Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 27 - Department of Medical Services
Rule 016.27.21-005 - Arkansas Medicaid Procedure Code Linking Table Project

218.000 Authorization for Services 2-1-22

All Adult Behavioral Health Services for Community Independence receiving Arkansas Medicaid healthcare benefits on a medical Spenddown basis are retrospectively reviewed for medical necessity.

View or print the procedure codes requiring retrospective review for authorization and for ABHSCI services.

240.100 Reimbursement 2-1-22

Reimbursement is based on the lesser of the billed amount or the Title XIX (Medicaid) maximum allowable for each procedure.

Reimbursement is contingent upon eligibility of both the beneficiary and provider at the time the service is provided and upon accurate completeness of the claim filed for the service. The provider is responsible for verifying that the beneficiary is eligible for Arkansas Medicaid prior to rendering services.

253.001 Partial Hospitalization 2-1-22

253.002 Adult Rehabilitative Day Service 2-1-22

253.003 Supportive Employment 2-1-22

253.004 Supportive Housing 2-1-22

253.005 Adult Life Skills Development 2-1-22

253.006 Peer Support 2-1-22

253.007 Treatment Plan 2-1-22

253.008 Aftercare Recovery Services 2-1-22

254.001 Therapeutic Communities 2-1-22

221.100 ARKids First-B Medical Care Benefits 2-1-22

Listed below are the covered services for the ARKids First-B program. This chart also includes benefits, whether Prior Authorization or a Primary Care Physician (PCP) referral is required, and specifies the cost-sharing requirements.

*Refer to your Arkansas Medicaid specialty provider manual for prior authorization and PCP referral procedures.

**ARKids First-B beneficiary cost-sharing is capped at 5% of the family's gross annual income.

***ARKids First-B beneficiaries will pay a maximum of $5.00 per prescription. The beneficiary will pay the provider the amount of co-payment that the provider charges non-Medicaid purchasers up to $5.00 per prescription.

****View or print the procedure codes for ARKids First-B procedures and services.

221.200 Exclusions 2-1-22

Services Not Covered for ARKids First-B Beneficiaries:

Adult Development Day Treatment (ADDT)

Audiological Services; EXCEPTION, Tympanometry, CPT procedure code*, when the diagnosis is within the ICD range. (View ICD codes.)

Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Diapers, Underpads, and Incontinence Supplies

Early Intervention Day Treatment (EIDT)

End Stage Renal Disease Services

Hearing Aids

Hospice

Hyperalimentation

Non-Emergency Transportation

Nursing Facilities

Orthotic Appliances and Prosthetic Devices

Personal Care

Private Duty Nursing Services

Rehabilitative Services for Children

Rehabilitative Services for Persons with Physical Disabilities (RSPD)

Targeted Case Management

Ventilator Services

*View or print the procedure codes for ARKids First-B procedures and services.

222.300 Dental Services Benefit 2-1-22

Dental services benefits for ARKids First-B beneficiaries are one periodic dental exam, bite-wing x-rays, and prophylaxis/fluoride treatments every six (6) months plus one (1) day. Scalings are covered once per State Fiscal Year (SFY). Orthodontia services are also covered for ARKids First-B beneficiaries.

The procedure codes listed in Section 262.150may be billed for the periodic dental exams, interperiodic dental exams and prophylaxis/fluoride, and orthodontia services for ARKids First-B beneficiaries.

Refer to Section II of the Medicaid Dental Provider Manual for a complete listing of covered dental and orthodontia services. Procedures for dental treatment services that are not listed as a payable service in the Medicaid Dental Provider Manual may be requested on individual treatment plans for prior authorization review. These individually requested procedures and dental and orthodontia treatment services are subject to determination of medical necessity, review and approval by the Division of Medical Services dental consultants.

222.710 Introduction 2-1-22

The ARKids First-B Program supports preventive medicine for beneficiaries by reimbursing primary care physicians (PCPs) who provide medical preventive health screens and qualified screening providers to whom PCPs refer beneficiaries. ARKids First-B outreach efforts vigorously promote the program's emphasis on preventive medical health care. Beneficiary cost sharing does not apply to covered preventive medical health screens, including those for newborns.

The supplemental eligibility response request to an ARKids First-B beneficiary's identification card will indicate to the provider the date of the beneficiary's last preventive health screen

View or print the procedure codes for ARKids First-B procedures and services.

