Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-053 - Official Notice DMS-2005-W-2 - 2005 HCPCS Procedure Code Conversion
Current through Register Vol. 49, No. 9, September, 2024
I. General Information
A review of the 2005 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 August 1, 2005.
II. 2005 HCPCS Payable Procedure Code Tables Information
Payable procedures codes have been broken into separate tables. Tables have been created for each affected 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 and third columns indicate any modifiers that must be used in conjunction with the procedure code, when billed, either electronically or on paper. The columns are titled ?M1? and ?M2?. This information is used in the prosthetics program.
The fourth column is the description of the procedure code.
The fifth column contains the type of service (TOS) code that may be used in conjunction with the procedure code. TOS codes are used with procedure codes billed on paper.
The sixth column indicates the diagnosis list and is titled ?Diag. List?. This information is used by physicians, hospitals, independent radiology, ambulatory surgical centers, area health education centers and nurse practitioners. Applicable lists will be shown in each provider?s section.
The seventh column indicates whether a procedure undergoes medical review before payment. The column is titled ?Review Y/N.? The letter ?Y? in a column means that a review is necessary; and 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 the service may be provided. The column is titled PA, Y/N.? The letter ?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.? A letter ?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
Below is the diagnosis lists referred to in column six. Certain procedure codes are covered only when the primary diagnosis is on the diagnosis lists. Diagnosis list 003, described below, is the only diagnosis list limiting any of the procedure codes in this notice.
Diagnosis List 003
ICD 9 Codes
042
140.0 through 208.91
IV. HCPCS Procedure Codes Payable to Physicians
* See coverage requirements and billing procedures for this procedure code in section XXI.
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
C |
N |
N |
N |
|||
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
T |
N |
N |
N |
|||
|
G0329 |
Electromagnetic ther, 1 or [GREATER THAN] areas, Stg 3 ? 4 ulcers, post 30 days conv care |
1 |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
C |
N |
N |
Y |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
P |
N |
N |
Y |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
T |
N |
N |
Y |
|||
|
G0363 |
Irrigation of implanted venous access device for drug delivery systems |
1 |
N |
N |
N |
|||
|
G0364 |
Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS |
2 |
N |
N |
N |
|||
|
G0364 |
Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS |
8 |
N |
Y |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
C |
N |
N |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
P |
N |
N |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
T |
N |
N |
N |
|||
|
J0128 |
Injection, abarelix, 10 mg |
1 |
003 |
N |
N |
N |
||
|
J0180* |
Injection, agalsidase beta, I mg |
1 |
Y |
N |
N |
|||
|
J1457 |
Injection, gallium nitrate, 1 mg |
1 |
003 |
N |
N |
N |
||
|
J1931* |
Injection, laronidase, 0.1 mg |
1 |
Y |
N |
N |
|||
|
J2469 |
Injection, palonosetron HCI, 25 mcg |
1 |
003 |
N |
N |
N |
||
|
J3396 |
Injection, verteporfin, 0.1 mg |
1 |
Y |
N |
N |
|||
|
J7518 |
Mycophenolic acid, oral, 180 mg |
1 |
003 |
N |
N |
N |
||
|
J9035 |
Injection, bevacizumab, 10 mg |
1 |
003 |
Y |
N |
N |
||
|
J9041 |
Injection, bortezomib, 0.1 mg |
1 |
003 |
Y |
N |
N |
||
|
J9055 |
Injection, cetuximab, 10 mg |
1 |
003 |
Y |
N |
N |
||
|
J9305 |
Injection, pemetrexed, 10 mg |
1 |
003 |
Y |
N |
N |
||
|
L8614 |
EP |
Tracheoesophageal puncture dilator, replacement only, each |
6 |
N |
Y |
Y |
||
|
L8615 |
EP |
Headset/headpiece for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8616 |
EP |
Microphone for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8617 |
EP |
Transmitting coil for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8618 |
EP |
Transmitter cable for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8620 |
EP |
Lithium ion battery for use with cochlear implant device, replacement, each |
6 |
N |
Y |
Y |
||
|
L8621 |
EP |
Lithium ion battery for use with cochlear implant device, replacement, each |
6 |
N |
Y |
Y |
||
|
L8622 |
EP |
Alkaline battery for use with cochlear implant device, any size, replacement, each |
6 |
N |
Y |
Y |
||
|
S0164 |
Injection, pantoprazole sodium, 40 mg |
1 |
003 |
N |
N |
N |
||
|
S0168 |
Injection, azacitidine, 100 mg |
1 |
003 |
N |
N |
N |
||
|
S2348 |
Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumbar |
2 |
N |
N |
Y |
|||
|
S2348 |
Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumbar |
8 |
N |
Y |
Y |
V. HCPCS Procedure Codes Payable to Hospitals
* See coverage requirements and billing procedures for this procedure code in section XXI.
