Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.09-036 - Hospital Update #165 & Physician Update #178

J9091

J9092

J9093

J9094

J9095

J9096

J9097

J9098*

J9100

J9110

J9120

J9130

J9140

J9150

J9151

J9165

J9170

J9181

J9182

J9185

J9190

J9200

J9201

J9202

J9206

J9208

J9209

J9211

J9212

J9213

J9214

J9215

J9216

J9217

J9218

J9230

J9245

J9260

J9265

J9266

J9268

J9270

J9280

J9290

J9291

J9300

J9310

J9320

J9340

J9355

J9357

J9360

J9370

J9375

J9380

J9390

J9600

J9999*

Q0166**

Q2009

Q2017

S0017

S0021

S0023

S0028

S0030

S0032

S0034

S0039

S0040

S0073

S0074

S0077

S0080

S0081

S0092

S0093

S0108

S0164

S0177

S0179

S0187

Procedure Code

Modifier(s)

Special Instructions

J0129*

Requires ICD-9-CM diagnosis code of 714.0-714.2 as primary diagnosis. Patient must have had inadequate response to one or more disease-modifying anti-rheumatic drugs such as Methotrexate or Tumor Necrosis Factor antagonists (Humira, Remicade, etc.). Records submitted with claim must include history and physical exam showing severity of rheumatoid arthritis, treatment with disease-modifying anti-rheumatic drugs, and treatment failure resulting in progression of joint destruction, swelling, tendonitis, etc. Prior approval letter from DMS Medical Director required to be attached to each claim. See 244.100 for information regarding requests for prior approval letters.

J0133

Payable for beneficiaries of all ages with diagnosis codes 053.0 -

054.9.

J0150

Procedure is covered for all ages with no diagnosis restriction. Maximum units 4 per day.

J0152*

Payable for all ages. When administered in the office, the provider must have nursing staff available to monitor the patient's vital signs during infusion. The provider must be able to treat cardiac shock and to provide advanced cardiac life support in the treatment area where the drug is infused. Requires paper claim with copy of report of diagnostic procedure. Maximum units 1 per day.

J0170

Payable if the service is performed on an emergency basis and is provided in a physician's office.

J0180*

This procedure is covered for treatment of Fabry's disease, ICD-9-CM diagnosis code 272.7. Procedure requires prior approval from DMS Medical Director. See section 244.100 for additional coverage information and instructions for requesting prior approval.

J0220*

Requires an ICD-9-CM diagnosis code of 271.0. Evaluation by a physician with a specialty in clinical genetics documenting progress required annually. A prior approval letter from DMS Medical Director required and must be attached to each claim. See 244.100 for information regarding acquiring the prior approval letter.

J0348

Valid for any condition below, along with ICD-9-CM diagnosis code of 112.5 or 112.8 (and any valid 5th digits), or 112.9. (1) End-stage Renal Disease (ICD-9-CM codes 584 - 586) or (2) AIDS or cancer (ICD-9-CM diagnosis codes 042, 140.0-208.9, 230.0-238.9) or (3) Post transplant status (i.e., ICD-9-CM diagnosis code 986.80-996.89) or specify transplanted organ and transplant date

J0570

Payable for beneficiaries of all ages with no diagnosis restrictions.

J0585

Payable for beneficiaries of all ages when medically necessary. Botox A is reviewed for medical necessity based on diagnosis.

J0636

Payable for beneficiaries of all ages receiving dialysis due to renal failure (diagnosis codes 584-586).

J0637*

Covered when administered to patients with refractory aspergillosis who also have a diagnosis of malignant neoplasm or HIV disease. Complete history and physical exam, documentation of failure with other conventional therapy and dosage. After 30 days of use, an updated medical exam and history must be submitted.

J0702

Payable for beneficiaries of all ages. However, when provided to beneficiaries aged 21 and older, there must be a diagnosis of AIDS, cancer or complications during pregnancy (diagnosis code range 640 - 648.93).