This information should be reviewed and verified, along with the beneficiary's eligibility, prior to performing a service. This information will assist the beneficiary's PCP or preventive health screen provider in determining the beneficiary's eligibility for the service and ensuring that preventive health screens are performed in a timely manner in compliance with the periodicity chart for ARKids First-B beneficiaries.

Newborn screens do not require PCP referral.

Certified nurse-midwives may provide newborn screens ONLY.

Nurse practitioners, in addition to newborn preventive health screens, are authorized to provide other preventive health screens with a PCP referral. Refer to Section 262.130for preventive health screens procedure codes.

222.750 Health Education 2-1-22

Health education is a required component of screening services and includes anticipatory guidance. The developmental assessment, comprehensive, physical examination, and the visual, hearing or dental screening provide the initial opportunity for providing health education. Health education and counseling to parents (or guardians) and children are required. Health education and counseling are designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. See Section 262.130 for procedure codes.

Health education can include but isn't limited to tobacco cessation counseling services to the parent/legal guardian of the child.

222.800 Schedule for Preventive Health Screens 2-1-22

The ARKids First - B periodic screening schedule follows the guidelines for the EPSDT screening schedule and is updated in accordance with the recommendations of the American Academy of Pediatrics.

From birth to 15 months of age, children may receive six (6) periodic screens in addition to the newborn screen performed in the hospital.

Children age 15 months to 24 months of age may receive two (2) periodic screens. Children age 24 months to 30 months may receive one (1) periodic screen, and children 30 months to 3 years old may receive one (1) periodic screen.

When a child has turned 3 years old, the following schedule will apply. There must be at least 365 days between each screen listed below for children age 3 years through 18 years.

Medical screens for children are required to be performed by the beneficiary's PCP or receive a PCP referral to an authorized Medicaid screening provider. Routine newborn care, vision screens, dental screens and immunizations for childhood diseases do not require PCP referral. See Section 262.130 for procedure codes.

224.000 Cost Sharing 2-1-22

Co-payment or coinsurance applies to all ARKids First-B services, with the exception of immunizations, preventive health screenings, family planning, prenatal care, eyeglasses, medical supplies and audiological services (only Tympanometry, CPT procedure code, when the diagnosis is within the ICD range (View ICD codes.)).

View or print the procedure codes for ARKids First-B procedures and services.

Co-payments or coinsurances range from up to $5.00 per prescription to 10% of the first day's hospital Medicaid per diem.

ARKids First-B families have an annual cumulative cost sharing maximum of 5% of their annual gross family income. The annual period is July 1 through June 30 SFY (state fiscal year). The ARKids First-B beneficiary's annual cumulative cost sharing maximum will be recalculated and the cumulative cost sharing counter reset to zero on July 1 each year.

The cost sharing provision will require providers to check and be alert to certain details about the ARKids First-B beneficiary's cost sharing obligation for this process to work smoothly. The following is a list of guidelines for providers:

240.200 Prior Authorization (PA) Process for Interperiodic Preventive Dental Screens 2-1-22

Prior authorization for procedure code, Interperiodic Dental Screening Exam, must be requested on the ADA claim form or online with a brief narrative through the Prior Authorization Manipulation (PAM) software. View or print the Department of Human Services Medicaid Dental Unit Address. Refer to your Arkansas Medicaid Dental Services Provider Manual for detailed information on obtaining prior authorizations.

View or print the procedure codes for ARKids First-B procedures and services.

Refer to Section 222.300 of this manual for coverage and Section 262.150 billing information.

262.110 Medical Supplies Procedure Codes 2-1-22

The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B beneficiaries.

View or print the procedure codes for ARKids First-B procedures and services.

NOTE: * must be prior authorized. Form DMS-679 must be used for the request for prior authorization. View or print form DMS-679 and instructions for completion.

**The costs are not subject to the $125 medical supplies monthly benefit limit.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

262.120 Durable Medical Equipment (DME) Procedure Codes 2-1-22

The following DME HCPCS procedure codes may be billed with appropriate modifiers by Medicaid-enrolled prosthetics providers for ARKids First-B beneficiaries.

View or print the procedure codes for ARKids First-B procedures and services.

NOTES: Codes denoted with an asterisk * must be prior authorized. Form DMS-679A must be used for the request for prior authorization. View or print form DMS-679A and instructions for completion.

** Code must be prior authorized through the Division of Medical Services, Utilization Review. Form DMS-679 must be used for the request for prior authorization. View or print form DMS-679 and instructions for completion.