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag List |
Review Y/N |
PA Y/N |
MP Y/N |
|
C9218 |
Injection, azacitidine, per 1 mg |
G |
003 |
N |
N |
Y |
||
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
G |
N |
N |
N |
|||
|
G0329 |
Electromagnetic ther, 1 or [GREATER THAN] areas, Stg 3 - 4 ulcers, post 30 days conv care |
G |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
G |
N |
N |
N |
|||
|
G0363 |
Irrigation of implanted venous access device for drug delivery systems |
G |
N |
N |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
G |
N |
N |
N |
|||
|
J0128 |
Injection, abarelix, 10 mg |
G |
003 |
N |
N |
N |
||
|
J0180* |
Injection, agalsidase beta, 1 mg |
G |
Y |
N |
N |
|||
|
J0878 |
Injection, daptomycin, 1 mg |
G |
003 |
N |
N |
N |
||
|
J1457 |
Injection, gallium nitrate, 1 mg |
G |
003 |
N |
N |
N |
||
|
J1931* |
Injection, laronidase, 0.1 mg |
G |
Y |
N |
N |
|||
|
J2469 |
Injection, palonosetron HCI, 25 mcg |
G |
003 |
N |
N |
N |
||
|
J3246 |
Injection, tirofiban HCI, 0.25 mg |
G |
N |
N |
N |
|||
|
J7343 |
Dermal & epidermal, tissue non-human origin, w/ or w/o bioengin or proc elements, per sq cm |
G |
Y |
N |
N |
|||
|
J7344 |
Dermal tissue, human origin, w/ or w/out other bioengineered or processed elements, per sq cm |
G |
Y |
N |
N |
|||
|
J7518 |
Mycophenelic acid, oral, 180 mg |
G |
003 |
N |
N |
N |
||
|
J9035 |
Injection, bevacizumab, 10 mg |
G |
003 |
Y |
N |
N |
||
|
J9041 |
Injection, bortezomib, 0.1 mg |
G |
003 |
Y |
N |
N |
||
|
J9055 |
Injection, cetuximab, 10 mg |
G |
003 |
Y |
N |
N |
||
|
J9305 |
Injection, pemetrexed, 10 mg |
G |
003 |
Y |
N |
N |
||
|
S0164 |
Injection, pantoprazole sodium, 40 mg |
G |
003 |
N |
N |
N |
||
|
S0168 |
Injection, azacitidine, 100 mg |
G |
003 |
N |
N |
N |
||
|
S2348 |
Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumber |
G |
N |
N |
Y |
VI. HCPCS Procedure Codes Payable to Independent Lab
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Ind |
PA Y/N |
MP |
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
C |
N |
N |
N |
|||
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
T |
N |
N |
N |
VII. HCPCS Procedure Codes Payable to Independent Radiology
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag List |
Review Y/N |
PA Y/N |
MP |
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
C |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
P |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
T |
N |
N |
N |
VIII. HCPCS Procedure Codes Payable to Home Health
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
A4349 |
NU |
Male external catheter with integral collection compartment, extended wear, each |
H |
N |
N |
N |
||
|
A7045 |
NU |
Exhalation port w/wo swivel used w/accessories for positive airway devices, replacement |
H |
N |
N |
N |
||
|
B4100 |
NU |
Food thickener, administered orally, per oz. |
H |
N |
N |
N |
||
|
T4521 |
NU |
Adult sized disposable incontinence product, brief/diaper, small, each |
H |
N |
N |
N |
||
|
T4522 |
NU |
Adult sized disposable incontinence product, brief/diaper, medium, each |
H |
N |
N |
N |
||
|
T4523 |
NU |
Adult sized disposable incontinence product, brief/diaper, large, each |
H |
N |
N |
N |
||
|
T4524 |
NU |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
H |
N |
N |
N |
||
|
T4526 |
NU |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
H |
N |
N |
N |
||
|
T4526 |
EP |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
6 |
N |
N |
N |
||
|
T4527 |
NU |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
H |
N |
N |
N |
||
|
T4527 |
EP |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
6 |
N |
N |
N |
||
|
T4528 |
NU |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea |
H |
N |
N |
N |
||
|
T4528 |
EP |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea |
6 |
N |
N |
N |
||
|
T4529 |
EP |
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each |
6 |
N |
N |
N |
||
|
T4529 |
EP |
U1 |
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each |
6 |
N |
N |
N |
|
|
T4530 |
EP |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
6 |
N |
N |
N |
||
|
T4531 |
EP |
Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea |
6 |
N |
N |
N |
||
|
T4531 |
EP |
U1 |
Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea |
6 |
N |
N |
N |
|
|
T4532 |
EP |
Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each |
6 |
N |
N |
N |
||
|
T4532 |
EP |
U1 |
Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each |
6 |
N |
N |
N |
|
|
T4533 |
EP |
Youth sized disposable incontinence product, brief/diaper, each |
6 |
N |
N |
N |
||
|
T4535 |
NU |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
H |
N |
N |
N |
||
|
T4535 |
NU |
U1 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
H |
N |
N |
N |
|
|
T4535 |
EP |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
6 |
N |
N |
N |
||
|
T4535 |
EP |
U1 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
6 |
N |
N |
N |
IX. HCPCS Procedure Codes Payable to Prosthetics
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
A4349 |
NU |
Male external catheter with integral collection compartment, extended wear, each |
H |
N |
N |
N |
||
|
A7045 |
NU |
Exhalation port w/wo swivel used w/accessories for positive airway devices, replacement |
H |
N |
N |
N |
||
|
B4100 |
NU |
Food thickener, administered orally, per oz. |
H |
N |
N |
Y |
||
|
B4149 |
EP |
Enteral formula, blenderized natural foods w/intact nutrients, adm with enteral feeding tube |
6 |
N |
N |
N |
||
|
B4150 |
EP |
U1 |
Enteral formula, nutritionally complete w/intact nutrients, adm via enteral feeding tube, 100 cal = 1 unit |
6 |
N |
N |
N |
|
|
B4155 |
EP |
U3 |
Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit |
6 |
N |
N |
N |
|
|
B4158 |
EP |
Enteral formula, pediatrics, nutritionally complete adm w/enteral feeding tube, 100 cal = 1 unit |
6 |
N |
N |
N |
||
|
B4159 |
EP |
Enteral form/pediatrics/nutritionally comp/soy based, adm w/enteral feeding tube, 100 cal/1 unit |
