Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.10-004 - 2010 HCPCS and CPT Procedure Code Conversion

I. General Information

A review of the 2010 CPT procedure codes has been completed, and the Arkansas Medicaid Program will begin accepting CPT 2010 procedure codes for dates of service on and after March 29, 2010.

Procedure codes that are identified as deletions in CPT 2010 (Appendix B) are non-payable for dates of service on and after March 29, 2010.

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 2010 CPT and HCPCS conversions.

II. Non-Covered 2010 CPT Procedure Codes

III. Prior Authorization

The following 2010 CPT procedure codes require prior authorization:

IV. Coverage for CT Colonography

V. Child Health Management Services (CHMS)

The following 2010 CPT procedure codes are payable to Child Heath Management Services:

VI. Hearing Program

The following 2010 CPT procedure codes are payable to Hearing Service Providers:

VII. Vaccines for Children (VFC)

The procedure code information below shows the coverage and billing protocol for VFC providers.

VIII. CPT Procedure Codes Payable to Ambulatory Surgical Centers

The following 2010 CPT procedure codes are payable to Ambulatory Surgical Centers:

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 (Local); 1-800-482 -5850, extension 2-8323 (Toil-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).

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.

I. General Information

A review of the 2010 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 29, 2010. Drug procedure codes require National Drug Code (NDC) billing protocol. Drug procedure codes that represent radiopharmaceuticals, vaccines, and allergen immunotherapy are exempt from the NDC billing protocol.

Procedure codes that are identified as deletions in 2010 HCPCS Level II will become non-payable for dates of service on and after March 29, 2010.

Please note: The Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2010 CPTand HCPCS conversions.

II. 2010 HCPCS Payable Procedure Codes Tables Information

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 is specified below. For any other diagnosis restrictions, reference the table for each individual program.

Diagnosis List 003

042

140.0 through 209.30

209.31 through 209.36

209.70 through 209.75

209.79

230.0 through 238.9

511.81

V58.11 through V58.12

V87.41

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

The following information is related to procedure codes found in the ASC table. For section IV, 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 list. In addition to the special circumstances listed below with each alpha character, any other processes or requirements indicated in the table are also applicable.

J7325 A Hyaluronon injections are covered for all ages. Prior authorization is required for coverage of the Hyaluronon injection for ASC providers. Providers must specify the brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization for this procedure code (J7325). (Current codes areJ7321, J7323, J7324)

A written request must be submitted to the Division of Medical Services Utilization Review Section (See Section II,C).The request must include the patient's name, Medicaid ID number, physicians' name, physician's Arkansas Medicaid provider number, patient's date of birth, and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one injection or series of injections per knee, per beneficiary, per lifetime.

A maximum of three injections per knee are allowed of Hylan polymers that are covered by Arkansas Medicaid. If additional injections are administered as part of the initial series, the cost of the additional injections is considered a component of the other approved unit(s) of these injection procedures.

V. HCPCS Procedure Codes Payable to ARKids First-B

VI. HCPCS Procedure Codes Payable to Certified Nurse Midwife

The following information is related to procedure codes payable to Certified Nurse Midwife providers.

VII. End Stage Renal Disease

The following information is related to procedure codes payable to End Stage Renal Disease providers.

VIII. HCPCS Procedure Codes Payable to Home Health

The following information is related to procedure codes payable to Home Health providers.

IX. HCPCS Procedure Codes Payable to Hospitals

The following information is related to procedure codes payable to hospital providers. For section IX. 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 list. Claims that require attachments (such as op-reports and prior approval letters) must be billed on a paper claim. See Section II of this notice for information on requesting a prior approval letter. See Section III of this notice for diagnosis codes contained in diagnosis list 003.

In addition to the special circumstances listed below with each alpha character, any other processes or requirements indicated in the table are also applicable.

C9256A Coverage of this procedure code is for ages 21 years and above in these diagnosis ranges: 363.20, 364.0 through 364.42, 378.9 and 446.7. A broad spectrum microbide should be given prior to the injection. The beneficiary must have failed conventional therapy such as oral medications for this drug to be approved. There must be documentation of why the beneficiary is a failure of treatment. The visual acuity must be documented and should show a decrease due to failure of treatment. There must be severe disease that could lead to blindness. The beneficiary must be under the care of an ophthalmologist who specializes in treatment of this condition.

A Prior approval letter from the DMS Medical Director is required and must be attached to each claim.

