Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.07-001 - 2007 HCPCS & CPT Procedure Code Conversion Official Notices

I. General Information

A review of the 2007 CPT procedure codes has been completed, and the Arkansas Medicaid Program will begin accepting CPT 2007 procedure codes for dates of service on and after March 1, 2007. Please add this information to your Medicaid provider manual until revised manual sections have been included in future updates.

Procedure codes that are identified as deletions in the CPT 2007 (Appendix B) are non-payable for dates of service on and after March 1, 2007.

II. Non-Covered CPT 2007 Procedure Codes

III. Prior Authorization

The following 2007 CPT procedure codes require prior authorization (PA).

IV. CPT 2007 Procedure Codes Manually Reviewed

Effective for dates of service on and after March 1, 2007, the CPT procedure codes listed below are manually reviewed before payment. Providers must submit paper claims with supporting documentation.

V. Podiatry Program

The following CPT 2007 procedure codes are payable to podiatry providers.

VI. Oral Surgery Program

The following CPT 2007 procedure codes are payable to oral surgeons.

Thank you for your participation in the Arkansas Medicaid Program.

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 (TDD only)

If you have questions regarding this notice, please contact the EDS Provider Assistance Center at In-State WATS 1 - 800-457-4454, or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www, medicaid, state, or. us.

I. General Information

A review of the 2007 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 March 1, 2007.

II. 2007 HCPCS Payable Procedure Code Tables Information

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

The tables of payable procedure codes 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. The procedure code may be shown on multiple lines of the table, depending on the number of types of service (TOS) for which it can be used by a provider.

The second 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 by some provider types. This information is provided when pertinent to billing protocol.

The third column shows procedure codes that require manual pricing and is titled Manually Priced 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. This information is provided when pertinent to billing protocol. Providers should consult their program manual to review the process involved in manual pricing.

Certain procedure codes are covered only when the primary diagnosis is covered within a specific diagnosis range. This information is used, for example, by physicians, hospitals and others. The fourth and fifth columns indicate the beginning and ending range of diagnoses for which a procedure code may be used, (e.g.: 0530 through 0549).

The sixth column indicates whether a procedure is subject to medical review before payment. The column is titled "Review Y/N". The letter "Y" in the column indicates 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 seventh 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" indicates 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 eighth column indicates any modifiers that must be used in conjunction with the procedure code, when billed, either electronically or on paper.

The ninth column indicates which procedure code requires a "prior approval letter" from the Arkansas Medicaid Medical Director. The letter "Y" in the column indicates that a procedure code requires a prior approval letter and an "N" indicates that a prior approval letter is not required. A prior approval letter, when required, must be attached to the paper claim when it is filed.

III. HCPCS Procedure Codes Payable to ARKids

IV. HCPCS Procedure Codes Payable to Ambulatory Surgical Centers (ASC)

The following information is related to procedure codes found in the ASC table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid.

J J7319 Prior authorization must be obtained through the Utilization

Review Section of the Division of Medical Services (DMS). Providers must specify the brand name of Hyaluronon or derivative when requesting prior authorization for this procedure code. A written request must be submitted to the Division of Medical Services Utilization Review Section.

The request must include the patient's name, Medicaid ID number, physician's name, Physician's Medicaid provider number and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one series of injections per knee, per beneficiary, per lifetime.

The contact information for Utilization Review is:

In-State WATS:

Direct: (501) 682-8340

Voice Mail: 1-800-482 -1141

FAX: (501) 682-8013

Mailing Arkansas Division of Medical Services Utilization

Review Section Address: P. O. Box 1437, Slot S413

Little Rock, AR 72203-1437

V. HCPCS Procedure Codes Payable to Family Planning Clinic

Family planning services require a family planning detail diagnosis code.

The following information is related to procedure codes found in the family planning clinic table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid. A family planning diagnosis code is required.

VI. HCPCS Procedure Codes Payable to Federally Qualified Health Centers (FQHC)

Family planning services require a family planning detail diagnosis code.

The following information is related to procedure codes found in the FQHC table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid. A primary family planning diagnosis code is required.

