging whole body; restaging; lung cancer; non-small	T	007	N	N	N
G0213	PET imaging whole body; diagnosis; colorectal	C	008	N	N	N
G0213	PET imaging whole body; diagnosis; colorectal	P	008	N	N	N
G0213	PET imaging whole body; diagnosis; colorectal	T	008	N	N	N

* Procedure code limited to diagnosis range 1720 through 1729.

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review Y/N	PA Y/N	MP Y/N
G0214	PET imaging whole body; initial staging; initial staging; colorectal	C	00	00	008	N	N	N
G0214	PET imaging whole body; initial staging; initial staging; colorectal	P	00	00	008	N	N	N
G0214	PET imaging whole body; initial staging; initial staging; colorectal	T	00	00	008	N	N	N
G0215	PET imaging whole body; restaging; colorectal cancer	C	00	00	008	N	N	N
G0215	PET imaging whole body; restaging; colorectal cancer	P	00	00	008	N	N	N
G0215	PET imaging whole body; restaging; colorectal cancer	T	00	00	008	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	C	00	00	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	P	00	00	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	T	00	00	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	C	00	00	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	P	00	00	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	T	00	00	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	C	00	00	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	P	00	00	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	T	00	00	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	C	00	00	009	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	P	00	00	009	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	T	00	00	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	C	00	00	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	P	00	00	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	T	00	00	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	C	00	00	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	P	00	00	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	T	00	00	009	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	C	00	00	010	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	P	00	00	010	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	T	00	00	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	C	00	00	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	P	00	00	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	T	00	00	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	C	00	00	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	P	00	00	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	T	00	00	010	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	C	00	00	011	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	P	00	00	011	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	T	00	00	011	N	N	N

G0227	PET imaging whole body; initial staging; esophageal cancer	C	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	P	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	T	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	C	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	P	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	T	011	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	C	012	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	P	012	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	T	012	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	C	013	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	P	013	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	T	013	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	C	008	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	P	008	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	T	008	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	C	009	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	P	009	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	T	009	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	C	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	P	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	T	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	C	007	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	P	007	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	T	007	N	N	N
G0242	Multi-source photon stereotactic radiosurg, per course oftx	2	N	N	Y
G0242	Multi-source photon stereotactic radiosurg, per course oftx	8	N	N	Y
G0243	Multi-source photon stereotactic radiosurg, complete course oftx	2	N	N	Y
G0243	Multi-source photon stereotactic radiosurg, complete course oftx	8	N	N	Y
G0251	Linear accel based stereotactic radiosurg, all lesions, max 5 sessions	2	N	N	Y
G0251	Linear accel based stereotactic radiosurg, all lesions, max 5 sessions	8	N	N	Y

G0253	PET imaging, breast cancer recurrence or distant metastases	C	014	N	N	N
G0253	PET imaging, breast cancer recurrence or distant metastases	P	014	N	N	N
G0253	PET imaging, breast cancer recurrence or distant metastases	T	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course oftx	C	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course oftx	P	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course oftx	T	014	N	N	N
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	C	N	N	Y
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	P	N	N	Y
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	T	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	C	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	P	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	T	N	N	Y
G0267	Bone marrow/perip stem cell harvest mod or tx to elim cell type	2	N	N	Y
G0267	Bone marrow/perip stem cell harvest mod or tx to elim cell type	8	N	N	Y
G0269	Placement occlusive device venous/arterial access site, post surg	2	N	N	Y
G0269	Placement occlusive device venous/arterial access site, post surg	8	N	N	Y
G0269	Placement occlusive device venous/arterial access site, post surg	G	N	N	Y
G0275	Renal angiography, unilat or bilat, perf at time of cardiac cath, w/radiologic super & interpret	C	N	N	N
G0275	Renal angiography, unilat or bilat, perf at time of cardiac cath, w/radiologic super & interpret	P	N	N	N
G0278	Iliac artery angiography, at same time of cardiac cath, radiologic supervision & intepret	C	N	N	N
G0278	Iliac artery angiography, at same time of cardiac cath, radiologic supervision & intepret	P	N	N	N
G0279	Extracorporeal shock wave therapy; involving elbow epicondylitis	2	N	N	Y
G0279	Extracorporeal shock wave therapy; involving elbow epicondylitis	8	N	N	Y
G0280	Extracorp Shockwave ther; involv oth than elbow epicon/plant fascitis	2	N	N	Y
G0280	Extracorp Shockwave ther; involv oth than elbow epicon/plant fascitis	8	N	N	Y
G02961	Pet imaging, restaging thyroid cancer	C	015	N	N	Y
G02961	Pet imaging, restaging thyroid cancer	P	015	N	N	Y
G02961	Pet imaging, restaging thyroid cancer	T	015	N	N	Y
J0200	Injection, alatrofloxacin mesylate, 100mg	1	003	N	N	N
J0275	Alprostadil urethral suppository	1	003	N	N	N
J0287	Injection, amphotericin B cholesteryl sulfate	1	003	N	N	N
J0288	Injection, amphotericin B cholesteryl sulfate complex, 10mg	1	003	N	N	N

J0289	Injection, amphotericin B liposome, 10 mg	003	N	N	N
J0456	Injection, azithromycin, 500 mg	003	N	N	N
J0476	Injection, baclofen, 50 meg for intrathecal trial	003	N	N	N
J0592	Injection, buprenorphine hydrochloride, 0.1 mg	003	N	N	N
J0637	Injection, caspofungin acetate, 5 mg	N	N	N
J0692	Injection, cefepime HCI, 500 mg	003	N	N	N
J0706	Injection, caffeine citrate, 5 mg	003	N	N	N
J0744	Injection, ciprofloxacin for intravenous infusion, 200 mg	003	N	N	N
J0880	Injection, darbepoetin alfa, 5 meg	Y	N	N
J1270	Injection, doxercalciferol, 1 meg	003	N	N	N
J1450	Injection, fluconazole, 200 mg	003	N	N	N
J1452	Injection, omivirsen sodium, intraocular, 1.65 mg	003	N	N	N
J1590	Injection, gatifloxacin, 10 mg	003	N	N	N
J1652	Injection, fondaparinux sodium, 0.5 mg	003	N	N	N
J1655	Injection, tinzaparin sodium, 1000 IU	003	N	N	N
J1835	Injection, itraconazole, 50 mg	003	N	N	N
J1956	Injection, levofloxacin, 250 mg	003	N	N	N
J2020	Injection, linezolid, 200 mg	003	N	N	N
J2271	Injection, morphine sulfate, 100 mg	003	N	N	N
J2355	Injection, oprelvekin, 5 mg	003	N	N	N
J2501	Injection, paricalcitol, 1 meg	003	N	N	N
J2543	Inject, piperacillin sodium/tazobactam sodium, 1 g/0.125 g (1.125 g)	003	N	N	N
J2770	Injection, quinupristin/dalfopristin, 500 mg (150/350)	003	N	N	N
J2780	Injection, ranitidine HCI, 25 mg	003	N	N	N
J2792	Inject, Rho D immune globulin, IV, human, solvent detergent, 100 IU	N	N	N
J2941	Injection, somatropin, 1 mg	003	N	N	N
J3315	Injection, triptorelin pamoate, 3.75 mg	003	N	N	N
J3395	Injection, verteporfin, 15 mg	Y	N	N
J3485	Injection, zidovudine, 10 mg	003	N	N	N
J3487	Injection, zoledronic acid, 1 mg	Y	N
J3590	Unclassified biologies	Y	N	Y
J7193	Factor IX, (antihemophilic factor, purified, non-recombinant) perlU	N	N	N
J7195	Factor IX, (antihemophilic factor, recombinant) per IU	N	N
J7198	Anti-inhibitor, per IU	003	N	N	N
J7308	Aminolevulinic acid HCI, top adm, 20%, sgl unit dose form (354 mg)	003	N	N	N
J7330	Autologous cultured chondrocytes, implant	003	N	Y	N
J7350	Dermal tissue, human, inj, w/o metabolized active elem, per 10 mg	N	N	Y
J7502	Cyclosporine, oral, 100 mg	Y	N	N
J7511	Lymphocyte immune glob, antithymocyte glob, rabbit, paren, 25 mg	003	N	N	N
J7513	Daclizumab, parenteral, 25 mg	003	N	N	N
J7515	Cyclosporine, oral, 25 mg	Y	N	N
J7516	Cyclosporine, parenteral, 250 mg	Y	N	N
J7517	Mycophenolate mofetil, oral, 250 mg	Y	N	N