J0881

Use the lowest dose that will gradually increase the Hgb concentration to the lowest level sufficient to avoid the need for red

J0885

blood cell transfusion.

In addition to the primary diagnosis, an ICD-9-CM diagnosis code from each column below must be billed on the claim.

Column 1

Column II

Code

Description

285.9 Secondary Anemia

V58.11

Encounter for antineoplastic chemotherapy

V67.2

Following chemotherapy

E933.1

Antineoplastic and immunosuppressive drugs

Column I

Column II

Code

Description

285.29 Anemia of other chronic disease

070.54

Chronic Hepatitis C without mention of coma

238.72-238.75

Myelodysplastic

714.0-714.4

Rheumatoid Arthritis

J0882 J0886

Payable for dates of service on and after March 1, 2006. Covered when administered to patients diagnosed with ESRD (diagnosis range 584 - 586).

J0894*

Requires ICD-9-CM diagnosis codes of 205.00-205.91, 238.71-238.76, or 238.79. Prior approval letter from DMS Medical Director required to be attached to each claim. Refer to 244.100 for information regarding requesting prior approval.

J1100

Payable for beneficiaries of all ages. However, when provided to beneficiaries aged 21 and older, there must be a diagnosis of AIDS, cancer or complications during pregnancy (diagnosis code range 640 - 648.93).

J1270

Payable for beneficiaries with diagnosis codes 042,140.0 -208.91 + 230. 0-238-9 + 787.2 + 588.81;

Or

ESRD 584 - 586 +787.2+ 588.81.

Claims will be manually reviewed prior to reimbursement.

J1440 J1441

Payable for beneficiaries of all ages with no diagnosis restrictions.

J1458*

Payable for treatment of mucopolysaccharidosis (MPS VI), diagnosis code 277.5. Prior approval letter from DMS Medical Director required. Copy of prior approval letter must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval.

J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1560

Covered for individuals of all ages with no diagnosis restrictions.

J1561

Claims are reviewed for medical necessity based on the diagnosis code.

J1562

Payable for all ages without diagnosis restriction.

J1566 J1568 J1569

Claims are reviewed for medical necessity, based on the diagnosis code.

J1600

Payable for patients with a detail diagnosis of rheumatoid arthritis (diagnosis code range 714.0 - 714.9).

J1640

Payable when administered to all beneficiaries with ICD-9-CM detail diagnosis 277.1).

J1650

Payable for all ages with no diagnosis restriction.

J1652

Payable for beneficiaries of all ages with no diagnosis restrictions.

J1740

Payable for beneficiaries of all ages with no diagnosis restrictions.

J1743*

Requires ICD-9-CM diagnosis code of 277.5 (MPS II). An evaluation by a physician with a specialty in clinical genetics, documenting progress and response to the medication is required annually. Requires prior approval letter from DMS Medical Director and a copy must be attached to each paper claim. Refer to section 244.100 for information on how to acquire a prior approval letter.

J1745*

For beneficiaries under 18 years of age:

Effective for dates of service on and after 05/20/06, J1745is payable without an approval letter for beneficiaries under age 18 years when the diagnosis is 555.0, 555.1 or 555.9. No other diagnosis is required. All other diagnoses for beneficiaries under age 18 years will continue to require a prior approval letter.

For beneficiaries aged 18 years and above:

Procedure code J1745is payable when one of the following conditions exist:

1) ICD-9-CM code 555.9 as the primary detail diagnosis ANDa secondary diagnosis of 565.1 or 569.81

OR

2) ICD-9-CM code range 556.0 - 556.9

OR

3) ICD-9-CM code 696.0

OR

4) ICD-9-CM code 714.0

NOTE:ICD-9 diagnosis code 714.0 requires a prior approval letter from the Medical Director. The request for approval must include documentation showing failed trial of Enbrel or Humira.

Claims must be submitted to EDS with any applicable attachments. Claims will be manually reviewed by Medicaid medical staff prior to payment.

OR

5) ICD-9-CM 724.9.

