Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-088 - Transportation Provider Manual Update Transmittal #73; Vision Care Provider Manual Update Transmittal #68; Private Duty Nursing Provider Manual Update Transmittal #61
Current through Register Vol. 49, No. 9, September, 2024
252.100 Ambulance Procedure Codes
|
93041* |
A0380 |
A0382 |
A0390 |
A0398 |
|
A0422 |
A0426 |
A0427 |
A0429 |
J0150* |
|
J1940* |
J2270* |
J3490* |
J0152* |
J0170* |
|
J0280* |
J0460* |
J1094* |
J1100* |
J1160* |
|
J1200* |
J2060* |
J2175* |
J2310* |
J2550* |
|
J2560* |
J3360* |
J3410* |
J3475* |
J3480* |
|
Q4076* |
* Procedure code can be billed only in conjunction with procedure code A0427.
|
Procedure Code |
Required Modifier |
Description |
|
A0436 |
Emergency, per mile, loaded, helicopter air ambulance |
|
|
A0422 |
U1 |
Emergency, oxygen, helicopter air ambulance |
|
A0431 |
Ambulance service, emergency, basic pick-up, helicopter, one unit per day |
|
|
A0428 |
Ambulance service, ILS intermediate transport, mileage and disposable supplies billed separately |
|
|
A0380 |
TF |
ILS mileage (per mile) |
|
T2002** |
Non-emergency ground ambulance transportation, hospital to nursing facility |
|
|
A0435 |
U1, UB U2, UB U3, UB U4, UB U5, UB U6, UB |
Piston propelled fixed air ambulance per mile Turboprop fixed wing air ambulance per mile Jet (fixed wing) one unit equals one mile Piston propelled fixed wing air ambulance per hour (Round to the nearest hour.) Turboprop fixed wing air ambulance per hour (Round to the nearest hour.) Jet (fixed wing) one unit equals one hour (Round to the nearest hour.) |
|
A0434 |
Air Ventilator/Respiratory Therapist, one unit equals one hour (Round to the nearest hour.) |
** Procedure code must be billed on a paper CMS-1500 claim form with the supporting documentation listed in section 213.100.
242.110 Visual Procedure Codes
The following services are covered under the Arkansas Medicaid Program.
|
Procedure Code |
Required Modifier |
Description |
Coverage |
|
|
Under 21 |
Over 21 |
|||
|
DIAGNOSTIC AND ANCILLARY SERVICES |
||||
|
S0620 S0621 |
VISION ANALYSIS AND DIAGNOSIS (SINGLE VISION) This service must include the following: case history, general health observation, external exam of the eye and adnexa, ophthalmoscopic examination, determination of refractive state, basic sensorimotor and binocularity examination. It may also include initiation of diagnostic and treatment programs or referral. |
yes |
yes |
|
|
92340 |
PRESCRIPTION SERVICES This service includes determination of prescription, sizing, ordering, verification, dispensing of spectacles and follow-up services for the life of the prescription. |
yes |
yes |
|
|
99173 |
UB |
PRELIMINARY EVALUATION (MODIFIED SCREENING) This procedure must include at minimum three of the services listed under procedure code V0100. This code may not be billed in conjunction with procedure code V0100. |
yes |
yes |
|
CONTACT LENS SERVICES |
||||
|
S0592 |
VISION ANALYSIS AND CONTACT LENS EXAM This service must include the following: biomicroscopy, multiple ophthalmometry, case history, tear flow, measurement of ocular adnexa, initial tolerance evaluation, and may include other tests. This procedure does not include contact lens and should be billed in conjunction with other contact lens procedure codes. If billing this code, DO NOT bill V0100. Contacts and glasses may be ordered using this code. |
yes W/PA |
yes W/PA |
|
|
S0512 |
SUPPLYING AND FITTING OF CONTACT LENS (HARD) Spherical, aphakic, lenticular, toric, prism ballast (per lens) |
yes W/PA |
yes W/PA |
|
|
S0512 |
SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical, aphakic, lenticular, toric, hydrophilic (per lens) |
yes W/PA |
yes W/PA |
|
|
S0512 |
SUPPLYING AND FITTING OF CONTACT LENS (GAS PERMEABLE) Spherical, aphakic, lenticular, toric, prism ballast (per lens) |
yes W/PA |
yes W/PA |
|
|
V2501 |
UA |
SUPPLYING AND FITTING OF KERATOCONUS LENS (HARD OR GAS PERMEABLE) - per lens |
yes W/PA |
yes W/PA |
|
S0512 |
SUPPLYING AND FITTING OF MONOCULAR LENS (HARD OR GAS PERMEABLE)-per lens |
yes W/PA |
yes W/PA |
|
|
V2501 |
U1 |
SUPPLYING AND FITTING OF MONOCULAR LENS (SOFT LENS) -per lens |
yes W/PA |
yes W/PA |
|
LOW VISION SERVICES |
||||
|
92002 |
UB |
LOWVISION EVALUATION |
yes W/PA |
yes W/PA |
|
SUPPLEMENTAL PROCEDURES |
||||
|
92081 |
U1 |
VISUAL FIELD - Electronic or Goldmann |
yes |
yes |
|
92081 |
U1 |
VISUAL FIELD - Confrontation Perimetry |
yes |
yes |
|
MISCELLANEOUS SERVICES |
||||
|
92100 |
UB |
TONOMETRY This procedure will only be covered when medically necessary. These conditions include, but are not limited to, diabetes, hypertension and age of the patient. |
yes |
yes |
|
92393 |
OCULAR PROSTHESIS This procedure must include fitting, prescriptions and supplying of stock artificial eyes with medical supervision of adaptation. |
yes W/PA |
no |
|
|
V2624 |
- |
CLEANING OF PROSTHESIS |
yes W/PA |
no |
|
REPAIRS AND MATERIAL SERVICES |
||||
|
V2025 |
FRAME REPLACEMENT This procedure is for professional services only when replacing the whole frame. This procedure may be billed in conjunction with procedure code 92390 (Z0146) for material cost or the material may be ordered through the current optical contractor. |
yes |
no |
|
|
PROFESSIONAL SERVICES FOR LENS REPLACEMENT |
||||
|
S0504 |
RP |
LENS REPLACEMENT - SINGLE VISION This procedure is for professional services only. It may be billed in conjunction with procedure code 92390 (Z0146) or through the current optical contractor. |
yes |
yes W/PA |
|
S0506 |
RP |
LENS REPLACEMENT - BIFOCAL This procedure is for professional services only. It may be billed in conjunction with procedure code 92390 (Z0146) or through the current optical contractor. |
yes |
yes W/PA |
|
CONTACT LENS REPLACEMENT |
||||
|
92326 |
" |
HARD LENS (PER LENS) This procedure code does not include a professional fee. |
yes W/PA |
no |
|
92326 |
" |
SOFT LENS (PER LENS) This procedure code does not include a professional fee. |
yes W/PA |
no |
|
92326 |
" |
GAS PERMEABLE (PER LENS) This procedure code does not include a professional fee. |
yes W/PA |
no |
|
92396 |
- |
APHAKIC LENS Post-operative cataract. |
yes |
yes W/PA |
|
92390 |
SPECTACLE MATERIAL Cost of material for replacing frame, front, temple. This procedure code may be billed in conjunction with V2025 (Z0124), S0504 (Z0134) and S0506 (Z0136). This price may not exceed our maximum rates established with our current optical contractor. When this code is used, an invoice must be attached. |
yes |
no |
|
|
V2799 |
- |
UNSPECIFIED PROCEDURE |
yes |
yes |
W/PA = Coverage with prior authorization.
242.120 Simultaneous Care of Two Patients
When a private duty nurse is caring for two patients simultaneously in the same location, the following procedure codes are to be used for the care provided to the second patient:
|
Procedure Code |
Required Modifier |
Description |
|
S9123 |
UB |
Private duty nurse, RN, 2nd patient. Medicaid maximum allowable is 50% of the rate for S9123. |
|
S9124 |
UB |
Private duty nurse, LPN, 2nd patient. Medicaid maximum allowable is 50% of the rate forS9124. |
242.130 Medical Supplies Procedure Codes
The following HCPCS procedure codes must be used when billing the Arkansas Medicaid Program for medical supplies.