J7520	Sirolimus, oral, 1 mg	00	Y	N	N
J7525	Tacrolimus, parenteral, 5 mg	00	Y	N	N
J9017	Arsenic trioxide, 1 mg (Trisenox)	00	003	N	N	N
J9151	Daunorubicin citrate, liposomal formulation, 10 mg	00	003	N	N	N
J9357	Valrubicin, intravesical, 200 mg	00	003	N	N	N
Q2006	Injection, digoxin immune fab (ovine), per vial	00	003	N	N	N
Q2008	Injection, fomepizole, 15 mg	00	003	N	N	N
Q2009	Injection, fosphenytoin, 50 mg	00	003	N	N	N
Q2011	Injection, hemin, per 1 mg	00	003	N	N	N
Q2012	Injection, pegademase bovine, 25 IU	00	003	N	N	N
Q2013	Injection, pentastarch, 10% solution, per 100 ml	00	003	N	N	Y
Q2017	Injection, teniposide, 50 mg	00	003	N	N	N
Q2019	Injection, basiliximab, 20 mg	00	003	N	N	N
Q2020	Injection, histrelin acetate, 10 mg	00	003	N	N	Y
Q2021	Injection, lepirudin, 50 mg	00	003	N	N	N
Q2022	von Willebrand factor complex, human, per IU	00	003	N	N	N
Q3025	Injection, interferon beta-1A, 11mcg for IM use	00	003	N	N	N
Q3026	Injection, interferon beta-1A, 11mcg for subcu use	00	003	N	N	N
S0016	Injection, amikacin sulfate, 500 mg	00	003	N	N	Y
S0017	Injection, aminocaproic acid, 5 grams	00	003	N	N	Y
S0021	Injection, ceftoperazone sodium, 1 gram	00	003	N	N	Y
S0023	Injection, cimetidine HCI, 300 mg	00	003	N	N	Y
S0028	Injection, famotidine, 20 mg	00	003	N	N	Y
S0030	Injection, metronidazole, 500 mg	00	003	N	N	Y
S0032	Injection, nafcillin sodium, 2 grams	00	003	N	N	Y
S0034	Injection, ofloxacin, 400 mg	00	003	N	N	Y
S0039	Injection, sulfamethoxazole and trimethoprim, 10 ml	00	003	N	N	Y
S0040	Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams	00	003	N	N	Y
S0071	Injection, acyclovir sodium, 50 mg	00	003	N	N	Y
S0072	Injection, amikacin sulfate, 100 mg	00	003	N	N	Y
S0073	Injection, aztreonam, 500 mg	00	003	N	N	Y
S0074	Injection, cefotetan disodium, 500 mg	00	003	N	N	Y
S0077	Injection, clindamycin phosphate, 300 mg	00	003	N	N	Y
S0080	injection, pentamidine isethionate, 300 mg	00	003	N	N	Y
S0081	Injection, piperacillin sodium, 500 mg	00	003	N	N	Y
S0092	Injection, hydromorphone hydrochloride, 250 mg	00	003	N	N	Y
S0093	Injection, morphine sulfate, 500 mg	00	003	N	N	Y
S0610	Annual gynecological examination; new patient	00	N	N	Y
S0610	Annual gynecological examination; new patient	N	00	N	N	Y
S0612	Annual gynecological examination; established patient	1	00	N	N	Y
S2112	Arthroscopy, knee, surgical for harvesting of cartilage	2	00	N	Y	Y
S2112	Arthroscopy, knee, surgical for harvesting of cartilage	8	00	N	Y	Y
S2115	Osteotomy, periacetabular, with internal fixation	2	00	N	N	Y
S2115	Osteotomy, periacetabular, with internal fixation	8	00	N	N	Y
S2202	Echosclerotherapy	1	00	N	N	Y

S2342	Nasal endoscopy for post-op debridement, unilateral or bilateral	2	N	N	Y
S2342	Nasal endoscopy for post-op debridement, unilateral or bilateral	8	N	N	Y
S2350	Diskectomy, anterior; lumbar, single interspace	2	N	N	Y
S2350	Diskectomy, anterior; lumbar, single interspace	8	N	N	Y
S2351	Diskectomy, anterior; lumbar, each additional interspace	2	N	N	Y
S2351	Diskectomy, anterior; lumbar, each additional interspace	8	N	N	Y
S2400	Repair, congenital diaphragmatic hernia in the fetus, in utero	2	Y	N	Y
S2400	Repair, congenital diaphragmatic hernia in the fetus, in utero	8	Y	N	Y
S2401	Repair, urinary tract obstruction in fetus, in utero	2	Y	N	Y
S2401	Repair, urinary tract obstruction in fetus, in utero	8	Y	N	Y
S2402	Repair, congenital cystic adenomatoid malformation in fetus, in utero	2	Y	N	Y
S2402	Repair, congenital cystic adenomatoid malformation in fetus, in utero	8	Y	N	Y
S2403	Repair, extralobar pulmonary sequestration in fetus, in utero	2	Y	N	Y
S2403	Repair, extralobar pulmonary sequestration in fetus, in utero	8	Y	N	Y
S2404	Repair, myelomeningocele in fetus, in utero	2	Y	N	Y
S2404	Repair, myelomeningocele in fetus, in utero	8	Y	N	Y
S2405	Repair of sacrococcygeal teratoma in fetus, in utero	2	Y	N	Y
S2405	Repair of sacrococcygeal teratoma in fetus, in utero	8	Y	N	Y
S2409	Repair, congenital malformation of fetus, in utero, NOC	2	Y	N	Y
S2409	Repair, congenital malformation of fetus, in utero, NOC	8	Y	N	Y
S2411	Fetoscopic laser therapy for tx of twin-to-twin transfusion syndrome	2	Y	N	Y
S2411	Fetoscopic laser therapy for tx of twin-to-twin transfusion syndrome	8	Y	N	Y
S3620	Newborn metabolic screening panel	C	N	N	Y
S3620	Newborn metabolic screening panel	T	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	C	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	P	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	T	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	C	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	P	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	T	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	C	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	P	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	T	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	C	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	P	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	T	N	N	Y

S3904	Masters two step	C	N	N	Y
S3904	Masters two step	P	N	N	Y
S3904	Masters two step	T	N	N	Y
S8030	Scleral app of tantalum ring(s) for local lesions for proton beam therapy	2	N	N	Y
S8030	Scleral app of tantalum ring(s) for local lesions for proton beam therapy	8	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	C	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	P	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	T	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	C	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	P	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	T	N	N	Y
S8110	Peak expiratory flow rate (physician services)	C	N	N	Y
S8110	Peak expiratory flow rate (physician services)	P	N	N	Y
S8110	Peak expiratory flow rate (physician services)	T	N	N	Y
S9015	Automated EEG monitoring	C	N	N	Y
S9015	Automated EEG monitoring	P	N	N	Y
S9015	Automated EEG monitoring	T	N	N	Y
S9024	Paranasal sinus ultrasound	C	N	N	Y
S9024	Paranasal sinus ultrasound	P	N	N	Y
S9024	Paranasal sinus ultrasound	T	N	N	Y
S9109	CHF telemonitoring, equip rent, and maintenance, per month	1	N	N	Y
V2623	Prosthetic eye, plastic, custom	D	N	N	Y
V2629	Prosthetic eye, other type	D	N	N	Y

1 Please note: For claims received on July 1, 2005 and after, procedure code G0296 will be restricted to a detail diagnosis included in List 015.

V. Payable HCPCS Procedure Codes for Hospitals

* Procedure code limited to diagnosis range 1720 through 1729.

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review	PA	MP Y/N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	G	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	G	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	G	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	G	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	G	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	G	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	G	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	G	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	G	00	00	006	N	N	N
G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	G	00	00	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	G	00	00	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stressN	G	00	00	006	N	N	N
G0042	PET myocard perf imag, (after 78481A78483) single study, rest/stress	G	00	00	006	N	N	N
G0043	PET myocard perf imag, (after 78481A78483) mult studies, rest/stress	G	00	00	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	G	00	00	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	G	00	00	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	G	00	00	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	G	00	00	006	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	G	00	00	007	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites; appendicular skeleton	G	00	00	N	N	N
G0166	External counterpulsation, per treatment session	G	00	00	N	N	N
G0173	Linear accelerator based stereotactic radiosurgery, complete course of therapy/1 session	G	00	00	N	N	Y
G0186	Destruction localized lesion of choroid, feeder vessel tech, 1 or [GREATER THAN] sess	G	00	00	N	N	Y
G0202	Screening mammography, producing direct digital image, bilateral, all views	G	00	00	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	G	00	00	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	G	00	00	N	N	N
G0210	PET imaging whole body; diagnosis; lung cancer, non-small cell	G	00	00	007	N	N	N
G0211	PET imaging whole body; initial staging; lung cancer; non-small cell	G	00	00	007	N	N	N
G0212	PET imaging whole body; restaging; lung cancer; non-small	G	00	00	007	N	N	N
G0213	PET imaging whole body; diagnosis; colorectal	G	00	00	008	N	N	N

G0214	PET imaging whole body; initial staging; initial staging; colorectal	G	008	N	N	N
G0215	PET imaging whole body; restaging; colorectal cancer	G	008	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	G	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	G	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	G	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	G	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	G	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	G	009	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	G	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	G	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	G	010	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	G	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	G	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	G	011	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	G	012	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	G	013	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	G	008	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	G	009	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	G	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	G	007	N	N
G0242	Multi-source photon stereotactic radiosurg, per course of tx	G	N	N	Y
G0243	Multi-source photon stereotactic radiosurg, complete course of tx	G	N	N	Y
G0251	Linear accel based stereotactic radiosurg, all lesions, max 5 sessions	G	N	N	Y
G0253	PET imaging, breast cancer recurrence or distant metastases	G	014	N	N
G0254	PET imag breast cancer, eval response to tx during course of tx	G	014	N	N
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	G	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	G	N	N	Y
G0267	Bone marrow/perip stem cell harvest mod or tx to elim cell typeY	G	N	N	Y
G0269	Placement occlusive device venous/arterial access site, post surg	G	N	N	Y
G0279	Extracorporeal shock wave therapy; involving elbow epicondylitis	G	N	N	Y
G0280	Extracorp shock wave ther; involv oth than elbow epicon/plant fascitis	G	N	N	Y
G02961	Pet imaging, restaging thyroid cancer	T	015	N	N	Y
J0130	Injection abciximab, 10 mg	G	003	N	N	N