NOTE:ICD-9 diagnosis code 724.9 requires a prior approval letter from the Medical Director. The request for approval must include documentation showing failed trial of Enbrel or Humira.

Claims must be submitted to EDS with any applicable attachments. Claims will be manually reviewed by Medicaid medical staff prior to payment.

J1750

Payable for all ages with no diagnosis restriction.

J1785*

This procedure is covered for the treatment of Type I Gaucher disease with complications, with a detail diagnosis of ICD-9 code 272.7. A prior approval letter from the DMS Medical Director is required. See section 244.001 and 244.100 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must be attached to each claim.

J1931*

This procedure is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5. Prior approval from DMS Medical Director is required. See section 244.001 and 244.100 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must

be attached to each claim.

J2260

Payable for Medicaid beneficiaries of all ages with congestive heart failure (ICD-9 diagnosis codes 428.0-428.9).

J2323*

Procedure requires a prior approval letter. See section 244.100. The history and physical showing a relapse of multiple sclerosis must be submitted with the request for the prior approval letter. This procedure must be billed on a paper claim. The approval letter must be attached to each claim. Requires review before payment.

J2353* J2354*

Payable for Medicaid beneficiaries of all ages. For ages 21 and older, J2353 and J2354 are covered for diagnosis of AIDs and cancer (ICD-9-CM diagnosis codes 140.0 - 208.91, 230.0 - 238.9 or 042). For other diagnoses, a prior approval letter is required and must be attached to each claim. See section 244.100 for information of requesting a prior approval letter.

J2503

Payable for beneficiaries diagnosed with macular degeneration (ICD-9-CM diagnosis code 362.50 - 362.52).

J2504

Payable for beneficiaries of all ages with a primary detail diagnosis of 279.2.

J2505

Payable for beneficiaries of all ages with a detail diagnosis from diagnosis code ranges 162.0 - 165.9, or174.0 - 175.9 or201.00 - 201.98 or202.80 - 202.88. Diagnosis codes 288.00-288.04, 288.09 or 288.4 or 288.50-288.51 or 288.59, 289.53, V58.69, V67.51 and E933.1 are covered along with a diagnosis of AIDS or cancer. Diagnosis codes must be shown on the claim form.

J2513

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2597

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2778*

Requires ICD-9-CM diagnosis code of 362.50 or 362.52 as primary diagnosis. Requires prior approval letter from DMS Medical Director attached to each claim. Refer to section 244.100 for information on how to acquire a prior approval letter.

J2788

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2790 J2791

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2792

Payable without restriction.

J2910

Payable for all beneficiaries with a primary detail diagnosis of rheumatoid arthritis (ICD-9 diagnosis codes 714.0 - 714.9).

J2916

Payable for beneficiaries of all ages with no restrictions.

J2993

Payable for beneficiaries of all ages with no diagnosis restrictions. Limited to 4 units per day in the office place of service. For the purpose of declotting catheters. Bill diagnosis 996.74 on the claim.

J2997

Payable for beneficiaries of all ages with no diagnosis restrictions. Limited to 4 units per day in the office place of service. For the purpose of declotting catheters. Bill diagnosis 996.74 on the claim.

J3396

Covered for all ages if one of the following diagnoses exist: ICD-9 diagnosis code 362.50 or 362.52; orICD-9 diagnosis code 360.21; orICD-9 diagnosis code 115.02 or115.12 or 115.92. Claims may be filed electronically or on paper. See section 244.002 for additional coverage information.

J3420

Payable for patients with a primary detail diagnosis of pernicious anemia, 281.0. Coverage includes the B-12, administration and supplies. It must not be billed in multiple units.

J3465*

Covered for non-pregnant beneficiaries of all ages with no restrictions.

J3487

Payable to physicians when provided in the office if one of the following diagnoses exist: A primary diagnosis of AIDS or cancer, or diagnosis code 275.42, 198.5, 203.0, or 733.90. Claims will be manually reviewed prior to payment. Payable for beneficiaries of all ages with no diagnosis restrictions.

