Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-008 - 2008 HCPCS & CPT Procedure Code Conversion

I. General Information

A review of the 2008 CPT procedure codes has been completed, and the Arkansas Medicaid Program will begin accepting CPT 2008 procedure codes for dates of service on and after March 1, 2008. 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 CPT 2008 (Appendix B) are non-payable for dates of service on and after March 1, 2008.

For the benefit of those programs impacted by the conversions, the Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2008 CPT and HCPCS conversions.

II. Non-Covered CPT 2008 Procedure Codes

III. Prior Authorization

IV. CPT 2008 Procedure Codes Manually Reviewed

Effective for dates of service on and after March 1, 2008, the new CPT procedure codes listed below are manually reviewed before payment. Providers must submit claims as indicated below:

V. Current Procedure Codes to Become Payable

The following existing CPT procedure codes will become payable effective for dates of service on or after March 1, 2008 for physicians, hospitals and ambulatory surgical centers. These procedure codes will be manually reviewed prior to payment and require prior authorization from AFMC and a paper claim with form DMS-2606 attached.

VI. New Local HCPCS Procedure Code

Effective for dates of service on and after March 1, 2008, the following locally assigned HCPCS procedure code is payable to Arkansas Medicaid physician providers. This procedure code requires manual review prior to payment and must be billed on a paper claim form with form DMS-2606 attached. See sections 272.100, 292.440, 292.444 and 292.447 of the Physician Provider Manual.

VII. The following codes are payable to podiatrists:

VIII. The following codes are payable to oral surgeons:

IX. Effective for dates of service on or after March 1, 2008 the following CPT procedure codes are payable to Certified Nurse Midwives:

X. CPT Procedure Codes Payable to Ambulatory Surgical Centers

XI. Additional Information

Procedure code 84704 is exempt from ARKids First-B copayment.

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) 682-8323 or (501) 682-6789 (TDD); In-State Toll Free at 800-482-1141 or Out-of-State Toll Free at 800-482-5850. The Toll-Free lines are voice only.

Please direct inquiries regarding this Official Notice to the EDS Provider Assistance Center at 501-376-2211 or (In-State Toll Free) 800-457-4454.

Arkansas Medicaid provider manuals, update transmittals, proposed rules for public comment, official notices and remittance advice (RA) messages can be downloaded without charge from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Roy Jeffus, Director

I. General Information

A review of the 2008 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, 2008.

II. 2008 HCPCS Payable Procedure Codes Tables Information

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

The tables of payable procedure codes for all affected programs 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 of the list contains the HCPCS procedure codes. The procedure code may be shown on multiple lines on the table, depending on the applicable modifier based on the service performed.

II. 2008 HCPCS Payable Procedure Code Tables Information

The second 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. 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 third and fourth columns, for all affected programs, indicate the beginning and ending range of diagnoses for which a procedure code may be used. (e.g.: 0530 through 0549).

The fifth column contains information about the diagnosis list for which a procedure code may be used. (See Section III below for more information about diagnosis range and lists.)

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 a procedure code requiring 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.

Please Note: The Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2008 CPT and HCPCS conversions.

III. Diagnosis Range and Diagnosis Lists

Certain procedure codes are covered only when the primary diagnosis is covered within a diagnosis range or on a diagnosis list.

Diagnosis List 003

042, 140.0 through 208.91

230.0 through 238.9

IV. HCPCS Procedure Codes Payable to Ambulatory Surgical Centers (ASC) The following information is related to procedure codes found in the ASC table.

J7321, J7322, J7323 J7324K

Prior authorization must be obtained through the Utilization Review Section of the Division of Medical Services (DMS). 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 Arkansas 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

Toll Free: 1-800-482 -5850, Extension 28340

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

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

V. HCPCS Procedure Codes Payable to ARKids First-B

B4087This procedure code is included in the $125 per month ARKidsFirst-B medical supply benefit limit.

VI. HCPCS Procedure Codes Payable to Certified Nurse Midwife

Family planning services require a primary 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 listed below applies to that procedure code in the grid.

J7307FThis procedure code requires a primary family planning detail diagnosis code. It is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

* Procedure codes J2791 and J7307 are exempt from ARKids First-B co-pay.

VII. HCPCS Procedure Codes Payable to Family Planning Clinic

Family planning services require a primary 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 listed below applies to that procedure code in the grid.

J7307FThis procedure code requires a primary family planning detail diagnosis code. It is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

* Procedure code J7307 is exempt from ARKids First-B co-pay.

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

Family planning services require a primary family planning 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 listed below applies to that procedure code in the grid.