Codes denoted with ^ symbol are approved for special circumstance "Initial" billing (See Section 242.111 of the Prosthetics Medicaid Provider Manual for details regarding "initial" billing). These codes must be billed WITHOUT A MODIFIER to indicate the "Initial" bill circumstance applies - EXCEPTION - if a modifier KH is specifically indicated, that modifier must be used.

262.130 Preventive Health Screening Procedure Codes 2-1-22

There are two (2) types of full medical preventive health screening procedure codes to be used when billing for this service for ARKids First-B beneficiaries; Newborn and Child Preventive Health Screening:

262.150 Billing Procedure Codes for Periodic Dental Screens and Services and Orthodontia Services 2-1-22

View or print the procedure codes for ARKids First-B procedures and services.

262.400 Billing Procedures for Preventive Health Screens 2-1-22

ARKids First-B reimburses providers for preventive health screenings performed at the intervals recommended by the American Academy of Pediatrics.

References in this section indicate that ARKids First-B preventive health screenings are similar to Arkansas Medicaid Child Health Services (EPSDT) screens in content and application.

View or print the procedure codes for ARKids First-B procedures and services.

However, please note this important distinction:

Claims for ARKids First-B preventive health screenings electronically or by paper must be billed in the CMS-1500 claim format.

NOTE: Certified nurse-midwives are restricted to performing the preventive health screen, Newborn, only, and must bill either code, with the required UA modifier, for initial newborn screen or codes for newborn illness care.

A Certified nurse-midwife may NOT bill procedure codes for child preventive health screens.

262.410 Primary Care Physician Referral Requirements for Preventive Health Screens 2-1-22

All preventive health screens for ARKids First-B beneficiaries must be provided by the primary care physician (PCP) of the beneficiary or by PCP referral to a qualified practitioner.

View or print the procedure codes for ARKids First-B procedures and services.

Newborn preventive health screens are exempt from the PCP referral requirement.

Immunizations for childhood diseases are exempt from the PCP referral requirement.

262.420 Limitation on Laboratory Procedures Performed During a Preventive Health Screen 2-1-22

ARKids First-B preventive health screens will not include laboratory procedures unless the screen is performed by the beneficiary's PCP, is conducted pursuant to a referral from the PCP or is included in the exceptions listed below.

View or print the procedure codes for ARKids First-B procedures and services.

Exceptions

The following tests are exempt from the above limitations and may continue to be billed in conjunction with a preventive health screen performed in accordance with existing Medicaid policy only if they are performed within seven (7) calendar days following the screen:

Claims for laboratory tests, other than those specified above, performed in conjunction with a preventive health screen will be denied unless the screen is performed by the PCP or pursuant to a referral from the PCP.

262.430 Vaccines for ARKids First-B Beneficiaries 2-1-22

ARKids First-B beneficiaries are not eligible for the Vaccines for Children (VFC) Program; however, vaccines can be obtained to administer to ARKids First-B beneficiaries who are under the age of 19 by contacting the Arkansas Department of Health and indicating the need to order ARKids-B SCHIP vaccines. View or print the Department of Health contact information.

Only a vaccine injection administration fee is reimbursed. When filing claims for administering vaccines for ARKids First-B beneficiaries, providers must use the CPT procedure code for the vaccine administered and the required modifier SL only for either electronic or paper claims. Providers must bill claims for ARKids First-B beneficiaries using the CMS-1500 claim format.

The following list contains the SCHIP vaccines available to ARKids-First-B beneficiaries through the Arkansas Department of Health.

View or print the procedure codes for ARKids First-B procedures and services.

262.431 Billing of Multi-Use and Single-Use Vials 2-1-22

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

242.100 Procedure Codes 2-1-22

The procedure codes for billing chiropractic services are below. View or print the procedure codes for Chiropractic services.

*Procedure code is to be used when filing claims for chiropractic x-ray. This benefit is limited to two (2) per state fiscal year. This service counts against the $500 per beneficiary per state fiscal year laboratory and X-ray benefit limit.

242.310 Completion of the CMS-1500 Claim Form 2-1-22

213.710 Fetal Non-Stress Test 2-1-22

The fetal non-stress test is limited to two (2) medically necessary fetal non-stress test procedures per pregnancy. Providers must follow the benefit extension procedures in Section 214.000 to request that Medicaid authorize payment of a third or subsequent claim after two (2) claims have been paid in a nine-month period. The procedure code for a fetal non-stress test is in the link below.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

Post procedural visits are covered within the 10-day period following a fetal non-stress test.