J3488

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7187 J7190 J7191 J7192 J7193 J7194 J7195 J7197

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7198

Payable for all ages with no diagnosis restrictions.

J7199

For consideration, this code must be billed on a paper claim form with the name of the drug, dosage and the route of administration.

J7321 J7322 J7323 J7324

Requires prior authorization through Utilization Review Section of DMS. Providers must specify brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization. Written request must be submitted to DMS Utilization Review. Refer to 261.240 for PA information.

J7330

Requires prior authorization from AFMC for all providers. See sections 260.000, 261.000, 261.100 and 261.110.

J7340

Payable for beneficiaries of all ages with no diagnosis restrictions

J7341

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7346

Requires submission of operative report with each claim.

J7502

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7515

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7516

Payable for beneficiaries of all ages with no diagnosis restrictions

J7517

Payable for beneficiaries of all ages with no diagnosis restrictions

J7520 J7525 J7599*

For consideration, this code must be billed on a paper claim form with the name of the drug, dosage and the route of administration.

J9025

Coverage of this procedure code requires an ICD-9-CM diagnosis within the code range of 205.00 - 205.91, 238.71 - 238.76 or 238.79. A prior approval letter from the DMS Medical Director is required to be attached to each claim. Refer to 244.100 for information regarding requesting prior approval.

J9035*

Coverage of this procedure code requires an ICD-9-CM diagnosis within the code range of 153.0 - 154.8, 162.0 - 162.9, 174.0-175.9, or 189.0 - 189.9. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9041

Coverage of this procedure code requires an ICD-9-CM diagnosis code of 203.0 - 203.8, and 200.40-200.48. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9055

This procedure code requires an ICD-9-CM diagnosis code of 140.0 - 140.9, 153.0 - 154,, 160.0 - 161.9, 171.0, 172.0 - 172.4,173.0 - 173.4, or 195.0. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9160

This procedure code is covered for all ages with ICD-9-CM diagnosis within the diagnosis range 202.10 - 202.18, 202.20 -202.28, or 202.80 - 202.88. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9178

This procedure code requires an ICD-9-CM diagnosis code of 150.0-150.8, 151.0-151.9, 162.0-162.9, 171.0-171.9,174.0 - 175.9, 183.0, 200.0-200.8 or 202.0 - 202.90. A prior approval letter from the DMS Medical Director is required and must be attached to

each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval.

J9219

Payable for male beneficiaries of all ages with ICD-9-CM diagnosis code 185, 198.82 or V10.46. Benefit limit is one procedure every 12 months.

J9225

Payable for male beneficiaries with a diagnosis of malignant neoplasm of prostate (ICD-9-CM code 185).

J9226

Supprelin LA: Coverage of this procedure code requires an ICD-9-CM diagnosis code 259.1 Approved only for children 12 years of age and under. A prior approval letter from the DMS Medical Director is required to be attached to each claim. Prior to initiation of treatment a clinical diagnosis of CPP, 259.1, should be confirmed by measurement of blood concentrations of total sex steroids, luteinizing hormone (LH) and follicle stimulating hormone (FSH) following stimulation with a GnRH analog, and assessment of bone age versus chronological age. Baseline evaluations should include height and weight measurements, diagnostic imaging of the brain (to rule out intracranial tumor),

pelvic/testicular/adrenal ultrasound (to rule out steroid secreting tumors), human chorionic gonadotropin levels (to rule out a chorionic gonadotropin secreting tumor, and adrenal steroids to exclude congenital adrenal hyperplasia. All tests and screenings must be documented by medical records and submitted with History and Physical examination when requesting prior approval. Refer to 244.100 for information regarding requesting prior approval.

J9250

Payable for beneficiaries of all ages without restriction.