6 |
N |
N |
N |
||
|
B4160 |
EP |
Enteral form/pediatrics/nutritionally comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit |
6 |
N |
N |
N |
||
|
B4160 |
EP |
U1 |
Enteral form/pediatrics/nutrition comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit |
6 |
N |
N |
N |
|
|
B4161 |
EP |
Enteral formula, pediatrics, administered through an enteral feeding tube, 100 cal = 1 unit |
6 |
N |
N |
N |
||
|
B4162 |
EP |
Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit |
6 |
N |
N |
N |
||
|
B4162 |
EP |
U1 |
Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit |
6 |
N |
N |
N |
|
|
B9998 |
EP |
U1 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U2 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U3 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U4 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U5 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U6 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U7 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
B9998 |
EP |
U8 |
NOC for enteral supplies |
6 |
N |
Y |
N |
|
|
E2206 |
NU |
Manual wheelchair accessory, wheel lock assembly, complete, each |
H |
N |
N |
N |
||
|
E2206 |
EP |
Manual wheelchair accessory, wheel lock assembly, complete, each |
6 |
N |
N |
N |
||
|
E2291 |
EP |
Back, planar, for pediatric size wheelchair including fixed attaching hardware |
6 |
N |
N |
Y |
||
|
E2292 |
EP |
Seat, planar, for pediatric size wheelchair including fixed attaching hardware |
6 |
N |
N |
Y |
||
|
E2293 |
EP |
Back, contoured, for pediatric size wheelchair including fixed attaching hardware |
6 |
N |
N |
Y |
||
|
E2294 |
EP |
Seat, contoured, for pediatric size wheelchair including fixed attaching hardware |
6 |
N |
N |
Y |
||
|
E2368 |
NU |
Power wheelchair component, motor, replacement only |
H |
N |
N |
N |
||
|
E2368 |
EP |
Power wheelchair component, motor, replacement only |
6 |
N |
N |
N |
||
|
E2369 |
NU |
Power wheelchair component, gear box, replacement only |
H |
N |
N |
N |
||
|
E2369 |
EP |
Power wheelchair component, gear box, replacement only |
6 |
N |
N |
N |
||
|
E2601 |
NU |
General use wheelchair seat cushion, width less than 22 in., any depth |
H |
N |
N |
N |
||
|
E2601 |
NU |
General use wheelchair seat cushion, width less than 22 in., any depth |
H |
N |
N |
N |
||
|
E2601 |
UE |
General use wheelchair seat cushion, width less than 22 in., any depth |
U |
N |
N |
N |
||
|
E2601 |
EP |
General use wheelchair seat cushion, width less than 22 in., any depth |
6 |
N |
N |
N |
||
|
E2602 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
||
|
E2602 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
||
|
E2602 |
UE |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
U |
N |
N |
N |
||
|
E2602 |
EP |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
6 |
N |
N |
N |
||
|
E2611 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
||
|
E2611 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
||
|
E2611 |
UE |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
U |
N |
N |
N |
||
|
E2611 |
EP |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
6 |
N |
N |
N |
||
|
E2612 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
||
|
E2612 |
NU |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
||
|
E2612 |
UE |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
U |
N |
N |
N |
||
|
E2612 |
EP |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
6 |
N |
N |
N |
||
|
E2618 |
NU |
PO WC access., solid seat suppbase, use w/ man WC or lightweight power WC, w/mounting hw |
H |
N |
N |
Y |
||
|
E2618 |
EP |
PO WC access., solid seat suppbase, use w/ man WC or lightweight power WC, w/mounting hw |
6 |
N |
N |
Y |
||
|
E2619 |
NU |
Replacement cover for wheelchair seat cushion or back cushion, each |
H |
N |
N |
N |
||
|
E2619 |
EP |
Replacement cover for wheelchair seat cushion or back cushion, each |
6 |
N |
N |
N |
||
|
E8000 |
EP |
Gait trainer, pediatric size, posterior support, w/all accessories and components, 14 in. |
6 |
N |
N |
N |
||
|
E8000 |
EP |
U1 |
Gait trainer, pediatric size, posterior support, w/all accessories and components, 19 in. |
6 |
N |
Y |
N |
|
|
E8000 |
EP |
U2 |
Gait trainer, pediatric size, posterior support, w/all accessories and components, intermediate |
6 |
N |
Y |
N |
|
|
E8001 |
EP |
Gait trainer, pediatric size, upright support, w/all accessories and components, 14 in. |
6 |
N |
N |
N |
||
|
E8001 |
EP |
U1 |
Gait trainer, pediatric size, upright support, w/all accessories and components, 19 in. |
6 |
N |
Y |
N |
|
|
E8001 |
EP |
U2 |
Gait trainer, pediatric size, upright support, w/all accessories and components, intermediate |
6 |
N |
Y |
N |
|
|
E8002 |
EP |
Gait trainer, pediatric size, anterior support, w/all accessories and components, 14 in. |
6 |
N |
N |
N |
||
|
E8002 |
EP |
U1 |
Gait trainer, pediatric size, anterior support, w/all accessories and components, 19 in. |
6 |
N |
Y |
N |
|
|
E8002 |
EP |
U2 |
Gait trainer, pediatric size, anterior support, w/all accessories and components, intermediate |
6 |
N |
Y |
N |
|
|
K0630 |
NU |
SO, flexible, pelvic-sacral supp, w/straps, closures, prefab, including fitting & adjustment |
H |
N |
N |
N |
||
|
K0630 |
EP |
SO, flexible, pelvic-sacral supp, w/straps, closures, prefab, including fitting & adjustment |
6 |
N |
N |
N |
||
|
K0631 |
NU |
SO, flexible, pelvic-sacral supp, including straps, closures, prefab, including fitting & adjustment |
H |
N |
N |
N |
||
|
K0631 |
EP |
SO, flexible, pelvic-sacral supp, including straps, closures, prefab, including fitting & adjustment |
6 |
N |
N |
N |
||
|
K0632 |
NU |
SO, flexible, pelvic-sacral supp, panels over sac & abd, w/straps, closures, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0632 |
EP |
SO, flexible, pelvic-sacral supp, panels over sac & abd, w/straps, closures, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0633 |
NU |
SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab |
H |
N |
N |
Y |
||
|
K0633 |
EP |
SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab |
6 |
N |
N |
Y |
||
|
K0634 |
NU |
SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab |
H |
N |
N |
N |
||
|
K0634 |
EP |
SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab |
6 |
N |
N |
N |
||
|
K0635 |
NU |
LO, sagittal control, rigid panels, L1 to L5 vert, prod intracavitary pressure, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0635 |
EP |
LO, sagittal control, rigid panels, L1 to L5 vert, prod intracavitary pressure, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0636 |
NU |
LO, sagittal control, w/rigid ant-pos panel, L1to L5 vert, prod intracavitary press, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0636 |
EP |
LO, sagittal control, w/rigid ant-pos panel, L1to L5 vert, prod intracavitary press, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0637 |
NU |
LSO, flex, lumbar suppt, sacro-coccygeal junc-T9 Vert, w/straps, clsrs, pad, stays, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0637 |
EP |
LSO, flex, lumbar suppt, sacro-coccygeal junc-T9 Vert, w/straps, clsrs, pad, stays, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0638 |
NU |
LSO, flex, lumbar suppt, sacrococcygeal junc-T9 Vert, w/stay, straps, pend abdom dsgn, cusfab |
H |
N |
N |
Y |
||
|
K0638 |
EP |
LSO, flex, lumbar suppt, sacrococcygeal junc-T9 Vert, w/stay, straps, pend abdom dsgn, cusfab |
6 |
N |
N |
Y |
||
|
K0639 |
NU |
LSO, sagittal ctrl, w/panels, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0639 |
EP |
LSO, sagittal ctrl, w/panels, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0640 |
NU |
LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0640 |
EP |
LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0641 |
NU |
LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, cust fab |
H |
N |
N |
Y |
||
|
K0641 |
EP |
LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, cust fab |
6 |
N |
N |
Y |
||
|
K0642 |
NU |
LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust |
H |
N |
N |
N |
||
|
K0642 |
EP |
LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust |
6 |
N |
N |
N |
||
|
K0643 |
NU |
LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigd, w/stay, straps, custfab |
H |
N |
N |
Y |
||
|
K0643 |
EP |
LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigd, w/stay, straps, custfab |
6 |
N |
N |
Y |
||
|
K0644 |
NU |
LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigid, w/stay, straps, prefab, fit & adj |
H |
N |
N |
N |
||
|
K0644 |
EP |
LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigid, w/stay, straps, prefab, fit & adj |
6 |
N |
N |
N |
||
|
K0645 |
NU |
LSO, sagittal-coronal control, lumbar flex, rigid, sacrococcygeal junc-T9 Vert, w/straps, cust fab |
H |
N |
N |
N |
||
|
K0645 |
EP |
LSO, sagittal-coronal control, lumbar flex, rigid, sacrococcygeal junc-T9 Vert, w/straps, cust fab |
6 |
N |
N |
N |
||
|
K0646 |
NU |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, w/straps, prefab & fitting |
H |
N |
N |
N |
||
|
K0646 |
EP |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, w/straps, prefab & fitting |
6 |
N |
N |
N |
||
|
K0647 |
NU |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft pad, cust fab |
H |
N |
N |
N |
||
|
K0647 |
EP |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft pad, cust fab |
6 |
N |
N |
N |
||
|
K0648 |
NU |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, prefab/fitting |
H |
N |
N |
N |
||
|
K0648 |
EP |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, prefab/fitting |
6 |
N |
N |
N |
||
|
K0649 |
NU |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, cust fab |
H |
N |
N |
N |
||
|
K0649 |
EP |
LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, cust fab |
6 |
N |
N |
N |
||
|
L1932 |
NU |
AFO, rigid anterior tibial section, total Carbon fiber or = material, prefab, w/fitting and adjustment |
H |
N |
N |
N |
||
|
L1932 |
EP |
AFO, rigid anterior tibial section, total Carbon fiber or = material, prefab, w/fitting and adjustment |
6 |
N |
N |
N |
||
|
L2005 |
NU |
KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab |
H |
N |
N |
N |
||
|
L2005 |
EP |
KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab |
6 |
N |
N |
N |
||
|
L2232 |
NU |
KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab |
H |
N |
N |
Y |
||
|
L2232 |
EP |
KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab |
6 |
N |
N |
Y |
||
|
L4002 |
NU |
Replacement strap, any orthosis, includes all components, any length, any type |
H |
N |
N |
Y |
||
|
L4002 |
EP |
Replacement strap, any orthosis, includes all components, any length, any type |
6 |
N |
N |
Y |
||
|
L5685 |
NU |
Add to lower extremity prosthesis, below knee, suspension/sealing sleeve, w/ or w/out valve, ea |
H |
N |
N |
Y |
||
|
L5685 |
EP |
Add to lower extremity prosthesis, below knee, suspension/sealing sleeve, w/ or w/out valve, ea |
6 |
N |
N |
Y |
||
|
T4521 |
NU |
Adult sized disposable incontinence product, brief/diaper, small, each |
H |
N |
N |
N |
||
|
T4522 |
NU |
Adult sized disposable incontinence product, brief/diaper, medium, each |
H |
N |
N |
N |
||
|
T4523 |
NU |
Adult sized disposable incontinence product, brief/diaper, large, each |
H |
N |
N |
N |
||
|
T4524 |
NU |
Adult sized disposable incontinence product, brief/diaper, extra large, each |
H |
N |
N |
N |
||
|
T4526 |
NU |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
H |
N |
N |
N |
||
|
T4526 |
EP |
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each |
6 |
N |
N |
N |
||
|
T4527 |
NU |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
H |
N |
N |
N |
||
|
T4527 |
EP |
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each |
6 |
N |
N |
N |
||
|
T4528 |
NU |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea |
H |
N |
N |
N |
||
|
T4528 |
EP |
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea |
6 |
N |
N |
N |
||
|
T4529 |
EP |