|
A4206 |
A4216 |
A4217 |
A4221 |
A4222 |
A4253 |
|
A4256 |
A4259 |
A4265 |
A4310 |
A4311 |
A4312 |
|
A4313 |
A4314 |
A4315 |
A4316 |
A4320 |
A4322 |
|
A4326 |
A4327 |
A4328 |
A4330 |
A4338 |
A4340 |
|
A4344 |
A4346 |
A4347 |
A4348 |
A4351 |
A4352 |
|
A4354 |
A4355 |
A4356 |
A4357 |
A4358 |
A4359 |
|
A4361 |
A4362 |
A4364 |
A4367 |
A4369 |
A4371 |
|
A4397 |
A4398 |
A4399 |
A4400 |
A4402 |
A4404 |
|
A4405 |
A4406 |
A4414 |
A4452 |
A4454 |
A4455 |
|
A4558 |
A4560 |
A4561 |
A4562 |
A4623 |
A4624 |
|
A4625 |
A4626 |
A4628 |
A4629 |
A4772 |
A4927 |
|
A5051 |
A5052 |
A5053 |
A5054 |
A5055 |
A5061 |
|
A5062 |
A5063 |
A5071 |
A5072 |
A5073 |
A5081 |
|
A5082 |
A5093 |
A5102 |
A5105 |
A5112 |
A5113 |
|
A5114 |
A5119 |
A5121 |
A5122 |
A5126 |
A5131 |
|
A6154 |
A6234 |
A6241 |
A6242 |
A6248 |
A6441 |
|
A6442 |
A6443 |
A6444 |
A6445 |
A6446 |
A6447 |
|
A6448 |
A6449 |
A6450 |
A6451 |
A6452 |
A6453 |
|
A6454 |
A6455 |
A7520 |
A7521 |
A7522 |
A7524 |
|
A7525 |
B4086 |
E0776 |
National HCPCS Codes
|
Procedure Code |
Required Modifier |
Description |
|
A6257 |
Transparent Film, each (16 square inches or less) |
|
A6258 |
Transparent Film, each (more than 16, but less than 48 square inches) |
|
|
A6259 |
Transparent Film, each (more than 48 square inches) |
|
|
A6216 A6219 A6228 |
Gauze Pad, Medicated or Non-Medicated, each (16 square inches or less) |
|
|
A6220 A6229 A6217 |
Gauze Pads, Medicated or Non-Medicated, each (more than 16, but less than 48 square inches) |
|
|
A6221 A6230 A6218 |
Gauze Pads, Medicated or Non-Medicated, each (more than 48 square inches) |
|
|
A4450 |
Gauze, Non-Elastic, Per Roll (1 linear yard) |
|
|
A6245 A6242 |
Hydro gel Dressing, each (16 square inches or less) |
|
|
A6246 |
Hydro gel Dressing, each (more than 16, but less than 48 square inches) |
|
|
A6247 A6244 |
Hydro gel Dressing, each (more than 48 square inches) |
|
|
A6248 |
Hydro gel Dressing, each (1 ounce) |
|
|
A6237 A6234 |
Hydrocolloid Dressing, each (16 square inches or less) |
|
|
A6238 A6235 |
Hydrocolloid Dressing, each (more than 16, but less than 48 square inches) |
|
|
A6236 A6239 |
Hydrocolloid Dressing, each (more than 48 square inches) |
|
|
A6196 |
Alginate Dressing, each (16 square inches or less) |
|
|
A6197 |
Alginate Dressing, each (more than 16, but less than 48 square inches) |
|
|
A6198 |
Alginate Dressing, each (more than 48 square inches) |
|
|
A6197 |
UB |
Alginate Dressing, each (1 linear yard) |
|
A6209 |
Foam Dressing, each (16 square inches or less) |
|
|
A6210 |
Foam Dressing, each (more than 16, but less than 48 square inches) |
|
|
A6211 |
Foam Dressing, each (more than 48 square inches) |
|
|
A6200 |
Composite Dressing, each (16 square inches or less) |
|
|
A6201 |
Composite Dressing, each (more than 16, but less than 48 square inches) |
|
|
A6202 |
Composite Dressing, each (more than 48 square inches) |
|
|
A4253 |
UB |
Blood Glucose test or reagent strip for home blood glucose monitor, per 25 strips |
|
A4353 |
Urinary intermittent catheter with insertion tray |
|
|
A4394 |
Ostomy deodorant, all types, per ounce |
|
A4365 |
Adhesive remover wipes, 50 per box |
|
A4368 |
Ostomy filters, any type, each |
|
A4483 |
Tracheostomy vent-heat moisture device |
|
L8239* |
Stocking (Jobst) |
* Refer to section 242.430.