272.412 Pudendal Nerve Block 2-1-22

CPT code may be billed when administering a pudendal nerve block.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

272.430 Family Planning Services for Beneficiaries 2-1-22

See Sections 215.200 through 215.260 for family planning coverage information.

Laboratory procedure codes covered for family planning are listed in Section 272.431of this manual.

For other billable family planning services, see Sections 272.440-272.533.

272.431 Family Planning Services Laboratory Procedure Codes 2-1-22

Family planning services are covered for beneficiaries in full coverage aid categories and Aid Category 61 (PW-PL). For information regarding additional aid categories, see Section 124.000. For eligible beneficiaries, these codes are payable when used for purposes other than family planning. Claims require modifier FP when the service diagnosis indicates family planning.

The following procedure code table explains family planning laboratory procedure codes.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

272.440 Billable Family Planning Services for Beneficiaries 2-1-22

272.451 Specimen Collection 2-1-22

The policy in regard to collection, handling and/or conveyance of specimens is:

272.452 Tobacco Cessation Counseling Services 2-1-22

272.470 Newborn Care 2-1-22

All newborn services must be billed under the newborn's own Medicaid identification number midwife can refer interested individuals to the Department of Human Services through the The parent(s) of the newborn will be responsible for applying for and meeting eligibility requirements for a newborn to be certified eligible. The hospital/physician/certified nurse-midwife can refer interested individuals to the Department of Human Services through the Hospital/Physician/Certified Nurse-Midwife Referral Program. If the newborn is not certified as Medicaid eligible, the parent(s) will be responsible for the charges incurred by the newborn.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

For routine newborn care following a vaginal delivery or C-section, procedure code should be used one time to cover all newborn care visits. Payment of these codes is considered a global rate and subsequent visits may not be billed in addition to. These codes include the physical exam of the baby and the conference(s) with the newborn's parent(s), and are considered to be the initial Child Health Services (EPSDT) screen. Routine newborn care is exempt from the PCP requirement.

Note the descriptions, modifiers, and required diagnosis range. The newborn care procedure codes require a modifier and a primary detail diagnosis of V30.00-V37.21 for all providers. Refer to the appropriate manual(s) for additional information about newborn screenings.

For illness care (e.g., neonatal jaundice), use procedure codes. Do not bill in addition to these codes.

For newborn resuscitation, use procedure code.

May be billed on the CMS-1500 claim form or on the electronic claim transaction format. These codes may also be filed on the CMS-1500; paper or electronically for ARKids A beneficiaries. For ARKids B-beneficiaries, newborn screening codes must be billed electronically or on the paper CMS-1500 claim form. For information, call the Provider Assistance Center. View orprint the Provider Assistance Center contact information.

For ARKids A (EPSDT) - Requires a CMS-1500 claim form; may be billed electronically or on paper.

For ARKids First B - Requires a CMS-1500 claim form; may be billed electronically or on paper.

See Sections 241.000 - 243.310 of the EPSDT manual for specific EPSDT billing instructions.

272.491 Method 1 - "Global" or "All-Inclusive" Rate 2-1-22

272.492 Method 2 - "Itemized Billing" 2-1-22

Itemized billing must be used when the following conditions exist:

272.493 Obstetrical Care Without Delivery 2-1-22

Certified nurse-midwives must use procedure code with modifier UA to bill for one to three visits for antepartum care without delivery.

Procedure code with no modifier must be used by providers to bill four to six visits for antepartum care without delivery. Procedure code with no modifier is to be used for 7 or more visits without delivery.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

This enables certified nurse-midwives rendering care to the patient during the pregnancy, but not delivering the baby, to receive reimbursement for their services provided. Coverage for this service will include routine sugar and protein analysis. One unit equals one visit. Units of service billed with this procedure code will not be counted against the patient's office visit benefit limit.

Providers must enter the "from" and "through" dates of service on the claim and the number of units being billed. One visit equals one unit of service. Providers must submit the claim within 12 months of the first date of service.

For example: An OB patient is seen by the certified nurse-midwife on 1-10-05, 2-10-05, 3-10-05, 4-10-05, 5-10-05 and 6-10-05. The patient then moves and begins seeing another provider prior to the delivery. The certified nurse-midwife may submit a claim with dates of service shown as 1-10-05 through 6-10-05 and 6 units of service entered in the appropriate field. This claim must be received by the Arkansas Medicaid fiscal agent prior to 12 months from 1-1005 to fall within the 12-month filing deadline. The certified nurse-midwife must have on file the patient's medical record that reflects each date of service being billed.