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each |
6 |
N |
N |
N |
||
|
T4529 |
EP |
U1 |
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each |
6 |
N |
N |
N |
|
|
T4530 |
EP |
Pediatric sized disposable incontinence product, brief/diaper, large size, each |
6 |
N |
N |
N |
||
|
T4531 |
EP |
Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea |
6 |
N |
N |
N |
||
|
T4531 |
EP |
U1 |
Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea |
6 |
N |
N |
N |
|
|
T4532 |
EP |
Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each |
6 |
N |
N |
N |
||
|
T4532 |
EP |
U1 |
Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each |
6 |
N |
N |
N |
|
|
T4533 |
EP |
Youth sized disposable incontinence product, brief/diaper, each |
6 |
N |
N |
N |
||
|
T4535 |
NU |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
H |
N |
N |
N |
||
|
T4535 |
NU |
U1 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
H |
N |
N |
N |
|
|
T4535 |
EP |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
6 |
N |
N |
N |
||
|
T4535 |
EP |
U1 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
6 |
N |
N |
N |
X. HCPCS Procedure Codes Payable to Rehabilitation Centers
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
03 G28 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
G |
N |
N |
N |
XI. HCPCS Procedure Codes Payable to Ambulatory Surgical Centers (ASC)
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
C9218 |
Injection, azacitidine, per 1 mg |
G |
003 |
N |
0 |
Y |
||
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
T |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
T |
N |
N |
N |
|||
|
G0363 |
Irrigation of implanted venous access device for drug delivery systems |
G |
N |
N |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
T |
N |
N |
N |
|||
|
J7344 |
Dermal tissue, human origin, w/ or w/out other bioengineered or processed elements, per sq cm |
G |
Y |
N |
N |
|||
|
J7518 |
Mycophenelic acid, oral, 180 mg |
G |
003 |
N |
N |
N |
||
|
S2348 |
Decomp proc, percu, nucleas pulposus intervert disc, radiofreq energy, single/multiple lvls, lumbar |
G |
N |
N |
N |
XII. HCPCS Procedure Codes Payable to Hyperalimentation
Effective for dates of service on and after August 1, 2005, providers of hyperalimentation services may bill electronically, using the procedure codes shown below. For instructions on electronic billing, providers may consult section III of their program manual.
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
B4035 |
Enteral feeding supply kit; pump, fed, per day |
9 |
N |
Y |
N |
|||
|
B4149 |
U9 |
Enteral formula, blenderized natural foods w/intact nutrients, adm with enteral feeding tube |
9 |
N |
Y |
N |
||
|
B4150 |
U9 |
Enteral formula, nutritionally complete w/intact nutrients, adm via enteral feeding tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
||
|
B4152 |
U9 |
Enteral formula, nutritionally complete, calorically dense, adm via enteral feeding tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
||
|
B4153 |
U9 |
Enteral formula, nutritionally complete, hydrolyzed proteins, adm via enteral feeding tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
||
|
B4154 |
U9 |
Enteral formula, nutritionally complete, special metabolic needs, adm via enteral feeding tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
||
|
B4155 |
U9 |
Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit |
9 |
N |
N |
N |
||
|
B4155 |
U9 |
U1 |
Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
|
|
B4155 |
U9 |
U2 |
Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
|
|
B4155 |
U9 |
U3 |
Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit |
9 |
N |
Y |
Y |
|
|
B4158 |
U9 |
Enteral formula, pediatrics, nutrition complete adm w/enteral feeding tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
||
|
B4159 |
U9 |
Enteral form/pediatrics/nutrition comp/soy based, adm w/enteral feeding tube, 100 cal/1 unit |
9 |
N |
Y |
N |
||
|
B4160 |
U9 |
Enteral form/pediatrics/nutrition comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit |
9 |
N |
Y |
N |
||
|
B4160 |
U9 |
U1 |
Enteral form/pediatrics/nutrition comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit |
9 |
N |
Y |
N |
|
|
B4161 |
U9 |
Enteral formula, pediatrics, administered through an enteral feeding tube, 100 cal = 1 unit |
9 |
N |
Y |
N |
||
|
B4162 |
U9 |
Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit |
9 |
N |
Y |
N |
||
|
B4162 |
U9 |
U1 |
Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit |
9 |
N |
Y |
N |
|
|
B9000 |
U9 |
Enteral nutrition infusion pump, w/o alarm |
9 |
N |
Y |
N |
||
|
B9002 |
U9 |
Enteral nutrition infusion pump, w/alarm |
9 |
N |
Y |
N |
||
|
E1340 |
U9 |
Repair or nonroutine svc for DME, labor component |
9 |
N |
Y |
N |
XIII. HCPCS Procedure Codes Payable to Private Duty Nursing
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
A4349 |
Male external catheter with integral collection compartment, extended wear, each |
1 |
N |
N |
N |
|||
|
B4100 |
Food thickener, administered orally, per oz. |
1 |
N |
N |
N |
XIV. HCPCS Procedure Codes Payable to Nurse Practitioner
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
N |
N |
N |
N |
|||
|
J0128 |
Injection, abarelix, 10 mg |
N |
003 |
N |
N |
N |
||
|
J1457 |
Injection, gallium nitrate, 1 mg |
N |
003 |
N |
N |
N |
||
|
J7518 |
Mycophenelic acid, oral, 180 mg |
N |
003 |
N |
N |
N |
||
|
J9035 |
Injection, bevacizumab, 10 mg |
N |
003 |
Y |
N |
N |
||
|
J9041 |
Injection, bortezomib, 0.1 mg |
N |
003 |
Y |
N |
N |
||
|
J9055 |
Injection, cetuximab, 10 mg |
N |
003 |
Y |
N |
N |
||
|
J9305 |
Injection, pemetrexed, 10 mg |
N |
003 |
Y |
N |
N |
||
|
S0164 |
Injection, pantoprazole sodium, 40 mg |
N |
003 |
N |
N |
N |
||
|
S0168 |
Injection, azacitidine, 100 mg |
N |
003 |
N |
N |
N |
XV. HCPCS Procedure Codes Payable to Area Health Education Centers
(AHEC)
* See coverage requirements and billing procedures for this procedure code in section XXI.