J0200	Injection, alatrofloxacin mesylate, 100mg	G	003	N	N	N
J0275	Alprostadil urethral suppository	G	003	N	N	N
J0282	Injection, amiodarone HCI, 30 mg	G	003	N	N	N
J0287	Injection, amphotericin B cholesteryl sulfate	G	003	N	N	N
J0288	Injection, amphotericin B cholesteryl sulfate complex, 10mg	G	003	N	N	N
J0289	Injection, amphotericin B liposome, 10 mg	G	003	N	N	N
J0456	Injection, azithromycin, 500 mg	G	003	N	N	N
J0476	Injection, baclofen, 50 meg for intrathecal trial	G	003	N	N	N
J0592	Injection, buprenorphine hydrochloride, 0.1 mg	G	003	N	N	N
J0637	Injection, caspofungin acetate, 5 mg	G	N	N	N
J0692	Injection, cefepime HCI, 500 mg	G	003	N	N	N
J0706	Injection, caffeine citrate, 5 mg	G	003	N	N	N
J0744	Injection, ciprofloxacin for intravenous infusion, 200 mg	G	003	N	N	N
J0880	Injection, darbepoetin alfa, 5 meg	G	Y	N	N
J1270	Injection, doxercalciferol, 1 meg	G	003	N	N	N
J1327	Injection, eptifibatide, 5 mg	G	003	N	N	N
J1450	Injection, fluconazole, 200 mg	G	003	N	N	N
J1452	Injection, omivirsen sodium, intraocular, 1.65 mg	G	003	N	N	N
J1590	Injection, gatifloxacin, 10 mg	G	003	N	N	N
J1652	Injection, fondaparinux sodium, 0.5 mg	G	003	N	N	N
J1655	Injection, tinzaparin sodium, 1000 IU	G	003	N	N	N
J1835	Injection, itraconazole, 50 mg	G	003	N	N	N
J1956	Injection, levofloxacin, 250 mg	G	003	N	N	N
J2020	Injection, linezolid, 200 mg	G	003	N	N	N
J2271	Injection, morphine sulfate, 100 mg	G	003	N	N	N
J2324	Injection, nesiritide, 0.25 mg	G	003	N	N	N
J2355	Injection, oprelvekin, 5 mg	G	003	N	N	N
J2501	Injection, paricalcitol, 1 meg	G	003	N	N	N
J2543	Inject, piperacillin sodium/tazobactam sodium, 1 g/0.125 g (1.125 g)	G	003	N	N	N
J2770	Injection, quinupristin/dalfopristin, 500 mg (150/350)	G	003	N	N	N
J2780	Injection, ranitidine HCI, 25 mg	G	003	N	N	N
J2792	Inject, Rho D immune globulin, IV, human, solvent detergent, 100 IU	G	N	N	N
J2941	Injection, somatropin, 1 mg	G	003	N	N	N
J2993	Injection, reteplase, 18.1 mg	G	003	N	N	N
J3245	Injection, tirofiban HCI, 12.5 mg	G	003	N	N	N
J3315	Injection, triptorelin pamoate, 3.75 mg	G	003	N	N	N
J3395	Injection, verteporfin, 15 mg	G	Y	N	N
J3485	Injection, zidovudine, 10 mg	G	003	N	N	N
J3487	Injection, zoledronic acid, 1 mg	G	Y	N	N
J3590	Unclassified biologies	G	Y	N	Y
J7193	Factor IX, (antihemophilic factor, purified, non-recombinant) per IU	G	N	N	N
J7195	Factor IX, (antihemophilic factor, recombinant) per IU	G	N	N	N
J7198	Anti-inhibitor, per IU	G	003	N	N	N

Q1005	New technology intraocular lens category 5	G	N	N	Y
Q2006	Injection, digoxin immune fab (ovine), per vial	G	003	N	N	N
Q2008	Injection, fomepizole, 15 mg	G	003	N	N	N
Q2009	Injection, fosphenytoin, 50 mg	G	003	N	N	N
Q2011	Injection, hemin, per 1 mg	G	003	N	N	N
Q2012	Injection, pegademase bovine, 25 IU	G	003	N	N	N
Q2013	Injection, pentastarch, 10% solution, per 100 ml	G	003	N	N	Y
Q2017	Injection, teniposide, 50 mg	G	003	N	N	N
Q2019	Injection, basiliximab, 20 mg	G	003	N	N	N
Q2020	Injection, histrelin acetate, 10 mg	G	003	N	N	Y
Q2021	Injection, lepirudin, 50 mg	G	003	N	N	N
Q2022	von Willebrand factor complex, human, per IU	G	003	N	N	N
Q3025	Injection, interferon beta-1A, 11mcg for IM use	G	003	N	N	N
Q3026	Injection, interferon beta-1A, 11mcg for subcu use	G	003	N	N	N
S0016	Injection, amikacin sulfate, 500 mg	G	003	N	N	Y
S0017	Injection, aminocaproic acid, 5 grams	G	003	N	N	Y
S0020	Injection, bupivicaine HCI, 30 mg	G	N	N	Y
S0021	Injection, ceftoperazone sodium, 1 gram	G	003	N	N	Y
S0023	Injection, cimetidine HCI, 300 mg	G	003	N	N	Y
S0028	Injection, famotidine, 20 mg	G	003	N	N	Y
S0030	Injection, metronidazole, 500 mg	G	003	N	N	Y
S0032	Injection, nafcillin sodium, 2 grams	G	003	N	N	Y
S0034	Injection, ofloxacin, 400 mg	G	003	N	N	Y
S0039	Injection, sulfamethoxazole and trimethoprim, 10 ml	G	003	N	N	Y
S0040	Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams	G	003	N	N	Y
S0071	Injection, acyclovir sodium, 50 mg	G	003	N	N	Y
S0072	Injection, amikacin sulfate, 100 mg	G	003	N	N	Y
S0073	Injection, aztreonam, 500 mg	G	003	N	N	Y
S0074	Injection, cefotetan disodium, 500 mg	G	003	N	N	Y
S0077	Injection, clindamycin phosphate, 300 mg	G	003	N	N	Y
S0078	Injection, fosphenytoin sodium, 750 mg	G	003	N	N	Y
S0080	injection, pentamidine isethionate, 300 mg	G	003	N	N	Y
S0081	Injection, piperacillin sodium, 500 mg	G	003	N	N	Y
S0092	Injection, hydromorphone hydrochloride, 250 mg	G	003	N	N	Y
S0093	Injection, morphine sulfate, 500 mg	G	003	N	N	Y
S0171	Injection, bumetanide, 0.5 mg	G	003	N	N	Y
S2112	Arthroscopy, knee, surgical for harvesting of cartilage	G	N	Y	Y
S2115	Osteotomy, periacetabular, with internal fixation	G	N	N	Y
S2202	Echosclerotherapy	G	N	N	Y
S2342	Nasal endoscopy for post-op debridement, unilateral or bilateral	G	N	N	Y
S2350	Diskectomy, anterior; lumbar, single interspace	G	N	N	Y
S2400	Repair, congenital diaphragmatic hernia in the fetus, in utero	G	Y	N	Y
S2401	Repair, urinary tract obstruction in fetus, in utero	G	Y	N	Y
S2402	Repair, congenital cystic adenomatoid malformation in fetus, in utero	G	Y	N	Y
S2403	Repair, extralobar pulmonary sequestration in fetus, in utero	G	Y	N	Y

S2404	Repair, myelomeningocele in fetus, in utero	G	Y	N	Y
S2405	Repair of sacrococcygeal teratoma in fetus, in utero	G	Y	N	Y
S2409	Repair, congenital malformation of fetus, in utero, NOC	G	Y	N	Y
S2411	Fetoscopic laser therapy for tx of twin-to-twin transfusion syndrome	G	Y	N	Y
S3620	Newborn metabolic screening panel	G	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	G	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	G	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	G	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	G	N	N	Y
S3904	Masters two step	G	N	N	Y
S8030	Scleral app of tantalum ring(s) for local lesions for proton beam therapy	G	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	G	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	G	N	N	Y
S8110	Peak expiratory flow rate (physician services)	G	N	N	Y
S9015	Automated EEG monitoring	G	N	N	Y
S9024	Paranasal sinus ultrasound	G	N	N	Y

iPlease note: For claims received on July 1, 2005 and after, procedure code G0296 will be restricted to a detail diagnosis included in List 015.

VI. Payable HCPCS Procedure Codes for Independent Radiology

1 Please note: For claims received on July 1, 2005 and after, procedure code G0296 will be restricted to a detail diagnosis included in List 015.