272.494 Fetal Non-Stress Test, Fetal Echography (Ultrasound) and External Fetal Monitoring 2-1-22

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

272.495 Risk Management Services for Pregnancy 2-1-22

A certified nurse-midwife may provide the risk management services listed below if he or she employs the professional staff indicated in the service descriptions below. If a certified nursemidwife does not choose to provide the risk management services but believes the patient would benefit from them, he or she may refer the patient to a clinic that offers risk management services for pregnancy. Each of the risk management services described in parts A through E has a limited number of units of service that may be furnished. Coverage of these risk management services is limited to a maximum of 32 cumulative units.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

272.502 Non-Emergency Services 2-1-22

Procedure code (modifier U3) should be billed for a non-emergency certified nurse-midwife visit.

View or print the procedure codes for Certified Nurse Midwife (CNM) services.

272.533 Injections, Therapeutic and/or Diagnostic Agents 2-1-22

262.100 Children's Services Targeted Case Management Procedure Code 2-1-22

Providers of Children's Services targeted case management (TCM) must bill for services provided using the procedure code and modifiers shown in the table below. Providers must use this procedure code and the indicated modifiers when billing either electronically or on paper for Children's Services TCM services.

View or print the procedure codes for Children's Services Targeted Case Management (TCM) services.

212.000 Summary of Coverage 2-1-22

The Dental Program covers an array of common dental procedures for individuals of all ages. However, there are specific limitations for coverage for individuals age 21 and over.

Effective for dates of service on and after July 1, 2009, dental procedures will be covered for Medicaid eligible beneficiaries age 21 and over. However, there is a benefit limit for covered services of $500.00 per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. Extractions and complete and partial dentures are excluded from the $500.00 benefit limit for adults.

Medicaid dental procedure codes are listed in Section 262.100 for beneficiaries under age 21. Procedure codes for individuals age 21 and over are listed in Section 262.200. Each section lists the procedure codes covered, prior authorization requirements and the necessity of submitting X-rays with the treatment plan. Section 262.200 also lists the procedure codes that are benefit limited.

214.100 Tobacco Cessation Products and Counseling Services 2-1-22

Tobacco cessation products either prescribed or initiated through statewide pharmacist protocol are available without prior authorization (PA) to eligible Medicaid beneficiaries. Additional information can be found on the DHS Contracted Pharmacy Vendor websiteor in the Prescription Drug Program Prior Authorization Criteria.

Counseling services and benefits are defined below:

NOTE: The course of treatment is defined as three consecutive months.

215.000 Child Health Services (EPSDT) Dental Screening 2-1-22

The Child Health Services (EPSDT) periodic and interperiodic dental screening exams consist of an inspection of the oral cavity by a licensed dentist. The purpose of the dental screening exams is to check for obvious dental abnormalities and to assure access to needed dental care. Regular screening exams should be performed in accordance with the recommendations of the Child Health Services (EPSDT) periodicity schedule.

The Child Health Services (EPSDT) periodic dental screening exam is limited to two screening exams every six (6) months plus one (1) day for individuals under age 21. These benefits may be extended if documentation is provided that verifies medical necessity. See Section 262.100 to view the procedure code for periodic dental screening exams.

Individuals under age 21 enrolled in the EPSDT Program may receive an interperiodic dental screening exam twice per SFY. Extension of benefits is available in cases of medical necessity.

View or print form ADA-J430. See Section 262.100 for the interperiodic dental screening exam procedure code.

NOTE: ARKids First-B beneficiaries may also receive an interperiodic dental screening exam twice per SFY. There is no extension of benefits for ARKids First-B beneficiaries.

Extension of benefits requests, in addition to a narrative and any supporting documentation, should be submitted to the Division of Medical Services Dental Care Unit - ATTN Dental Extension of Benefits. View or print the Division of Medical Services Dental Care Unit contact information.

Infant oral health care examinations must be based on the recommendations of the American Academy of Pediatric Dentistry. Essential elements of an infant oral health care visit are a thorough medical and dental history, oral examination, parental counseling, preventive health education and determination of appropriate periodic re-evaluation. See Section 201.500 for information regarding the dentist's role in the EPSDT Program.