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
C |
N |
N |
N |
|||
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
T |
N |
N |
N |
|||
|
G0329 |
Electromagnetic ther, 1 or [GREATER THAN] areas, Stg 3 - 4 ulcers, post 30 days conv care |
1 |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
C |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
P |
N |
N |
N |
|||
|
G0336 |
PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia |
T |
N |
N |
N |
|||
|
G0363 |
Irrigation of implanted venous access device for drug delivery systems |
1 |
N |
N |
N |
|||
|
G0364 |
Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS |
2 |
N |
N |
N |
|||
|
G0364 |
Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS |
8 |
N |
Y |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
C |
N |
N |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
P |
N |
N |
N |
|||
|
G0365 |
Vessel mapping of vessels for hemodialysis access |
T |
N |
N |
N |
|||
|
J0128 |
Injection, abarelix, 10 mg |
1 |
003 |
N |
N |
N |
||
|
J0180* |
Injection, agalsidase beta, I mg |
1 |
Y |
N |
N |
|||
|
J1457 |
Injection, gallium nitrate, 1 mg |
1 |
003 |
N |
N |
N |
||
|
J1931* |
Injection, laronidase, 0.1 mg |
1 |
Y |
N |
N |
|||
|
J2469 |
Injection, palonosetron HCI, 25 mcg |
1 |
003 |
N |
N |
N |
||
|
J3396 |
Injection, verteporfin, 0.1 mg |
1 |
Y |
N |
N |
|||
|
J7518 |
Mycophenelic acid, oral, 180 mg |
1 |
003 |
N |
N |
N |
||
|
J9035 |
Injection, bevacizumab, 10 mg |
1 |
003 |
Y |
N |
N |
||
|
J9041 |
Injection, bortezomib, 0.1 mg |
1 |
003 |
Y |
N |
N |
||
|
J9055 |
Injection, cetuximab, 10 mg |
1 |
003 |
Y |
N |
N |
||
|
J9305 |
Injection, pemetrexed, 10 mg |
1 |
003 |
Y |
N |
N |
||
|
L8614 |
EP |
Tracheoesophageal puncture dilator, replacement only, each |
6 |
N |
Y |
Y |
||
|
L8615 |
EP |
Headset/headpiece for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8616 |
EP |
Microphone for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8617 |
EP |
Transmitting coil for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8618 |
EP |
Transmitter cable for use with cochlear implant device, replacement |
6 |
N |
Y |
Y |
||
|
L8620 |
EP |
Lithium ion battery for use with cochlear implant device, replacement, each |
6 |
N |
Y |
Y |
||
|
L8621 |
EP |
Lithium ion battery for use with cochlear implant device, replacement, each |
6 |
N |
Y |
Y |
||
|
L8622 |
EP |
Alkaline battery for use with cochlear implant device, any size, replacement, each |
6 |
N |
Y |
Y |
||
|
S0164 |
Injection, pantoprazole sodium, 40 mg |
1 |
003 |
N |
N |
N |
||
|
S0168 |
Injection, azacitidine, 100 mg |
1 |
003 |
N |
N |
N |
||
|
S2348 |
Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumber |
2 |
N |
N |
N |
|||
|
S2348 |
Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumber |
8 |
N |
Y |
N |
XVI. HCPCS Procedure Codes Payable to Benefit Arkansas and Others
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
G0328 |
Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations |
9 |
N |
N |
Y |
XVII. HCPCS Procedure Codes Payable to ARKids First-B
|
2005 Codes |
M1 |
M2 |
Description |
T O S |
Diag. List |
Review Y/N |
PA Y/N |
MP Y/N |
|
E2601 |
General use wheelchair seat cushion, width less than 22 in., any depth |
H |
N |
N |
N |
|||
|
E2602 |
General use wheelchair seat cushion, width 22 in. or greater, any depth |
H |
N |
N |
N |
|||
|
E2611 |
General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware |
H |
N |
N |
N |
|||
|
E2612 |
General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware |
H |
N |
N |
N |
XVIII. Miscellaneous Changes
Several previously payable HCPCS codes have been deleted in the 2005 HCPCS conversion. Also, within some programs, local ?Z? codes had remained payable when there was no HCPCS code to replace it. Some of those codes are being replaced by a HCPCS code because during the 2005 conversion, a code has been developed that will cover the procedure or item.
The table below lists the deleted HCPCS code, any replacement code and the program(s) affected.