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review	PA	MP Y/N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	C	00	00	006	N	N	N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	P	00	00	006	N	N	N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	T	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	C	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	P	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	T	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	C	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	P	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	T	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	C	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	P	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	T	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	C	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	P	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	T	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	C	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	P	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	T	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	C	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	P	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	T	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	C	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	P	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	T	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	C	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	P	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	T	00	00	006	N	N	N

G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	C	006	N	N	N
G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	P	006	N	N	N
G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	T	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	C	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	P	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	T	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	C	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	P	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	T	006	N	N	N
G0042	PET myocard perf imag, (after 78481/78483) single study, rest/stress	C	006	N	N	N
G0042	PET myocard perf imag, (after 78481/78483) single study, rest/stress	P	006	N	N	N
G0042	PET myocard perf imag, (after 78481/78483) single study, rest/stress	T	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	C	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	P	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	T	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	C	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	P	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	T	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	C	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	P	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	T	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	C	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	P	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	T	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	C	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	P	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	T	006	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	C	007	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	P	007	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	T	007	N	N	N

G0130	Bone density study, 1 or [GREATER THAN] sites, appendicular skeleton	C	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites, appendicular skeleton	P	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites, appendicular skeleton	T	N	N	N
G0166	External counterpulsation, per treatment session	C	N	N	N
G0166	External counterpulsation, per treatment session	P	N	N	N
G0166	External counterpulsation, per treatment session	T	N	N	N
G0202	Screening mammography, producing direct digital image, bilateral, all views	C	N	N	N
G0202	Screening mammography, producing direct digital image, bilateral, all views	P	N	N	N
G0202	Screening mammography, producing direct digital image, bilateral, all views	T	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	C	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	P	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	T	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	C	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	P	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all views	T	N	N	N
G0210	PET imaging whole body, diagnosis, lung cancer, non-small cell	C	007	N	N	N
G0210	PET imaging whole body, diagnosis, lung cancer, non-small cell	P	007	N	N	N
G0210	PET imaging whole body, diagnosis, lung cancer, non-small cell	T	007	N	N	N
G0211	PET imaging whole body, initial staging, lung cancer, non-small cell	C	007	N	N	N
G0211	PET imaging whole body, initial staging, lung cancer, non-small cell	P	007	N	N	N
G0211	PET imaging whole body, initial staging, lung cancer, non-small cell	T	007	N	N	N
G0212	PET imaging whole body, restagmg, lung cancer, non-small	C	007	N	N	N
G0212	PET imaging whole body, restagmg, lung cancer, non-small	P	007	N	N	N
G0212	PET imaging whole body, restagmg, lung cancer, non-small	T	007	N	N	N
G0213	PET imaging whole body, diagnosis, colorectal	C	008	N	N	N
G0213	PET imaging whole body, diagnosis, colorectal	P	008	N	N	N
G0213	PET imaging whole body, diagnosis, colorectal	T	008	N	N	N
G0214	PET imaging whole body, initial staging, initial staging, colorectal	C	008	N	N	N
G0214	PET imaging whole body, initial staging, initial staging, colorectal	P	008	N	N	N
G0214	PET imaging whole body, initial staging, initial staging, colorectal	T	008	N	N	N
G0215	PET imaging whole body, restagmg, colorectal cancer	C	008	N	N	N
G0215	PET imaging whole body, restagmg, colorectal cancer	P	008	N	N	N
G0215	PET imaging whole body, restagmg, colorectal cancer	T	008	N	N	N

*G0216	PET imaging whole body; diagnosis; melanoma	C	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	P	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	T	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	C	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	P	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	T	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	C	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	P	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	T	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	C	009	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	P	009	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	T	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	C	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	P	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	T	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	C	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	P	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	T	009	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	C	010	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	P	010	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	T	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	C	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	P	010	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	T	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	C	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	P	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	T	010	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	C	011	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	P	011	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	T	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	C	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	P	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	T	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	C	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	P	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	T	011	N	N	N

G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	C	012	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	P	012	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	T	012	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	C	013	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	P	013	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	T	013	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	C	008	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	P	008	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	T	008	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	C	009	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	P	009	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	T	009	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	C	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	P	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	T	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	C	007	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	P	007	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	T	007	N	N	N
G0253	PET imaging, breast cancer recurrence or distant metastases	C	014	N	N	N
G0253	PET imaging, breast cancer recurrence or distant metastases	P	014	N	N	N
G0253	PET imaging, breast cancer recurrence or distant metastases	T	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course of tx	C	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course of tx	P	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course of tx	T	014	N	N	N
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	C	N	N	Y
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	P	N	N	Y
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	T	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	C	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	P	N	N	Y

G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	T	N	N	Y
G0275	Renal angiography, unilat or bilat, perf at time of cardiac cath, w/radiologic super & interpret	C	N	N	N
G0275	Renal angiography, unilat or bilat, perf at time of cardiac cath, w/radiologic super & interpret	P	N	N	N
G0278	Iliac artery angiography, at same time of cardiac cath, radiologic supervision & intepret	C	N	N	N
G0278	Iliac artery angiography, at same time of cardiac cath, radiologic supervision & intepret	P	N	N	N
G02961	Pet Imaging, restaging thyroid cancer	c	015	N	N	Y
G02961	Pet Imaging, restaging thyroid cancer	p	015	N	N	Y
G02961	Pet Imaging, restaging thyroid cancer	T	015	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	c	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	p	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	T	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	C	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	P	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	T	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	C	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	P	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	T	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	C	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	P	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	T	N	N	Y
S3904	Masters two step	C	N	N	Y
S3904	Masters two step	P	N	N	Y
S3904	Masters two step	T	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	C	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	P	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	T	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	C	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	P	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	T	N	N	Y
S8110	Peak expiratory flow rate (physician services)	C	N	N	Y
S8110	Peak expiratory flow rate (physician services)	P	N	N	Y
S8110	Peak expiratory flow rate (physician services)	T	N	N	Y
S9015	Automated EEG monitoring	C	N	N	Y
S9015	Automated EEG monitoring	P	N	N	Y
S9015	Automated EEG monitoring	T	N	N	Y
S9024	Paranasal sinus ultrasound	C	N	N	Y
S9024	Paranasal sinus ultrasound	P	N	N	Y
S9024	Paranasal sinus ultrasound	T	N	N	Y

VII. Payable HCPCS Procedure Codes for Ambulatory Surgical Centers * Procedure code limited to diagnosis rage of 1720 through 1729.

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review	PA	MP Y/N
G0030	PET myocard perf imag, (after G0030-G0047) single study, rest/stress	T	00	00	006	N	N	N
G0031	PET myocard perf imag, (after G0030-G0047) mult studies, rest/stress	T	00	00	006	N	N	N
G0032	PET myocard perf imag, (after rest, 78464) single study, rest/stress	T	00	00	006	N	N	N
G0033	PET myocard perf imag, (after rest,78464) multi studies, rest/stress	T	00	00	006	N	N	N
G0034	PET myocard perf imag, (after stress, 78465) single study, rest/stress	T	00	00	006	N	N	N
G0035	PET myocard perf imag, (after stress, 78465) multi studies, rest/stress	T	00	00	006	N	N	N
G0036	PET myocard perf imag, (after 93510-93529) single study rest/stress	T	00	00	006	N	N	N
G0037	PET myocard perf imag, (after 93510-93529) mult studies, rest/stress	T	00	00	006	N	N	N
G0038	PET myocard perf imag, (after 78460) single study, rest/stress	T	00	00	006	N	N	N
G0039	PET myocard perf imag, (after 78460) mult studies, rest/stress	T	00	00	006	N	N	N
G0040	PET myocard perf imag, (after 93350) single study, rest/stress	T	00	00	006	N	N	N
G0041	PET myocard perf imag, (after 93350) mult studies, rest/stress	T	00	00	006	N	N	N
G0042	PET myocard perf imag, (after 78481 /78483) single study, rest/stress	T	00	00	006	N	N	N
G0043	PET myocard perf imag, (after 78481/78483) mult studies, rest/stress	T	00	00	006	N	N	N
G0044	PET myocard perf imag, (after 93000) single study, rest/stress	T	00	00	006	N	N	N
G0045	PET myocard perf imag, (after 93000) mult studies, rest/stress	T	00	00	006	N	N	N
G0046	PET myocard perf imag, (after 93015) single study, rest/stress	T	00	00	006	N	N	N
G0047	PET myocard perf imag, (after 93015) mult studies, rest/stress	T	00	00	006	N	N	N
G0125	PET imag regional/whole body; single pulmonary nodule	T	00	00	007	N	N	N
G0130	Bone density study, 1 or [GREATER THAN] sites; appendicular skeleton	T	00	00	N	N	N
G0166	External counterpulsation, per treatment session	T	00	00	N	N	N
G0173	Linear accelerator based stereotactic radiosurgery, complete course of therapy/1 session	G	00	00	N	N	Y
G0186	Destruction localized lesion of Dhoroids, feeder vessel tech, 1 or [GREATER THAN] sess	G	00	00	N	N	Y
G0202	Screening mammography, producing direct digital image, bilateral, all views	T	00	00	N	N	N
G0204	Diagnostic mammography, producing direct digital image, bilateral, all views	T	00	00	N	N	N
G0206	Diagnostic mammography, producing direct digital image, unilateral, all viewsN	T	00	00	N	N	N
G0210	PET imaging whole Nbody; diagnosis; lung cancer, non-small cell	T	00	00	007	N	N	N
G0211	PET imaging whole body; initial staging; lung cancer; non-small cell	T	00	00	007	N	N	N
G0212	PET imaging whole body; restaging; lung cancer; non-small	T	00	00	007	N	N	N
G0213	PET imaging whole body; diagnosis; colorectal	T	00	00	008	N	N	N