J9261

Requires ICD-9-CM diagnosis codes of 202.80 - 202.89 or 204.0 -208.90. The disease must have not responded to, or either has relapsed, following treatment with at least 2 chemotherapy regimens. Prior approval letter from DMS Medical Director required. See section 244.100 for information on requesting prior approval.

J9263

Payable for beneficiaries of all ages with diagnosis of 151.0-151.9, 153.0 - 154.8, 183.0 - 183.9 and 202.00 - 202.99. Prior approval letter from DMS Medical Director required with letter attached to claim. See section 244.100 for additional coverage information and instructions for prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9264

Coverage of this procedure code requires an ICD-9-CM diagnosis code of 141.0 - 151.9, 158.8, 158.9, 160.9, 161.9, 162.0 - 162.9, 174.0 - 176.9, 180.9, 182.0, 183.0 - 183.9, 185.0, 186.0 - 186.9, 188.0 - 188.9, 195.9, 199.0 and 199.1. A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage

information and instructions for requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9293

Payable for all ages. Will be manually reviewed for medical necessity based on diagnosis code for cancer or AIDS or diagnosis code 340.

J9303*

Requires ICD-9-CM diagnosis code of 153.0 - 154.8. Prior approval letter from DMS Medical Director required with copy attached to each claim. Refer to section 244.100 for information on how to acquire a prior approval letter.

J9305

Coverage of this procedure code requires an ICD-9-CM diagnosis code of 162.0 - 163.9. A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9350

Payable for beneficiaries of all ages with a primary detail diagnosis of 162.0-162.9 or 180.0-180.9 or 183.0 or 205.10-205.11 or 230.9-238.9.

J9395*

Payable for beneficiaries of all ages, with a diagnosis of 174.0 - 175.9.

A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval. Any one of the diagnosis codes from the above listed range is acceptable.

P9041

Payable to beneficiaries of all ages with no restrictions.

P9045

Payable to beneficiaries of all ages with no restrictions.

P9046

Payable to beneficiaries of all ages with no restrictions.

P9047

Payable to beneficiaries of all ages with no restrictions.

Q3025 Q3026

These procedure codes are covered for all ages based on medical necessity.

S0145 S0146

Procedures are payable when there is a primary detail diagnosis ICD-9-CM 070.54

Z1847

Torecan oral tablets. Limit of (4) 10mg tabs per day.

90371

One unit equals 1/2 cc, with a maximum of 10 units payable per day. Payable for Medicaid beneficiaries of all ages in the physician's office.

90375* 90376*

Covered for all ages. Billing requires paper claims with procedure code and dosage entered infield 24.D of claim form CMS-1500 for each date of service. If date spans are used, units of service must

be identified for each date within the span. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.

90385

Limited to one injection per pregnancy.

90581*

Payable for ages 18 years and older. Indicate dose and attach manufacturer's invoice.

90585

Payable for all ages.

90586

Payable for ages 18 years and older.

90632

Payable when administered to beneficiaries ages 19 years and older.

90633 90634

EP, TJ

Payable when administered to beneficiaries ages 12 months - 18 years. See section 292.593.

90636

EP, TJ

Payable when administered to beneficiaries age 18 years and older. Modifiers are required only when administered to beneficiaries aged 18 years. See section 292.593.

90645 90646 90647

EP, TJ

Payable when administered to beneficiaries of all ages. Modifiers are required only when administered to beneficiaries aged 18 years and younger. See section 292.593 for billing instructions when administered to beneficiaries aged 18 years and younger.

90648

EP, TJ

Payable when administered to beneficiaries aged 18 years and younger. Refer to section 292.593 for more information.

90655 90657

EP, TJ

Influenza vaccines payable through the VFC program for beneficiaries 6 - 35 months of age. See section 292.593 for billing instructions.

90656 90658

EP, TJ

Influenza vaccines payable for beneficiaries aged 3 years and older. Modifiers required only when administered to children under age 19. Refer to sections 292.593 and 292.594 for influenza vaccine policy.

90660

EP, TJ

Covered for healthy individuals aged 2-49 and not pregnant. Modifiers required only when administered to beneficiaries under age 19. See sections 292.593 and 292.594 of this manual.