C9257B Coverage of this procedure code is for ages 21 years and above with a diagnosis code of 362.02, 362.07, 362.16, 362.26, 362.29,362.35,362.52,364.42 or 365.63. Documentation included with prior approval letter request must include Fluoroscein angiogram or OCT, patient screen for conditions that would contraindicate the use of Avastin, and documentation of patient consent. A prior approval letter is required and must be attached to each claim.

J0586c Payable for beneficiaries of all ages when medically necessary. Botox A is reviewed for medical necessity based on diagnosis code billed on the claim.

J0718D Arkansas Medicaid considers certolizumab pegol (Cimzia®) medically necessary for adult beneficiaries 18 years of age and above with:

Moderately-to-severely active Crohn's disease as manifested by any of the following signs/symptoms:

AND

Crohn's disease has remained active despite treatment with one of the following: Corticosteroids OR 6-mercaptopurine/azathioprine

Arkansas Medicaid considers certolizumab pegol, alone or in combination with methotrexate (MTX), medically necessary for the treatment of adult beneficiaries 18 years of age and above with moderately-to-severely active rheumatoid arthritis( RA) and considers certolizumab pegol experimental and investigational for all other indications.

A Prior Approval Letter from the DMS Medical Director is required to be attached to each claim.

J2562E This procedure code is covered for ages 21 years and above and requires prior authorization by Arkansas Foundation for Medical Care (AFMC). Prior authorization will be provided by a telephone review. Approval is granted in conjunction with the use of granulocyte-colony stimulating factor to mobilize hematopoietic stem cells for collection and subsequent autologous transplantation in patients with non-Hodgkin's lymphoma and multiple myeloma. Applicants will only be considered for approval if a transplant has been approved by AFMC. There must be documentation of failure to mobilize cells with conventional therapy for consideration of this drug. The drug will only be approved for four doses, one daily times four days. The total dosage for the four days must be indicated at the time of the request.

J2796F This procedure code is payable forages 19 years and above with a diagnosis of 287.31. Beneficiaries must have failed corticosteroids, immunoglobulins or have had a splenectomy. Beneficiaries must have thrombocytopenia and a clinical condition that causes increased risk of bleeding.

Romiplostim is not to be used to normalize platelet counts.

This procedure code may be billed electronically and on paper claims.

J7325G Hyaluronon injections are covered for all ages. Prior authorization is required for coverage of the Hyaluronon injection for outpatient hospital providers. Providers must specify the brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization for this procedure code (J7325). (Current codes are J7321, J7323, J7324)

A written request must be submitted to the Division of Medical Services Utilization Review Section (See Section II, C.).The request must include the patient's name, Medicaid ID number, physicians' name, physician's Arkansas Medicaid provider number, patient's date of birth and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one injection or series of injections per knee, per beneficiary, per lifetime.

A maximum of three injections/per knee are allowed of Hylan polymers that are covered by Arkansas Medicaid. If additional injections are administered as part of the initial series, the cost of the additional injections is considered a component of the other approved unit(s) of these injection procedures.

J9328H Coverage of this procedure code is payable for ages 21 years and above and requires a diagnosis in the range of 191.0-191.9. The diagnosis must be for:

X. HCPCS Procedures Codes Payable to Hyperalimentation Providers

XI. HCPC Procedure Codes Payable to Independent Radiology

The following information is related to procedure codes payable to Independent Radiology Providers.

XII. HCPCS Procedure Codes Payable to Nurse Practitioners

The following information is related to procedure codes payable to Nurse Practitioner providers.

J0586A Payable for beneficiaries of all ages when medically necessary. Botox A is reviewed for medical necessity based on diagnosis code billed.

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

XIV. HCPCS Procedure Codes Payable to Private Duty Nurses

The following information is related to procedure codes payable to Private Duty Nursing providers.

A4456A Indicates the code is payable in the school setting.

XV. HCPCS Procedure Codes Payable to Prosthetics

XVI. HCPCS Procedures Codes Payable to Transportation Providers

The following information is related to procedure codes payable to Transportation providers.

XVII. Non-Covered 2010 HCPCS with Elements of CPT or Other Procedure Codes

The following new 2010 HCPC procedure codes are not payable because these services are covered by a CPT code, another HCPCS code, or a revenue code.

XVIII. Non-Covered 2010 HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

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 (Local); 1-800-482 -5850, extension 2-8323 (Toil-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).

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.ar.us.

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