216.200 Bitewing Radiographs 2-1-22

Bitewing radiographs are covered for beneficiaries of all ages. There are different limitations of coverage for beneficiaries under age 21 and for those beneficiaries age 21 and older.

The EPSDT periodic screening exam may include only two bitewings and is allowed every six (6) months plus one (1) day for beneficiaries under age 21. See Section 262.100 for the appropriate procedure code.

Two bitewing films are allowed once per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. See Section 262.200 for appropriate procedure codes.

216.300 Intraoral Film 2-1-22

When submitting a claim for an intraoral single film, indicate the middle tooth number. Procedure code must be used for the first film and procedure code for each additional single film.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

Medicaid will only cover the complete series or the submitted group of individual X-rays. X-rays are to be mounted, marked R and L, labeled with the dentist's provider number and the beneficiary identification number and stapled to the back of the claim form, as noted in Section 216.000.

217.100 Dental Prophylaxis and Fluoride Treatment 2-1-22

Dental prophylaxis and a fluoride treatment are preventive treatments covered by Medicaid. Prophylaxis, in addition to application of topical fluoride and/or fluoride varnish, is covered every six (6) months plus one (1) day for beneficiaries under age 21. Arkansas Medicaid covers fluoride varnish application, ADA code, performed by physicians who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health. Eligible physicians may delegate the application to a nurse or other licensed healthcare professional under his or her supervision that has also completed the online training. Physicians and nurse practitioners must complete training on dental caries risk and have an approved fluoride varnish certification from the Arkansas Department of Health, Office of Oral Health. Each provider must maintain documentation to establish his or her successful completion of the training and submit a copy of the certificate to Provider Enrollment. The course that meets the requirements outlined by the ACT can be accessed at http://ar.train.org. If further treatment is needed due to severe periodontal problems, the provider must request prior authorization with a brief narrative.

Prophylaxis and fluoride treatments are each covered once per state fiscal year (July 1 through June 30) for beneficiaries age 21 and over. Topical fluoride treatment or fluoride varnish is covered every six (6) months plus one (1) day for beneficiaries under age 21.

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to Provider Enrollment before the specialty code will be added to their file in the MMIS. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code, Topical Application of Fluoride Varnish.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

Medicaid does not reimburse for nitrous oxide for examinations, fluorides, oral prophylaxis and sealants unless other procedures are performed at the same time.

A provider may generally perform the following procedures without prior authorization:

218.000 Space Maintainers 2-1-22

Space maintainers are covered for beneficiaries under age 21 and require prior authorization. X-rays must be submitted with the request for prior authorization. When submitting a treatment plan or claim for space maintainers, identify the missing tooth in the tooth column on the ADA claim form and submit the X-ray to show the tooth for which the space is maintained. See Section 262.100 for applicable procedure codes.

Space maintainers are not covered for beneficiaries age 21 and over.

219.100 Amalgam Restorations 2-1-22

Amalgam restorations are to be used on all teeth distal to the cuspids for beneficiaries of all ages. When submitting a claim for amalgam restorations, the tooth (teeth) and all surfaces to be restored must be indicated on the same line with appropriate code and provider fee. Amalgam restorations do not require prior authorization. If a provider chooses to do posterior composites, reimbursement will be given at the amalgam reimbursement rate. See Sections 262.100 and 262.200 for applicable procedure codes.

219.200 Composite Resin Restorations 2-1-22

Composite-resin restorations may be performed for anterior teeth for beneficiaries of all ages. Four or more surface composite-resin restorations require prior authorization. When submitting a claim for composite restorations, the tooth number(s) and all surfaces to be restored must be indicated on the same line with appropriate code and provider fee. If a provider chooses to do posterior composites, reimbursement will be given at the amalgam reimbursement rate. See Sections 262.100 and 262.200 for applicable procedure codes.

Only one amalgam or composite restoration per surface is allowed every 2 years.

220.000 Crowns - Single Restorations Only 2-1-22

Crowns are covered for individuals of all ages.

221.000 Endodontia 2-1-22

Pulpotomy for deciduous teeth may be performed without prior authorization for beneficiaries under age 21. Pulpotomies are not covered for individuals age 21 and over.

Current indications require carious exposure of the pulp. Payment for pulp caps is included in the fee for restorations and is not payable separately.

Endodontic therapy is not covered for individuals age 21 and over.