90665

Payable when administered to beneficiaries ages 19 years and older.

90669

EP, TJ

Administration of vaccine is covered for children under age 5 years. See section 292.593 for billing instructions.

90675* 90676*

Covered for all ages without diagnosis restrictions. Billing requires paper claims with procedure code and dosage entered in field 24.D of claim form CMS-1500 for each date of service. If date spans are used, appropriate units of service must be indicated and must be identified for each date within the span. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.

90680

EP, TJ

VFC vaccine payable when administered to beneficiaries ages 6 weeks - 32 weeks. See section 292.593 for more information.

90690

Payable for beneficiaries ages 6 years and older.

90691

Payable for beneficiaries aged 3 years and older.

90700

EP, TJ

VFC vaccine payable when administered to beneficiaries under age 7 years. Modifiers are required. See section 292.593 for more information.

90702

EP, TJ

Payable for beneficiaries ages 0-6 years of age.

90703

Payable for all ages without restrictions and without modifiers.

90704

Payable for beneficiaries aged 1 year and older.

90705

Payable for ages 9 months and older.

90706

Payable for ages 1 year and older.

90707

U1

Payable when provided to women of childbearing age, ages 21 through 44, who may be at risk of exposure to these diseases. Coverage is limited to two (2) injections per lifetime. U1 modifier is required for this age group.

Payable when administered to beneficiaries aged 19 and 20 years without modifiers.

90707

EP, TJ

Payable when administered to beneficiaries under age 19 years. Modifiers are required when administered to beneficiaries under age 19 years. See section 292.593.

90708

Payable for beneficiaries 9 months of age and older.

90710

EP, TJ

Payable for beneficiaries under age 21 years. Modifiers are required only when administered to children under age 19. See section 292.593 for additional information.

90713

EP, TJ

Payable for beneficiaries of all ages. However, modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

90714

EP, TJ

Payable for beneficiaries ages 7 years and older. Modifiers are required when administered to beneficiaries under age 19 years. See section 292.593.

90715

EP, TJ

This vaccine is covered for individuals aged 7 years and older. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

90716

EP, TJ

This vaccine is covered for beneficiaries under age 21. Modifiers are required only when administered to beneficiaries under age 19. See section 292.593.

90717

Payable for all ages. Submit invoice with claim.

90718

EP, TJ

This vaccine is covered for individuals aged 7 years and older. Modifiers are required only when administered to beneficiaries under age 19years. See section 292.593.

90719

This vaccine is covered for individuals of all ages.

90720

EP, TJ

This vaccine is covered under the VFC program for ages 0-18 years of age. Modifiers are required.

90721

EP, TJ

Covered for beneficiaries under age 21 years. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

90723

EP, TJ

Covered for beneficiaries under age 19 years. See section 292.593.

90725*

Payable for all ages; submit manufacturer's invoice.

90727*

Payable for all ages; submit manufacturer's invoice.

90732

This code is payable for individuals aged 2 years and older. Patients age 21 years and older who receive the injection must be considered by the provider as high risk. All beneficiaries over age 65 may be considered high risk.

90733

Covered for beneficiaries of all ages.

90734

EP, TJ

Covered for beneficiaries of all ages. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

90735

Payable for individuals under age 21 years.

90740

Three dose schedule. Payable for individuals of all ages.

90743

EP, TJ

Two dose schedule. Payable only when administered to children aged 0 - 18 years. See section 292.593.

90744

EP, TJ

Three dose schedule. Payable for ages 0 - 18 years. See section 292.593.

90746

Payable for ages 19 years and older.

90747

EP, TJ

Covered for beneficiaries of all ages. Modifiers are required onlywhen administered to beneficiaries under age 19 years. See section 292.593.

90748

EP, TJ

Covered for beneficiaries of all ages. Modifiers are required onlywhen administered to beneficiaries under age 19 years. See section 292.593.