|
Deleted Code |
Replacement Code |
Program(s) Affected |
|
A4347 |
N/A |
Physician |
|
A4521 |
T4521 |
Prosthetics |
|
A4522 |
T4522 |
Prosthetics |
|
A4523 |
T4523 |
Prosthetics |
|
A4524 |
T4524 |
Prosthetics |
|
A4526 |
T4526 |
Prosthetics |
|
A4527 |
T4527 |
Prosthetics |
|
A4528 |
T4528 |
Prosthetics |
|
A4531 |
T4531 |
Prosthetics |
|
A4532 |
T4532 |
Prosthetics |
|
A4533 |
T4533 |
Prosthetics |
|
A4535 |
T4535 |
Prosthetics |
|
B4151 |
N/A |
Prosthetics |
|
B4156 |
N/A |
Prosthetics |
|
C9208 |
J0180 |
Physician, Outpatient Hospital |
|
C9209 |
J1931 |
Physician, Outpatient Hospital |
|
D7281 |
N/A |
Dental |
|
E0176 |
N/A |
Prosthetics |
|
E0178 |
N/A |
Prosthetics |
|
E0192 |
E2601-E2602 |
Prosthetics |
|
E0962 |
E2611-E2612 |
Prosthetics |
|
E0963 |
E2611-E2612 |
Prosthetics |
|
E0964 |
E2611-E2612 |
Prosthetics |
|
E0965 |
E2511-E2612 |
Prosthetics |
|
E1013 |
E2293-E2294 |
Prosthetics |
|
K0023 |
E2291 |
Prosthetics |
|
K0024 |
N/A |
Prosthetics |
|
K0059 |
N/A |
Prosthetics |
|
K0081 |
N/A |
Prosthetics |
|
K0114 |
N/A |
Prosthetics |
|
K0115 |
N/A |
Prosthetics |
|
K0116 |
N/A |
Prosthetics |
|
L0476 |
N/A |
Prosthetics |
|
L0478 |
N/A |
Prosthetics |
|
L0500 |
K0637 |
Prosthetics |
|
L0510 |
N/A |
Prosthetics |
|
L0515 |
K0635 |
Prosthetics |
|
L0520 |
K0642 |
Prosthetics |
|
L0530 |
NA |
Prosthetics |
|
L0540 |
K0644 |
Prosthetics |
|
L0550 |
K0649 |
Prosthetics |
|
L0560 |
N/A |
Prosthetics |
|
L0565 |
K0648 |
Prosthetics |
|
L0600 |
K0630 |
Prosthetics |
|
L0610 |
K0631 |
Prosthetics |
|
L0620 |
K0632 |
Prosthetics |
|
L2435 |
N/A |
Prosthetics |
|
L5674 |
N/A |
Prosthetics |
|
L5675 |
N/A |
Prosthetics |
|
L5846 |
N/A |
Prosthetics |
|
L8490 |
N/A |
Prosthetics |
|
Q0182 |
N/A |
Physician, Podiatry, Outpatient Hospital |
|
S0115 |
N/A |
Physician, Outpatient Hospital, Nurse Practitioner |
|
S2113 |
N/A |
Surgery, Assistant Surgeons, Outpatient Hospital |
The following table lists the deleted local code and the HCPCS code that has been assigned to replace the code. The third column lists the program affected.
|
Deleted Code |
Replacement Code |
Program(s) Affected |
|
Z2090 |
E8000 |
Prosthetics |
|
Z2091 |
E8001 |
Prosthetics |
|
Z2092 |
E8002 |
Prosthetics |
|
Z2157 |
E2619 |
Prosthetics |
|
Z2158 |
E2619 |
Prosthetics |
|
Z2699 |
B9998, EP, U1 |
Hyperalimentation |
|
Z2700 |
B9998, EP, U2 |
Hyperalimentation |
|
Z2702 |
B9998, EP, U3 |
Hyperalimentation |
|
Z2703 |
B9998, EP, U4 |
Hyperalimentation |
|
Z2704 |
B9998, EP, U5 |
Hyperalimentation |
|
Z2705 |
B9998, EP U6 |
Hyperalimentation |
|
Z2706 |
B9998, EP, U7 |
Hyperalimentation |
|
Z2714 |
B9998, EP, U8 |
Hyperalimentation |
NOTE: One CPT procedure code, 69949, is being replaced by HPCPS procedure code L8614, described as ?cochlear device/system.? The CPT procedure code remains payable for other than the cochlear implant device.
XIX. Non-Covered HCPCS Procedure Codes
The following codes are not covered by Arkansas Medicaid.
|
A4520 |
D5226 |
E2603 |
G9018 |
L7181 |
|
A7040 |
D6094 |
E2604 |
G9019 |
L8515 |
|
A7041 |
D6190 |
E2605 |
G9020 |
S0109 |
|
A7527 |
D6194 |
E2606 |
G9035 |
S0117 |
|
A9152 |
D6205 |
E2607 |
G9036 |
S0160 |
|
A9153 |
D6214 |
E2608 |
G9037 |
S0162 |
|
A9180 |
D6624 |
E2609 |
J0135 |
S0166 |
|
B4102 |
D6634 |
E2610 |
J2357 |
S0167 |
|
B4103 |
D6710 |
E2613 |
J2794 |
S0194 |
|
B4104 |
D6794 |
E2614 |
J3110 |
S0196 |
|
C9211 |
D7283 |
E2615 |
J7304 |
S0515 |
|
C9212 |
D7288 |
E2616 |
J7611 |
S0618 |
|
C9704 |
D7311 |
E2617 |
J7612 |
S2082 |
|
D0416 |
D7321 |
E2620 |
J7613 |
S2083 |
|
D0421 |
D7511 |
E2621 |
J7614 |
S2215 |
|
D0431 |
D7521 |
G0110 |
J7616 |
S3890 |
|
D0475 |
D7953 |
G0111 |
J7617 |
S4042 |
|
D0476 |
D7963 |
G0112 |
J7674 |
S8093 |
|
D0477 |
D9942 |
G0113 |
J8501 |
S8301 |
|
D0478 |
E0118 |
G0114 |
J8565 |
S9976 |
|
D0479 |
E0464 |
G0115 |
K0628 |
S9977 |
|
D0481 |
E0637 |
G0116 |
K0629 |
S9988 |
|
D0482 |
E0639 |
G0330 |
K0630 |
T4525 |
|
D0483 |
E0640 |
G0331 |
K0669 |
T4534 |
|
D0484 |
E0849 |
G0339 |
L5856 |
T4536 |
|
D0485 |
E1039 |
G0340 |
L5857 |
T4537 |
|
D2915 |
E1229 |
G0341 |
L6694 |
T4538 |
|
D2934 |
E1239 |
G0342 |
L6695 |
T4539 |
|
D2971 |
E1841 |
G0343 |
L6696 |
T4540 |
|
D2975 |
E2205 |
G0344 |
L6697 |
T4541 |
|
D5225 |
E2370 |
G9017 |
L6698 |
T4542 |
|
V2702 |
XX. Non-Covered Procedure Codes with Elements of CPT or Other Codes
The following codes are non-covered because they contain elements of CPT procedure codes or other HCPCS procedure codes already covered by Arkansas Medicaid.