VII. HCPCS Procedure Codes Payable to Hemodialysis Providers

VIII. HCPCS Procedure Codes Payable to Home Health

IX. HCPCS Procedure Codes Payable to Hospitals

The following information is related to procedure codes found in the hospital table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid.

C9232 This procedure code requires an ICD-9-CM diagnosis code of

277.5 (MPSII) . An evaluation by a physician with a specialty in clinical genetics, documenting progress is required annually. A prior approval letter from the DMS Medical Director is required for billing, and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions or contact the DMS Medical Director at (501)-682-9868.

C9233 This procedure code requires an ICD-9-CM diagnosis code of

362.50 or 362.52 as the principle diagnosis. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

C9235 This procedure code requires an ICD-9-CM diagnosis code of

153.0-154.8. A prior approval letter from the DMS Medical Director is required for billing and must be attached to each claim. A copy of the prior approval letter must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

C9350 This procedure code requires attachment of manufacturer's invoice and procedure report to the claim.

E J0129 This procedure code requires an ICD-9-CM diagnosis code of

714.0-714.2 as a primary diagnosis. The patient must have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs, such as methotrexate or Tumor Necrosis Factor antagonists (Humira, Remicade, etc.). The records submitted must include a history and physical exam showing (1) the severity of the rheumatoid arthritis (2) Treatment with one of the above listed drugs (3) treatment failure resulting in progression of joint destruction, swelling, or tendonitis, etc. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

F J0348 This procedure code is covered for any of the conditions below,

along with an ICD-9-CM diagnosis code of 112.5 or 112.8 (and any valid 5th digits), or 112.9.

X. HCPCS Procedures Codes Payable to Independent Radiology

The following information is related to certain codes found within the independent radiology section below.

XI. HCPCS Procedure Codes Payable to Oral Surgeons

The following information is related to procedure codes found in the oral surgeon section table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid.

XII. HCPCS Procedure Codes Payable to Physicians and Area Health Care Education Centers (AHECs)

The following information is related to procedure codes found in the physicians and AHECs section table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid.

A C9232 This procedure code requires an ICD-9-CM diagnosis code of

277.5 (MPSII) . An evaluation by a physician with a specialty in clinical genetics, documenting progress is required annually. A prior approval letter from the DMS Medical Director is required for billing, and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions or contact the DMS Medical Director at (501)-682-9868.

B C9233 This procedure code requires an ICD-9-CM diagnosis code of

362.50 or 362.52 as the principle diagnosis. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

c C9235 This procedure code requires an ICD-9-CM diagnosis code of

153.0-154.8. A prior approval letter from the DMS Medical Director is required for billing and must be attached to each claim. A copy of the prior approval letter must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

D C9350 This procedure code requires attachment of manufacturer's invoice and procedure report to the claim.

E J0129 This procedure code requires an ICD-9-CM diagnosis code of

714.0-714.2 as a primary diagnosis. The patient must have had an inadequate response to one or more Disease-Modifying Anti-Rheumatic Drugs, such as methotrexate or Tumor Necrosis Factor antagonists (Humira, Remicade, etc.). The records submitted must include a history and physical exam showing (1) the severity of the rheumatoid arthritis (2) Treatment with one of the above listed drugs (3) treatment failure resulting in progression of joint destruction, swelling, or tendonitis, etc. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

F J0348 This procedure code is covered for any of the conditions below,

along with an ICD-9-CM diagnosis code of 112.5 or 112.8 (and any valid 5th digits), or 112.9.

XIII. HCPCS Procedure Codes Payable to Prosthetics

** Prior authorization is not required when other insurance pays at least

50% of the Medicaid maximum allowable reimbursement amount.

# The purchase of this wheelchair component is limited to one per five-year period for individuals age 21 and older.

+ Limited to one per 12 months.

NOTE: Procedure codes L7007 and L7008 are for replacement only.

XIV. Non-Covered HCPCS with Elements of CPT or Other Procedure Codes

The following 2007 HCPCS procedure codes are not payable because these services are covered by another CPT procedure code, another HCPCS procedure code or by a revenue code.

XV. Non-Payable HCPCS Procedure Codes for the ARKids First-B Program

XVI. Non-Covered HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

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 have already been 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 (TDD only).

If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457 -4454 (Toil-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