7307FThis procedure code is covered as a family planning benefit for

"regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit limited to two per seven years per beneficiary.

* Procedure code J7307 is exempt from ARKids First-B co-pay.

IX. HCPCS Procedure Codes Payable to Arkansas Department of Health * Procedure code J2791 is exempt from ARKids First-B co-pay.

X. HCPCS Procedure Codes Payable to Home Health

B4087This procedure code is included in the $250.00 per month medical supply benefit limit.

XI. 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 listed below applies to that procedure code in the grid.

C9240A.Coverage of this procedure code requires an ICD-9-CM diagnosis code of 174.0-175.9. Any one of the diagnosis codes from the above listed ranges is acceptable. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper 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.

J0220BThis procedure code requires an ICD-9-CM diagnosis code of 271.0. 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 paper 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.

XI. HCPCS Procedure Codes Payable to Hospitals

J1743CThis 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 and response to the medication is required annually. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper 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.

J2323DA prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. A history and physical showing a relapse of multiple sclerosis must be submitted. 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.

J2778EThis procedure code requires an ICD-9-CM diagnosis code of362.50 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 paper 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.

J7307FFamily planning services require a family planning diagnosis code.

This procedure code is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

J9303GThis 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 paper 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.

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

XI. HCPCS Procedure Codes Payable to Hospitals

J7321, J7322, J7323 J7324K

Prior authorization must be obtained through the Utilization Review Section of the Division of Medical Services (DMS). 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 Arkansas 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

Toll Free: 1-800-482 -5850 Extension 28340

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

* Procedure codes J2791 and J7307 are exempt from ARKids First-B co-pay.

* Procedure codes J1561,J1568and J1569will be reviewed for medical necessity based on diagnosis code.

* Bill any applicable modifiers with the procedure code.

XII. HCPCS Procedures Codes Payable to Independent Lab

S3800 H This procedure code requires prior authorization by AFMC based on the following criteria:

XIII. HCPCS Procedures Codes Payable to Independent Radiology

*Bill any applicable modifiers with the procedure code.

XIV. HCPCS Procedure Codes Payable to Nurse Practitioners

*Procedure codes J1561will be reviewed for medical necessity base on diagnosis code.

XV. 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.

C9240A.Coverage of this procedure code requires an ICD-9-CM diagnosis code of 174.0-175.9. Any one of the diagnosis codes from the above listed ranges is acceptable. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper 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.

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

J0220BThis procedure code requires an ICD-9-CM diagnosis code of 271.0. 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 paper 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.

J1743CThis 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 and response to the medication is required annually. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper 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.

J2323DA prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. A history and physical showing a relapse of multiple sclerosis must be submitted. 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.

J2778EThis 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.

J7307FFamily planning services require a family planning diagnosis code.

This procedure code is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

J9303GThis 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 paper 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.

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

J7321, J7322, J7323 J7324K

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

Toll Free: 1-800-482 -5850 Extension 28340

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

* Procedure codes J2791 and J7307 are exempt from PCP referral and exempt from ARKids First-B co-pay.

* Procedure codes J1561,J1568and J1569will be reviewed for medical necessity base on diagnosis code.

Effective for dates of service on and after March 1, 2008, locally assigned HCPCS procedure code Z9950, "Anesthesia for laparoscopic supracervical hysterectomy," is payable to physicians and CRNAs. The procedure requires manual review before payment and it must be billed on a redlined paper claim form with form DMS-2606 attached.

*Bill any applicable modifiers with the procedure code.

XVI. HCPCS Procedure Codes Payable to Private Duty Nursing

B4087This procedure code is included in the medical supply benefit limit of $80.00 per month.

XVII. HCPCS Procedure Codes Payable to Prosthetics

B4087This procedure code is included in the medical supply benefit limit of $250.00 per month. L3925This procedure code is included in the orthotic benefit limit of

$3000.00 per SFY for beneficiaries age 21 and over. L3929This procedure code is included in the orthotic benefit limit of

$3000.00 per SFY for beneficiaries age 21 and over L3931This procedure code is included in the orthotic benefit limit of

$3000.00 per SFY for beneficiaries age 21 and over.

XVIII. HCPCS Procedure Codes Payable to Rehabilitation Center

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

XIX. Non-Covered 2008 HCPCS with Elements of CPT or Other Procedure Codes

XX. Non-Covered 2008 HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

XXI. Miscellaneous Changes

T4530 Pediatric sized disposable incontinence product,

brief/diaper, large size, each

T4532 Pediatric size disposable incontinence product, protective underwear/pull-on, large size, each

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) 682-8323 or (501) 682-6789 (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