|
A4223 |
C1772 |
C2620 |
C9430 |
G0349 |
|
A4605 |
C1773 |
C2621 |
C9431 |
G0350 |
|
A4644 |
C1776 |
C2622 |
C9432 |
G0351 |
|
A4645 |
C1777 |
C2625 |
C9433 |
G0353 |
|
A4646 |
C1778 |
C2626 |
C9435 |
G0354 |
|
B9999 |
C1779 |
C2627 |
C9437 |
G0355 |
|
C1093 |
C1780 |
C2628 |
C9438 |
G0356 |
|
C1305 |
C1781 |
C2629 |
C9439 |
G0357 |
|
C1713 |
C1782 |
C2630 |
C9713 |
G0358 |
|
C1714 |
C1784 |
C2631 |
C9716 |
G0359 |
|
C1715 |
C1785 |
C2634 |
C9718 |
G0360 |
|
C1721 |
C1786 |
C2635 |
C9719 |
G0361 |
|
C1722 |
C1787 |
C2636 |
C9720 |
G0362 |
|
C1724 |
C1788 |
C9205 |
C9721 |
G0366 |
|
C1725 |
C1789 |
C9206 |
C9722 |
G0367 |
|
C1726 |
C1813 |
C9220 |
E0769 |
G0368 |
|
C1727 |
C1815 |
C9221 |
G0260 |
G9013 |
|
C1728 |
C1816 |
C9222 |
G0308 |
G9014 |
|
C1729 |
C1817 |
C9399 |
G0309 |
G9021 |
|
C1730 |
C1874 |
C9400 |
G0310 |
G9022 |
|
C1731 |
C1875 |
C9401 |
G0311 |
G9023 |
|
C1732 |
C1876 |
C9402 |
G0312 |
G9024 |
|
C1733 |
C1877 |
C9403 |
G0313 |
G9025 |
|
C1750 |
C1878 |
C9404 |
G0314 |
G9026 |
|
C1751 |
C1879 |
C9405 |
G0315 |
G9027 |
|
C1752 |
C1880 |
C9410 |
G0316 |
G9028 |
|
C1753 |
C1881 |
C9411 |
G0317 |
G9029 |
|
C1754 |
C1882 |
C9413 |
G0318 |
G9030 |
|
C1755 |
C1883 |
C9414 |
G0319 |
G9031 |
|
C1756 |
C1885 |
C9415 |
G0320 |
G9032 |
|
C1757 |
C1887 |
C9417 |
G0321 |
G9034 |
|
C1758 |
C1891 |
C9418 |
G0322 |
K0628 |
|
C1759 |
C1892 |
C9419 |
G0323 |
K0629 |
|
C1760 |
C1893 |
C9420 |
G0324 |
S0116 |
|
C1762 |
C1894 |
C9421 |
G0325 |
S0158 |
|
C1763 |
C1895 |
C9422 |
G0326 |
S0159 |
|
C1764 |
C1896 |
C9423 |
G0327 |
S0161 |
|
C1766 |
C1897 |
C9424 |
G0337 |
S0257 |
|
C1767 |
C1898 |
C9425 |
G0338 |
S2152 |
|
C1768 |
C1899 |
C9426 |
G0345 |
S9097 |
|
C1769 |
C2615 |
C9427 |
G0346 |
S9482 |
|
C1770 |
C2617 |
C9428 |
G0347 |
T2049 |
|
C1771 |
C2619 |
C9429 |
G0348 |
XXI. Coverage and Billing Requirements for Procedure Codes J0180 and J1931
Coverage Requirements
Special criteria for coverage of these two injections apply.
Procedure code J0180 ? Adgalsidase beta, per 1 mg is covered for treatment of Fabry?s disease, ICD-9-CM diagnosis code 272.7.
Procedure code J1931 ? Laronidase, per 2.9 mg is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5.
The injections may be provided in the outpatient hospital or emergency room. If the physician provides the service in the office, the following conditions apply:
The provider must have nursing staff available to monitor the patient?s vital signs during the infusion.
The provider must be able to treat anaphylactic shock in the treatment area where the drugs are infused.
Prior Approval and Billing Procedures
Providers must obtain prior approval for the use of J0180 and J1931 in accordance with the following procedures:
When the physician determines the injection is needed for a Medicaid-eligible patient, he or she must obtain prior approval from the Medical Director for the Division of Medical Services (DMS) before beginning therapy.
The Medical Director?s prior approval is necessary to ensure payment of the provider?s charges.
The provider must submit a history and physical examination with the treatment protocol before beginning the treatment.
Send all requests for prior approval to: Division of Medical Services P. O. Box 1437, Slot S472
Attention: Medical Director
The provider will be notified by mail of the DMS Medical Director?s decision.
Claims for prior-approved therapeutic agents must be submitted to EDS on paper.
Each claim must reflect, in the description of service field, the number in the treatment series of each administration for which you are billing Medicaid.
No prior approval authorization number is issued; therefore, a copy of the Medical Director?s approval letter must be attached to each claim filed.
The physician must supply the hospital a copy of the Medical Director?s approval letter if the administration is to be provided at the outpatient hospital (POS 22) or the emergency room (POS 23).
Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes will be automatically incorporated.
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 or 1-877-708 -8191. Both telephone numbers are voice and TDD.
If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457 -4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.
Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.
Thank you for your participation in the Arkansas Medicaid Program.
_______________________________________________
Roy Jeffus, Director