G0214	PET imaging whole body; initial staging; initial staging; colorectal	T	008	N	N	N
G0215	PET imaging whole body; restaging; colorectal cancer	T	008	N	N	N
*G0216	PET imaging whole body; diagnosis; melanoma	T	N	N	N
*G0217	PET imaging whole body; initial staging; melanoma	T	N	N	N
*G0218	PET imaging whole body; restaging; melanoma	T	N	N	N
G0220	PET imaging whole body; diagnosis; lymphoma	T	009	N	N	N
G0221	PET imaging whole body; initial staging; lymphoma	T	009	N	N	N
G0222	PET imaging whole body; restaging; lymphoma	T	009	N	N	N
G0223	PET imag whole body/region; diag; head/neck ca; ex/thyroid/CNS ca	T	010	N	N	N
G0224	PET imag whole body/region; init stag; head/neck ca; ex thyroid/CNS ca	T	010	N	N	N
G0225	PET imag whole body/region; restag; head/neck ca; ex thyroid/CNS ca	T	010	N	N	N
G0226	PET imaging whole body; diagnosis; esophageal cancer	T	011	N	N	N
G0227	PET imaging whole body; initial staging; esophageal cancer	T	011	N	N	N
G0228	PET imaging whole body; restaging; esophageal cancer	T	011	N	N	N
G0229	PET imaging; metabolic brain imag/pre-surg eval, refractory seizures	T	012	N	N	N
G0230	PET imag, metab assess/myocardial viability after inconclu SPECT	T	013	N	N	N
G0231	PET, whole body, recurrence colorectal cancer; gamma cameras only	T	008	N	N	N
G0232	PET, whole body, recurrence of lymphoma; gamma cameras only	T	009	N	N	N
*G0233	PET, whole body, recurrence of melanoma; gamma cameras only	T	N	N	N
G0234	PET, regional/whole body, pul nodule, lung ca, gamma cameras only	T	007	N	N	N
G0242	Multi-source photon stereotactic radiosurg, per course of tx	G	N	N	Y
G0243	Multi-source photon stereotactic radiosurg, complete course of tx	G	N	N	Y
G0251	Linear accel based stereotactic radiosurg, all lesions, max 5 sessions	G	N	N	Y
G0253	PET imaging, breast cancer recurrence or distant metastases	T	014	N	N	N
G0254	PET imag breast cancer, eval response to tx during course of tx	T	014	N	N	N
G0255	Curr percep threshold/sensory nerve conduct test, per limb, any nerve	T	N	N	Y
G0256	Prostate brachytherapy, Palladium seeds, perm interstitial rad source	T	N	N	Y
G0267	Bone marrow/perip stem cell harvest mod or tx to elim cell typeY	G	N	N	Y
G0269	Placement occlusive device venous/arterial access site, post surg	G	N	N	Y
G0279	Extracorporeal shock wave therapy; involving elbow epicondylitis	G	N	N	Y
G02961	Pet imaging, restaging thyroid cancer	G	N	N	Y
G0280	Extracorp shock wave ther; involv oth than elbow epicon/plant fascitis	G	N	N	Y
Q1001	New technology intraocular lens category 1	G	N	N	Y

Q1002	New technology intraocular lens category 2	G	N	N	Y
Q1003	New technology intraocular lens category 3	G	N	N	Y
Q1004	New technology intraocular lens category 4	G	N	N	Y
Q1005	New technology intraocular lens category 5	G	N	N	Y
Q2020	Injection, histrelin acetate, 10 mg	G	003	N	N	Y
S0092	Injection, hydromorphone hydrochloride, 250 mg	G	003	N	N	Y
S0093	Injection, morphine sulfate, 500 mg	G	003	N	N	Y
S2112	Arthroscopy, knee, surgical for harvesting of cartilage	G	N	Y	Y
S2115	Osteotomy, periacetabular, with internal fixation	G	N	N	Y
S2202	Echosclerotherapy	G	N	N	Y
S2342	Nasal endoscopy for post-op debridement, unilateral or bilateral	G	N	N	Y
S3620	Newborn metabolic screening panel	G	N	N	Y
S3701	Immunoassay for nuclear matrix protein 22, quantitative	T	N	N	Y
S3831	Single-mutation analysis for HNPCC genetic testing	T	N	N	Y
S3835	Complete gene seq analysis for cystic fibrosis genetic testing	T	N	N	Y
S3837	Complete gene sequence analy for hemochromatosis genetic testing	T	N	N	Y
S39041	Masters two step	T	N	N	Y
S8030	Scleral app of tantalum ring(s) for local lesions for proton beam therapy	G	N	N	Y
S8037	Magnetic resonance cholangiopancreatography	T	N	N	Y
S8075	Computer analy full-field dig mammogram & phy review for interpretation	T	N	N	Y
S8110	Peak expiratory flow rate (physician services)	T	N	N	Y
S9015	Automated EEG monitoring	T	N	N	Y
S9024	Paranasal sinus ultrasound	T	N	N	Y

1 Please note: For claims received on July 1, 2005 and after, procedure code G0296 will be restricted to a detail diagnosis included in List 015.

VIII. Payable HCPCS Procedure Codes for Area Health Education Centers (AHECs)

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review	PA	MP Y/N
J0200	Injection, alatrofloxacin mesylate, 100mg	00	00	003	N	N	N
J0275	Alprostadil urethral suppository	00	00	003	N	N	N
J0287	Injection, amphotericin B cholesteryl sulfate	00	00	003	N	N	N
J0288	Injection, amphotericin B cholesteryl sulfate complex, 10mg	00	00	003	N	N	N
J0289	Injection, amphotericin B liposome, 10 mg	00	00	003	N	N	N
J0456	Injection, azithromycin, 500 mg	00	00	003	N	N	N
J0476	Injection, baclofen, 50 meg for intrathecal trial	00	00	003	N	N	N
J0592	Injection, buprenorphine hydrochloride, 0.1 mg	00	00	003	N	N	N
J0637	Injection, caspofungin acetate, 5 mg	00	00	N	N	N
J0692	Injection, cefepime HCI, 500 mg	00	00	003	N	N	N
J0706	Injection, caffeine citrate, 5 mg	00	00	003	N	N	N
J0744	Injection, ciprofloxacin for intravenous infusion, 200 mg	00	00	003	N	N	N
J0880	Injection, darbepoetin alfa, 5 meg	00	00	Y	N	N
J1270	Injection, doxercalciferol, 1 meg	00	00	003	N	N	N
J1450	Injection, fluconazole, 200 mg	00	00	003	N	N	N
J1452	Injection, omivirsen sodium, intraocular, 1.65 mg	00	00	003	N	N	N
J1590	Injection, gatifloxacin, 10 mg	00	00	003	N	N	N
J1652	Injection, fondaparinux sodium, 0.5 mg	00	00	003	N	N	N
J1655	Injection, tinzaparin sodium, 1000 IU	00	00	003	N	N	N
J1835	Injection, itraconazole, 50 mg	00	00	003	N	N	N
J1956	Injection, levofloxacin, 250 mg	00	00	003	N	N	N
J2020	Injection, linezolid, 200 mg	00	00	003	N	N	N
J2271	Injection, morphine sulfate, 100 mg	00	00	003	N	N	N
J2355	Injection, oprelvekin, 5 mg	00	00	003	N	N	N
J2501	Injection, paricalcitol, 1 meg	00	00	003	N	N	N
J2543	Inject, piperacillin sodium/tazobactam sodium, 1 g/0.125 g (1.125 g)	00	00	003	N	N	N
J2770	Injection, quinupristin/dalfopristin, 500 mg (150/350)	00	00	003	N	N	N
J2780	Injection, ranitidine HCI, 25 mg	00	00	003	N	N	N
J2792	Inject, Rho D immune globulin, IV, human, solvent detergent, 100 IU	00	00	N	N	N
J2941	Injection, somatropin, 1 mg	00	00	003	N	N	N
J3315	Injection, triptorelin pamoate, 3.75 mg	00	00	003	N	N	N
J3395	Injection, verteporfin, 15 mg	00	00	Y	N	N
J3485	Injection, zidovudine, 10 mg	00	00	003	N	N	N
J3487	Injection, zoledronic acid, 1 mg	00	00	Y	N	N
J3590	Unclassified biologies	00	00	Y	N	Y
J7193	Factor IX, (antihemophilic factor, purified, non-recombinant) perlU	00	00	N	N	N
J7195	Factor IX, (antihemophilic factor, recombinant) per IU	00	00	N	N	N
J9017	Arsenic trioxide, 1 mg (Trisenox)	00	00	003	N	N	N
Q2013	Injection, pentastarch, 10% solution, per 100 ml	00	00	003	N	N	Y
Q2006	Injection, digoxin immune fab (ovine), per vial	00	00	003	N	N	N
Q2008	Injection, fomepizole, 15 mg	00	00	003	N	N	N
Q2009	Injection, fosphenytoin, 50 mg	00	00	003	N	N	N
Q2011	Injection, hemin, per 1 mg	00	00	003	N	N	N
Q2012	Injection, pegademase bovine, 25 IU	00	00	003	N	N	N
Q2013	Injection, pentastarch, 10% solution, per 100 ml	00	00	003	N	N	Y
Q2017	Injection, teniposide, 50 mg	00	00	003	N	N	N

