Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.11-022 - Physician Update #5-10 and Hospital Update #6-10
Current through Register Vol. 49, No. 9, September, 2024
Section II Physician/Independent Lab/CRNA/Radiation therapy Center roc
The following procedure codes require prior authorization:
|
Procedi |
ire Codes |
||||||
|
D9220* |
J7319 |
J7320 |
J7330 |
S2112 |
V2623 |
V2625 |
01966 |
|
11960 |
11970 |
11971 |
15400 |
15830 |
15847 |
19318 |
19324 |
|
19325 |
19328 |
19330 |
19340 |
19342 |
19350 |
19355 |
19357 |
|
19361 |
19364 |
19366 |
19367 |
19368 |
19369 |
19370 |
19371 |
|
19380 |
20974 |
20975 |
21076 |
21077 |
21079 |
21080 |
21081 |
|
21082 |
21083 |
21084 |
21085 |
21086 |
21087 |
21088 |
21089 |
|
21120 |
21121 |
21122 |
21123 |
21125 |
21127 |
21137 |
21138 |
|
21139 |
21141 |
21142 |
21143 |
21145 |
21146 |
21147 |
21150 |
|
21151 |
21154 |
21155 |
21159 |
21160 |
21172 |
21175 |
21179 |
|
21180 |
21181 |
21182 |
21183 |
21184 |
21188 |
21193 |
21194 |
|
21195 |
21196 |
21198 |
,21199 |
21208 |
21209 |
21244 |
21245 |
|
21246 |
21247 |
21248 |
21249 |
21255 |
21256 |
27412 |
27415 |
|
27416 |
28446 |
29866 |
29867 |
29868 |
30220 |
30400 |
30410 |
|
30420 |
30430 |
30435 |
30450 |
30460 |
30462 |
32851 |
32852 |
|
32853 |
32854 |
33140 |
33282 |
33284 |
33945 |
36470 |
36471 |
|
37785 |
37788 |
38240 |
38241 |
38242 |
42820 |
42821 |
42825 |
|
42826 |
42842 |
42844 |
42845 |
42860 |
42870 |
43257 |
43644 |
|
43645 |
43770 |
43771 |
43772 |
43773 |
43774 |
43842 |
43845 |
|
43846 |
43847 |
43848 |
43850 |
43855 |
43860 |
43865 |
47135 |
|
48155 |
48160 |
48554 |
48556 |
50320 |
50340 |
50360 |
50365 |
|
50370 |
50380 |
51925 |
54360 |
54400 |
54415 |
54416 |
54417 |
|
55400 |
57335 |
58150 |
58152 |
58180 |
58260 |
58262 |
58263 |
|
58267 |
58270 |
58275 |
58280 |
58290 |
58291 |
58292 |
58293 |
|
58294 |
58345 |
58541 |
58542 |
58543 |
58544 |
58550 |
58552 |
|
58553 |
58554 |
58570 |
58571 |
58572 |
58573 |
58672 |
58673 |
|
58750 |
58752 |
59135 |
59840 |
59841 |
59850 |
59851 |
59852 |
|
59855 |
59856 |
59857 |
59866 |
61850 |
61860 |
61862 |
61870 |
|
61875 |
61880 |
61885 |
61886 |
61888 |
63650 |
63655 |
63660 |
|
63685 |
63688 |
64555 |
64573 |
64585 |
64809 |
64818 |
65710 |
|
65730 |
65750 |
65755 |
67900 |
69300 |
69310 |
69320 |
69714 |
|
69715 |
69717 |
69718 |
69930 |
87901 |
87903 |
87904 |
92326 |
* Manually Priced
The procedures represented by the CPT and HCPCS codes in the following table require prior authorization (PA). The performing physician or dentist (or the referring physician or dentist, when lab work is ordered or injections are given by non-physician staff) is responsible for obtaining required PA and forwarding the PA control number to appropriate hospital staff for documentation and billing purposes. A claim for any hospital services that involve a PA-required procedure must contain the assigned PA control number or Medicaid will deny it. (See Sections 240.000 -244.000 of this manual for instructions for obtaining prior authorization.)
|
J2501 |
J7330 |
J9300 |
S2066 |
S2067 |
S2ri2 |
S3800 |
11960 |
|
11970 |
11971 |
15400 |
15830 |
19318 |
19324 |
19325 |
19328 |
|
19330 |
19340 |
19342 |
19350 |
19355 |
19357 |
19361 |
19364 |
|
19366 |
19367 |
19368 |
19369 |
19370 |
19371 |
19380 |
20974 |
|
20975 |
21076 |
21077 |
21079 |
21080 |
21081 |
21082 |
21083 |
|
21084 |
21085 |
21086 |
21087 |
21088 |
21089 |
21120 |
21121 |
|
21122 |
21123 |
21125 |
21127 |
21137 |
21138 |
21139 |
21141 |
|
21142 |
21143 |
21145 |
21146 |
21147 |
21150 |
21151 |
21154 |
|
21155 |
21159 |
21160 |
21172 |
21175 |
21179 |
21180 |
21181 |
|
21182 |
21183 |
21184 |
21188 |
21193 |
21194 |
21195 |
21196 |
|
21198 |
21199 |
21208 |
21209 |
21244 |
21245 |
21246 |
21247 |
|
21248 |
21249 |
21255 |
21256 |
27412 |
27415 |
27416 |
28446 |
|
29866 |
29867 |
29868 |
30220 |
30400 |
30410 |
30420 |
30430 |
|
30435 |
30450 |
30460 |
30462 |
33282 |
33284 |
36470 |
36471 |
|
37785 |
37788 |
38242 |
42820 |
42821 |
42825 |
42826 |
42842 |
|
42844 |
42845 |
42860 |
42870 |
43257 |
43644 |
43645 |
43842 |
|
43845 |
43846 |
43847 |
43848 |
43850 |
43855 |
43860 |
43865 |
|
48155 |
50320 |
50340 |
50360 |
50365 |
50370 |
50380 |
51925 |
|
54360 |
54400 |
54415 |
54416 |
54417 |
55400 |
57335 |
58150 |
|
58152 |
58180 |
58260 |
58262 |
58263 |
58267 |
58270 |
58275 |
|
58280 |
58290 |
58291 |
58292 |
58293 |
58294 |
58345 |
58541 |
|
58542 |
58543 |
58544 |
58550 |
58552 |
58553 |
58554 |
58570 |
|
58571 |
58572 |
58573 |
58672 |
58673 |
58750 |
58752 |
59135 |
|
59840 |
59841 |
59850 |
59851 |
59852 |
59855 |
59856 |
59857 |
|
61850 |
61860 |
61870 |
61875 |
61880 |
61885 |
61888 |
63650 |
|
63655 |
63660 |
63685 |
64555 |
64573 |
64809 |
64818 |
65710 |
|
65730 |
65750 |
65755 |
65756 |
67900 |
69300 |
69310 |
69320 |
|
69714 |
69715 |
69717 |
69718 |
69930 |
87901 |
87903 |
87904 |
|
92607 |
92608 |
|
Procedure Code |
Modifier |
Description |
|
Z1930 |
Non-emergency hysterectomy following c-section |