Q2019	Injection, basiliximab, 20 mg	00	003	N	N	N
Q2020	Injection, histrelin acetate, 10 mg	00	003	N	N	Y
Q2021	Injection, lepirudin, 50 mg	00	003	N	N	N
Q2022	von Willebrand factor complex, human, per IU	00	003	N	N	N
Q3025	Injection, interferon beta-1 A, 11 meg for IM use	00	003	N	N	N
Q3026	Injection, interferon beta-1 A, 11 meg forsubcu use	00	003	N	N	N
S0092	Injection, hydromorphone hydrochloride, 250 mg	00	003	N	N	Y
S0093	Injection, morphine sulfate, 500 mg	00	003	N	N	Y
S0610	Annual gynecological examination; new patient	00	N	N	Y
S0612	Annual gynecological examination; established patient	00	N	N	Y
S2202	Echosclerotherapy	00	N	N	Y
S2342	Nasal endoscopy for post-op debridement, unilateral or bilateral	2	00	N	N	Y
S2342	Nasal endoscopy for post-op debridement, unilateral or bilateral	8	00	N	N	Y
S2350	Diskectomy, anterior; lumbar, single interspace	2	00	N	N	Y
S2350	Diskectomy, anterior; lumbar, single interspace	8	00	N	N	Y
S2351	Diskectomy, anterior; lumbar, each additional interspace	2	00	N	N	Y
S2351	Diskectomy, anterior; lumbar, each additional interspace	8	00	N	N	Y
S2400	Repair, congenital diaphragmatic hernia in the fetus, in utero	2	00	Y	N	Y
S2400	Repair, congenital diaphragmatic hernia in the fetus, in utero	8	00	Y	N	Y
S2401	Repair, urinary tract obstruction in fetus, in utero	2	00	Y	N	Y
S2401	Repair, urinary tract obstruction in fetus, in utero	8	00	Y	N	Y
S2402	Repair, congenital cystic adenomatoid malformation in fetus, in utero	2	00	Y	N	Y
S2402	Repair, congenital cystic adenomatoid malformation in fetus, in utero	8	00	Y	N	Y
S2403	Repair, extralobar pulmonary sequestration in fetus, in utero	2	00	Y	N	Y
S2403	Repair, extralobar pulmonary sequestration in fetus, in utero	8	00	Y	N	Y
S2404	Repair, myelomeningocele in fetus, in utero	2	00	Y	N	Y
S2404	Repair, myelomeningocele in fetus, in utero	8	00	Y	N	Y
S2405	Repair of sacrococcygeal teratoma in fetus, in utero	2	00	Y	N	Y
S2405	Repair of sacrococcygeal teratoma in fetus, in utero	8	00	Y	N	Y
S2409	Repair, congenital malformation of fetus, in utero, NOC	2	00	Y	N	Y
S2409	Repair, congenital malformation of fetus, in utero, NOC	8	00	Y	N	Y
S2411	Fetoscopic laser therapy fortx of twin-to-twin transfusion syndrome	2	00	Y	N	Y
S2411	Fetoscopic laser therapy fortx of twin-to-twin transfusion syndrome	8	00	Y	N	Y
S3620	Newborn metabolic screening panel	T	00	N	N	Y

IX. Payable HCPCS Procedure Codes for Prosthetics Providers

HCPCS Code	Description	TOS	M1	M2	Diag. List	Review	PA	MP Y/N
A4207	Syringe with needle, sterile 2 cc, each	H	00	00	N	N	N	N
A4209	Syringe with needle, sterile 5 cc or greater, each	H	00	00	N	N	N	N
A4331	Ext drng tube, any type/length, for urine leg bag/urostomy pouch, ea	H	00	00	N	N	N	N
A4407	Ostomy skin barrier w/flange, ext wear, w/blt in convexity 4x4 or[LESS THAN], ea	H	00	00	N	N	N	N
B9998	NOC for enteral supplies (MIC-KEY Kit)	6	EP	00	N	N	Y	N
E0186	PO Air pressure mattress	H	00	00	N	N	Y	N
E0186	PO Air pressure mattress	6	EP	00	N	N	Y	N
E0187	PO Water pressure mattress	H	00	00	N	N	Y	N
E0187	PO Water pressure mattress	6	EP	00	N	N	Y	N
E0198	PO Water pressure pad for mattress, standard mattress length and width	H	00	00	N	N	Y	N
E0198	PO Water pressure pad for mattress, standard mattress length and width	6	EP	00	N	N	Y	N
E0244	PO Raised toilet seat	H	00	00	N	N	N	Y
E0244	PO Raised toilet seat	6	EP	00	N	N	N	Y
E0431	RO Portable gaseous oxygen system	H	00	00	N	N	N	N
E0431	RO Portable gaseous oxygen system	I	00	00	N	N	N	N
E0434	RO Portable liquid oxygen system	H	00	00	N	N	N	N
E0434	RO Portable liquid oxygen system	I	00	00	N	N	N	N
E0445	RO Oximeter device for measuring blood oxygen levels non-invasively	H	00	00	N	N	N	Y
E0445	RO Oximeter device for measuring blood oxygen levels noninvasively	I	00	00	N	N	N	Y
E0621	Sling or seat, patient lift, canvas or nylon	H	00	00	N	N	N	N
E1001	Wheel, single (Replacement)	H	00	00	N	N	N	Y
E1236	W/C, pediatric size, folding, adjustable, with seating system	6	EP	00	N	N	Y	N
E1399	Durable medical equipment, miscellaneous	H	00	00	N	N	N	Y
K0075	Semipneumatic caster tire, any size, each	H	00	00	N	N	N	N
K0075	Semipneumatic caster tire, any size, each	6	EP	00	N	N	N	N
K0077	Front caster assembly, complete, with solid tire, each	H	00	00	N	N	N	N
K0077	Front caster assembly, complete, with solid tire, each	6	EP	00	N	N	N	N
K0092	Rear wheel assembly for power wheelchair, complete, each	H	00	00	N	N	N	N
K0092	Rear wheel assembly for power wheelchair, complete, each	6	EP	00	N	N	N	N

X. Payable HCPCS Procedure Code for Home Health Providers

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
A4207	Syringe with needle, sterile 2 cc, each	H	00	00	N	N	N	N
A4209	Syringe with needle, sterile 5 cc or greater, each	H	00	00	N	N	N	N

XI. Payable HCPCS Procedure Codes for Ventilator Equipment Providers

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
E0431	RO Portable gaseous oxygen system	9	00	00	N	N	N	N
E0434	RO Portable liquid oxygen system	9	00	00	N	N	N	N

XII. Payable HCPCS Procedure Codes for Nurse Practitioners

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
J0200	Injection, alatrofloxacin mesylate, 100mg	N	00	00	003	N	N	N
J0275	Alprostadil urethral suppository	N	00	00	003	N	N	N
J3485	Injection, zidovudine, 10 mg	N	00	00	003	N	N	N
J7193	Factor IX, (antihemophilic factor, purified, non-recombinant) perlU	N	00	00	N	N	N
J7195	Factor IX, (antihemophilic factor, recombinant) per IU	N	00	00	N	N	N
J7513	Daclizumab, parenteral, 25 mg	N	00	00	003	N	N	N
J9017	Arsenic trioxide, 1 mg (Trisenox)	N	00	00	003	N	N	N
Q3025	Injection, interferon beta-1 A, 11 meg for IM use	N	00	00	003	N	N	N
Q3026	Injection, interferon beta-1 A, 11 meg forsubcu use	N	00	00	003	N	N	N
S0610	Annual gynecological examination; new patient	N	00	00	N	N	Y
S0612	Annual gynecological examination; established patient	N	00	00	N	N	Y

XIII. Payable HCPCS Procedure Codes for Private Duty Nursing Providers

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
A4207	Syringe with needle, sterile 2 cc, each	S	00	00	N	N	N	N
A4207	Syringe with needle, sterile 2 cc, each	1	00	00	N	N	N	N
A4209	Syringe with needle, sterile 5 cc or greater, each	s	00	00	N	N	N	N
A4209	Syringe with needle, sterile 5 cc or greater, each	1	00	00	N	N	N	N
A4331	Ext drng tube, any type/length, for urine leg bag/urostomy pouch, ea	1	00	00	N	N	N	N
A4407	Ostomy skin barrier w/flange, ext wear, w/blt in convexity 4x4 or[LESS THAN], ea	1	00	00	N	N	N	N

XIV. HCPCS Codes for Independent Laboratory Providers

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
S3620	Newborn metabolic screening panel	C	00	00	N	N	N	Y
S3620	Newborn metabolic screening panel	T	00	00	N	N	N	Y

XV. Payable HCPCS Procedure Codes for Optometrists

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
S0518	Sunglasses frames	D	00	00	N	N	N	Y
V2623	Prosthetic eye, plastic, custom	D	00	00	N	N	N	Y
V2629	Prosthetic eye, other type	D	00	00	N	N	N	Y

XVI. Payable HCPCS Procedure Codes for Optical Dispensing Contractor

HCPCS Code	Description	TOS	M1	M2	Diag List	Review	PA	MP Y/N
S0518	Sunglasses frames	D	00	00	N	N	N	Y

XVII. Non-Covered HCPCS Procedure Codes

The following list of codes are non-covered by Arkansas Medicaid.

A0160	A4378	A4575	A6231	A7030	D0425	D2751	D3426	D5410	D5922
A0170	A4379	A4580	A6232	A7031	D0460	D2780	D3430	D5411	D5923
A0180	A4380	A4590	A6233	A7032	D0472	D2781	D3450	D5421	D5924
A0190	A4381	A4606	A6240	A7033	D0473	D2782	D3460	D5422	D5925
A0200	A4382	A4608	A6250	A7035	D0474	D2783	D3470	D5510	D5926
A0210	A4383	A4611	A6251	A7036	D0480	D2790	D3910	D5520	D5927
A0420	A4384	A4612	A6252	A7037	D0502	D2791	D3920	D5630	D5928
A0430	A4385	A4613	A6253	A7038	D0999	D2792	D3950	D5660	D5929
A0432	A4387	A4614	A6254	A7039	D1310	D2799	D3999	D5670	D5931
A0888	A4388	A4615	A6255	A7042	D1330	D2910	D4210	D5671	D5932
A4207	A4389	A4616	A6256	A7043	D1550	D2932	D4211	D5710	D5933
A4209	A4390	A4617	A6260	A7044	D2391	D2933	D4245	D5711	D5934
A4210	A4391	A4618	A6261	A7501	D2392	D2940	D4249	D5720	D5935
A4211	A4392	A4619	A6262	A7502	D2393	D2950	D4260	D5721	D5936
A4215	A4393	A4620	A6266	A7503	D2394	D2951	D4261	D5730	D5937
A4220	A4395	A4630	A6402	A7504	D2410	D2952	D4263	D5731	D5951
A4244	A4396	A4632	A6410	A7505	D2420	D2953	D4264	D5740	D5952
A4246	A4407	A4633	A6411	A7506	D2430	D2954	D4265	D5741	D5953
A4247	A4408	A4634	A6412	A7507	D2510	D2955	D4266	D5751	D5954
A4254	A4409	A4639	A7000	A7508	D2520	D2957	D4267	D5760	D5955
A4255	A4410	A4640	A7001	A7509	D2530	D2960	D4268	D5761	D5958
A4257	A4413	A4651	A7002	A9270	D2542	D2961	D4270	D5810	D5959
A4258	A4415	A4652	A7003	A9300	D2543	D2962	D4271	D5811	D5960
A4261	A4421	A4870	A7004	A9900	D2544	D2980	D4273	D5820	D5982
A4266	A4422	A4890	A7005	B4034	D2610	D2999	D4274	D5821	D5983
A4267	A4458	A5200	A7006	B4036	D2620	D3110	D4275	D5850	D5984
A4268	A4462	A5508	A7007	B4081	D2630	D3120	D4276	D5851	D5985
A4269	A4465	A6000	A7008	B4082	D2642	D3230	D4320	D5860	D5986
A4280	A4470	A6010	A7009	B4083	D2643	D3240	D4321	D5861	D5987
A4281	A4480	A6011	A7010	B9002	D2644	D3331	D4342	D5862	D5988
A4282	A4481	A6025	A7011	C9003	D2650	D3332	D4355	D5867	D5999
A4283	A4490	A6199	A7012	D0150	D2651	D3333	D4381	D5875	D6010
A4284	A4495	A6206	A7013	D0160	D2652	D3346	D4910	D5899	D6040
A4285	A4500	A6207	A7014	D0170	D2662	D3347	D4920	D5911	D6050
A4286	A4510	A6208	A7015	D0180	D2663	D3348	D4999	D5912	D6053
A4372	A4534	A6214	A7016	D0290	D2664	D3351	D5130	D5913	D6054
A4373	A4556	A6215	A7017	D0310	D2720	D3352	D5140	D5914	D6055
A4375	A4557	A6222	A7018	D0320	D2721	D3353	D5213	D5915	D6056
A4376	A4565	A6223	A7025	D0321	D2722	D3421	D5214	D5916	D6057
A4377	A4570	A6224	A7026	D0322	D2750	D3425	D5281	D5919	D6058
D6059	D6606	D7310	D7840	D0415	E0188	E0459	E0757	E1300	E1821
D6060	D6607	D7320	D7850	D7999	E0193	E0460	E0758	E1310	E1825
D6061	D6608	D7340	D7852	D8010	E0194	E0461	E0759	E1353	E1830

D6062	D6609	D7350	D7854	D8020	E0198	E0462	E0760	E1355	E1840
D6063	D6610	D7410	D7856	D8030	E0199	E0481	E0761	E1372	E1902
D6064	D6611	D7411	D7858	D8040	E0203	E0484	E0780	E1399	E2000
D6065	D6612	D7412	D7860	D8050	E0210	E0550	E0781	E1405	E2100
D6066	D6613	D7413	D7865	D8060	E0215	E0555	E0782	E1406	E2101
D6067	D6614	D7414	D7870	D8660	E0218	E0571	E0783	E1500	G0108
D6068	D6615	D7415	D7871	D8670	E0220	E0572	E0785	E1510	G0109
D6069	D6720	D7440	D7872	D8680	E0221	E0574	E0786	E1530	G0128
D6070	D6721	D7441	D7873	D8690	E0230	E0590	E0791	E1540	G0129
D6071	D6722	D7450	D7874	D8691	E0231	E0601	E0830	E1550	G0176
D6072	D6740	D7451	D7875	D8692	E0232	E0602	E0855	E1560	G0177
D6073	D6750	D7460	D7876	D9210	E0242	E0603	E0968	E1570	G0179
D6074	D6751	D7461	D7877	D9211	E0243	E0604	E0977	E1575	G0180
D6075	D6752	D7465	D7880	D9212	E0244	E0610	E0995	E1580	G0181
D6076	D6780	D7471	D7899	D9215	E0251	E0615	E0996	E1590	G0182
D6077	D6781	D7472	D7910	D9241	E0256	E0616	E0997	E1592	G0219
D6078	D6782	D7473	D7911	D9242	E0261	E0617	E0998	E1594	G0252
D6079	D6783	D7485	D7912	D9248	E0265	E0620	E0999	E1600	G0281
D6080	D6790	D7490	D7920	D9310	E0266	E0621	E1000	E1610	G0282
D6090	D6791	D7520	D7940	D9410	E0270	E0625	E1001	E1615	G0283
D6095	D6792	D7530	D7941	D9420	E0274	E0627	E1011	E1620	G0288
D6100	D6793	D7540	D7943	D9450	E0277	E0628	E1014	E1625	G0290
D6199	D6920	D7550	D7944	D9610	E0290	E0629	E1015	E1630	G0291
D6210	D6940	D7560	D7945	D9910	E0291	E0635	E1016	E1632	G0293
D6211	D6950	D7610	D7946	D9911	E0292	E0636	E1017	E1635	G0294
D6212	D6970	D7620	D7947	D9930	E0293	E0651	E1018	E1636	G0295
D6240	D6971	D7650	D7948	D9940	E0294	E0652	E1025	E1637	G9001
D6241	D6972	D7660	D7949	D9941	E0295	E0660	E1027	E1639	G9002
D6242	D6973	D7670	D7950	D9950	E0296	E0665	E1037	E1699	G9003
D6245	D6975	D7671	D7955	D9951	E0297	E0666	E1038	E1700	G9004
D6250	D6976	D7680	D7970	D9952	E0315	E0669	E1195	E1701	G9005
D6251	D6977	D7710	D7971	D9970	E0316	E0671	E1221	E1702	G9006
D6252	D6980	D7720	D7972	D9971	E0350	E0672	E1222	E1800	G9007
D6253	D6985	D7730	D7980	D9972	E0352	E0673	E1223	E1801	G9008
D6545	D6999	D7750	D7981	D9973	E0370	E0710	E1226	E1802	G9009
D6548	D7260	D7760	D7982	D9974	E0371	E0731	E1227	E1805	G9010
D6600	D7261	D7770	D7983	E0117	E0372	E0744	E1236	E1806	G9011
D6601	D7272	D7771	D7990	E0144	E0373	E0746	E1236	E1811	G9012
D6602	D7282	D7780	D7991	E0148	E0431	E0752	E1295	E1815	H0001
D6603	D7287	D7810	D7995	E0162	E0434	E0754	E1296	E1816	H0003
D6604	D7290	D7820	D7996	E0169	E0455	E0755	E1297	E1818	H0005
D6605	D7291	D7830	D7997	E0186	E0457	E0756	E1298	E1820	H0006
H0007	J1056	K0007	L3330	E0187	M0076	S0250	S3818	S5180	S9140
H0008	J1438	K0009	L3340	L7367	M0100	S0255	S3819	S5181	S9141
H0009	J1756	K0018	L3380	L7368	M0300	S0320	S3902	S5185	S9145
H0010	J1817	K0037	L3390	L7900	M0301	S0340	S4011	S5190	S9208

H0011	J2795	K0041	L3410	L8001	P2028	S0341	S4013	S5199	S9209
H0012	J2940	K0042	L3430	L8002	P2029	S0342	S4014	S5517	S9211
H0013	J7317	K0046	L3440	L8039	P2031	S0500	S4015	S5518	S9212
H0014	J7608	K0050	L3460	L8040	P2038	S0508	S4016	S5520	S9213
H0015	J7622	K0051	L3470	L8041	Q2002	S0510	S4017	S5521	S9214
H0016	J7624	K0052	L3480	L8042	Q2003	S0514	S4018	S5522	S9325
H0017	J7626	K0053	L3485	L8043	Q2004	S0516	S4020	S5523	S9326
H0018	J7628	K0069	L3500	L8044	Q2007	S0580	S4021	S8035	S9327
H0019	J7629	K0075	L3510	L8045	Q2014	S0581	S4022	S8040	S9328
H0020	J7631	K0077	L3520	L8046	Q2018	S0590	S4023	S8042	S9329
H0021	J7633	K0090	L3530	L8047	S0012	S0622	S4025	S8049	S9330
H0022	J7635	K0092	L3550	L8048	S0014	S0800	S4026	S8055	S9331
H0023	J7636	K0095	L3560	L8049	S0088	S0810	S4027	S8080	S9336
H0024	J7637	K0096	L3570	L8110	S0090	S0812	S4028	S8085	S9338
H0025	J7638	K0195	L3595	L8120	S0091	S0820	S4030	S8092	S9339
H0026	J7639	K0415	L3610	L8130	S0104	S1001	S4031	S8095	S9340
H0027	J7641	K0416	L3640	L8140	S0106	S1002	S4035	S8189	S9341
H0028	J7642	K0455	L3651	L8150	S0114	S1030	S4036	S8190	S9342
H0029	J7643	K0462	L3652	L8160	S0122	S1031	S4037	S8260	S9343
H0030	J7644	L0999	L3677	L8170	S0126	S2055	S4040	S8262	S9345
H0031	J7648	L1005	L3701	L8180	S0128	S2080	S4990	S8265	S9346
H0033	J7649	L1005	L3760	L8190	S0132	S2103	S4991	S8415	S9347
H0034	J7658	L1652	L3762	L8195	S0155	S2107	S4993	S8424	S9348
H0035	J7659	L1836	L3807	L8200	S0156	S2120	S4995	S8427	S9349
H0036	J7668	L1901	L3890	L8210	S0157	S2205	S5000	S8428	S9351
H0037	J7669	L2768	L3909	L8220	S0170	S2206	S5001	S8429	S9353
H0038	J7680	L2860	L3911	L8230	S0172	S2207	S5101	S8430	S9355
H0039	J7681	L3001	L3923	L8505	S0173	S2208	S5102	S8490	S9357
H0040	J7682	L3003	L4386	L8507	S0174	S2209	S5105	S8950	S9359
H0041	J7683	L3160	L5781	L8509	S0175	S2250	S5110	S8999	S9361
H0042	J7684	L3201	L5782	L8510	S0176	S2265	S5111	S9001	S9363
H0043	J7699	L3203	L5848	L8606	S0178	S2300	S5115	S9007	S9370
H0044	J7799	L3212	L5990	L8614	S0181	S2340	S5121	S9025	S9372
H0045	J8510	L3213	L5995	L8630	S0182	S2341	S5126	S9055	S9373
H0047	J8520	L3214	L6025	L8641	S0183	S2360	S5131	S9056	S9374
H0048	J8521	L3251	L6638	L8642	S0190	S2361	S5136	S9090	S9375
H1011	J8700	L3252	L6646	L8658	S0191	S2370	S5141	S9092	S9376
H2000	K0001	L3254	L6647	L8670	S0195	S2371	S5145	S9117	S9377
H2001	K0002	L3255	L6648	L8699	S0199	S3650	S5146	S9127	S9379
J0395	K0003	L3300	L6881	L9900	S0220	S3652	S5151	S9129	S9381
J0587	K0006	L3320	L6882	M0064	S0221	S3655	S5175	S9131	S9430
S9435	S9460	S9538	S9992	M0075	V2211	V2312	V2520	V2730	V5271
S9436	S9465	S9542	S9994	T2003	V2212	V2313	V2521	V2744	V5272
S9437	S9472	S9558	S9996	T2004	V2213	V2314	V2522	V2755	V5273
S9438	S9473	S9559	S9999	T2005	V2214	V2315	V2523	V2760	V5274
S9439	S9474	S9560	T1006	T2007	V2218	V2318	V2530	V2770	V2104

S9441	S9475	S9562	T1007	V2107	V2220	V2320	V2531	V2781
S9442	S9480	S9590	T1009	V2108	V2299	V2399	V2599	V2790
S9443	S9485	S9810	T1010	V2109	V2302	V2410	V2600	V5010
S9444	S9490	S9900	T1012	V2110	V2303	V2430	V2610	V5070
S9445	S9494	S9970	T1013	V2112	V2304	V2499	V2615	V5080
S9446	S9497	S9975	T1018	V2118	V2305	V2500	V2625	V5095
S9447	S9500	S9981	T1020	V2199	V2306	V2502	V2626	V5100
S9449	S9501	S9982	T1022	V2204	V2307	V2503	V2627	V5263
S9451	S9502	S9986	T1026	V2206	V2308	V2510	V2628	V5265
S9452	S9503	S9989	T1028	V2207	V2309	V2511	V2631	V5268
S9454	S9504	S9990	T1029	V2208	V2310	V2512	V2632	V5269
S9455	S9537	S9991	T1999	V2209	V2311	V2513	V2700	V5270

XVIII. Non Covered Procedure Codes

The following codes are non-payable because they contain elements of CPT procedure codes or other HCPCS procedure codes already covered by Arkansas Medicaid.

A0130	A4332	A4721	A4911	A9524	C2614	C9008	G0101	G0152
A0140	A4333	A4722	A4913	A9699	B9004	C2616	C9009	G0102	G0153
A0225	A4334	A4723	A4918	A9700	B9006	C2618	C9013	G0103	G0154
A0384	A4595	A4724	A4927	B4164	C1079	C2632	C9102	G0104	G0155
A0392	A4641	A4725	A4928	B4168	C1091	C2633	C9103	G0105	G0156
A0394	A4642	A4726	A4929	B4172	C1092	C8900	C9105	G0106	G0168
A0396	A4643	A4730	A4930	B4176	C1122	C8901	C9112	G0107	G0175
A0424	A4647	A4736	A4931	B4178	C1178	C8902	C9113	G0117	G0239
A0425	A4649	A4737	A4932	B4180	C1200	C8903	C9121	G0118	G0244
A0433	A4653	A4740	A9150	B4184	C1201	C8904	C9200	G0120	G0245
A0800	A4656	A4750	A9511	B4186	C1300	C8905	C9201	G0121	G0246
A4208	A4657	A4755	A9512	B4189	C1305	C8906	C9711	G0122	G0247
A4250	A4660	A4760	A9513	B4193	C1716	C8907	D0270	G0123	G0248
A4262	A4663	A4765	A9514	B4197	C1717	C8908	D0274	G0124	G0249
A4263	A4670	A4766	A9515	B4199	C1718	C8909	D0277	G0127	G0250
A4270	A4706	A4770	A9516	B4216	C1719	C8910	D1203	G0141	G0257
A4290	A4707	A4771	A9517	B4220	C1720	C8911	D1204	G0143	G0258
A4300	A4708	A4772	A9519	B4222	C1765	C8912	D1520	G0144	G0259
A4301	A4709	A4773	A9520	B4224	C1775	C8913	D2390	G0145	G0260
A4305	A4714	A4774	A9521	B5000	C1783	C8914	G0008	G0147	G0261
A4306	A4719	A4802	A9522	B5100	C1888	C9000	G0009	G0148	G0263
A4321	A4720	A4860	A9523	B5200	C1900	C9007	G0010	G0151	G0264
G0265	P9023	Q0144	Q4007	Q4033	S0215	S2262	S8101	S9150	V5241
G0266	P9031	Q2001	Q4008	Q4034	S0260	S3600	S8182	S9364	V5242
G0268	P9032	Q2001	Q4009	Q4035	S0302	S3601	S8183	S9365	V5243
G0270	P9033	Q2005	Q4010	Q4036	S0310	S3630	S8185	S9366	V5244
G0271	P9034	Q3000	Q4011	Q4037	S0315	S3645	S8186	S9367	V5245
G0289	P9035	Q3001	Q4012	Q4038	S0316	S3708	S8210	S9368	V5246
G9016	P9036	Q3002	Q4013	Q4039	S0390	S3830	S8420	S9401	V5247
H0033	P9037	Q3003	Q4014	Q4040	S0395	S3900	S8421	S9453	V5248
H1000	P9038	Q3004	Q4015	Q4041	S0400	S4005	S8422	S9484	V5249
H1001	P9039	Q3005	Q4016	Q4042	S0601	S4981	S8423	S9529	V5250
H1002	P9040	Q3006	Q4017	Q4043	S0605	S4981	S8425	T1000	V5251
H1003	P9041	Q3007	Q4018	Q4044	S0630	S4989	S8426	T1001	V5252
H1004	P9043	Q3008	Q4019	Q4045	S1015	S5010	S8431	T1002	V5253
H1005	P9044	Q3009	Q4020	Q4046	S1016	S5011	S8450	T1003	V5254
H1010	P9045	Q3010	Q4021	Q4047	S1025	S5012	S8451	T1004	V5255
P3000	P9046	Q3011	Q4022	Q4048	S1040	S5013	S8452	T1027	V5256
P3001	P9047	Q3012	Q4023	Q4049	S2053	S5014	S9022	T1030	V5257
P7001	P9048	Q3014	Q4024	Q4050	S2054	S5035	S9034	T1031	V5258
P9010	P9050	Q3019	Q4025	Q4051	S2060	S5036	S9061	T2006	V5259
P9011	P9604	Q3020	Q4026	R0075	S2061	S5497	S9075	V5011	V5260

P9016	Q0081	Q4001	Q4027	R0076	S2065	S5498	S9083	V5020	V5261
P9017	Q0083	Q4002	Q4028	S0189	S2102	S5501	S9088	V5090	V5262
P9019	Q0084	Q4003	Q4029	S0201	S2140	S5502	S9122	V5110	V5264
P9020	Q0085	Q4004	Q4030	S0207	S2142	S8004	S9125	V5160	V5266
P9021	Q0091	Q4005	Q4031	S0208	S2150	S8097	S9126	V5200	V5275
P9022	Q0092	Q4006	Q4032	S0209	S2260	S8100	S9128	V5240	V5298
V5362
V5363
V5364

Thank you for your participation in the Arkansas Medicaid Program.

Roy Jeffus, Director

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 and 1-877-708 -8191. Both telephone numbers are voice and TDD.

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Arkansas Administrative CodeAgency 016 - DEPARTMENT OF HUMAN SERVICESDivision 06 - Medical ServicesRule 016.06.05-027 - DMS-2005-W-1: 2004 HCPCS Final Procedure Code Conversion

Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-027 - DMS-2005-W-1: 2004 HCPCS Final Procedure Code Conversion