To be reimbursed, the completed endo-fill should conform to current standards, that is, complete obturation of all canals to within 1mm to 2mm of radiographic apex.

The fee for endodontic therapy does not include restoration to close a root canal access, but does include films for measurement control and post-op.

Medicaid does not cover endodontic retreatment, apexification, retrograde fillings or root amputation. See Section 262.100for applicable procedure codes.

222.000 Periodontal Procedures 2-1-22

Periodontal treatment is available for beneficiaries of all ages. When periodontal treatment is requested, a brief narrative of the patient's condition, photograph(s) and X-rays are required. Each quadrant to be treated must be indicated on separate lines when requesting prior authorization or payment. Prior authorization will require a report, a periochart, and a complete series of radiographs that reflects evidence of bone loss, numerous 4-5 mm pockets and obvious calculus. See Sections 262.100and 262.200for applicable procedure codes.

223.000 Removable Prosthetic Services (Full and Partial Dentures, Including Repairs 2-1-22

225.100 Simple Extraction 2-1-22

Simple extractions may be performed without prior approval. Simple extractions of 3rd molars do not require prior authorization.

When a simple extraction evolves into a surgical extraction, providers must write a brief explanation of the circumstances if the problem is not indicated on the X-ray. Normally, surgical extractions imply sectioning, suturing and bone removal or any combination of these procedures. Providers must submit the claim, with the X-ray, for authorization and payment to the Division of Medical Services Dental Care Unit. View or print the Division of Medical Services Dental Care Unit contact information. See Sections 262.100 and 262.200 for applicable procedure codes.

225.200 Surgical Extractions 2-1-22

Surgical extractions for beneficiaries of all ages require prior authorization and X-rays to substantiate need. The dental consultant may require a second opinion when reviewing treatment plans for extractions.

Surgical extractions performed on an emergency basis (See Section 234.000) for relief of pain may be reimbursed subject to the approval of a Medicaid dental consultant. In these cases, the claim with X-ray and a brief explanation should be submitted to the Division of Medical Services Dental Care Unit. View or print the Division of Medical Services Dental Care Unit contact information.

For beneficiaries under the age of 21, the fee for surgical extraction includes local anesthesia and routine post-operative care. See Sections 262.100 and 262.200 for applicable procedure codes. Anesthesia is not a covered service for beneficiaries 21 and over.

225.300 Traumatic Accident 2-1-22

In cases of traumatic accident and when time is of prime importance, the dental provider may perform the necessary procedure(s) immediately. The procedure code chart found in Sections 262.100 and 262.200 identifies the procedures that may be billed "By Report" and those which must be prior authorized before reimbursement may be made. The chart also indicates the procedures that require submission of X-rays. Pre- and post-operative X-rays, if requested, must be made available to the Division of Medical Services.

225.500 Deep Sedation and General Anesthesia 2-1-22

Providers administering general anesthesia services must possess the appropriate permit as required by Arkansas law. Services performed in the dental office must be documented in the patient's record to include specific information on intubation, pharmacologic agents and amounts used, monitoring of vital signs and total anesthesia time. Prior authorization is required for deep sedation and general anesthesia procedures. General anesthesia and intravenous sedation will not be reimbursed for periods of time in excess of two (2) hours. Are not allowed on the same day.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

These codes are subject to post payment review; therefore, providers should be prepared to justify utilization of these procedures and the amount of time patients were kept under deep sedation and general anesthesia.

227.000 Professional Visits 2-1-22

Professional visits are payable if prior authorized. Because it is not always possible to plan these calls, the provider should submit a claim with a concise explanation of the circumstances. These visits are subject to review by the dental consultant.

When a treatment is necessary and no procedure code is applicable, a written explanation of the treatment and the usual and customary fee charged to a private patient must be submitted to the Medicaid Program. The dental consultant will stipulate an exact fee to be paid if the treatment is authorized. See Sections 262.100 and 262.200 for applicable procedure codes.

262.100 ADA Procedure Codes Payable to Beneficiaries Under Age 21 2-1-22

The following ADA procedure codes are covered by the Arkansas Medicaid Program. These codes are payable for beneficiaries under the age of 21.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

NOTE: Only physicians who have completed the training on dental caries and have an approved fluoride varnish certification on file with Provider Enrollment can bill for the fluoride varnish treatment. Eligible physicians may delegate the application to a nurse or other licensed healthcare professional under his or her supervision that has also completed the online training. Providers must check the Supplemental Eligibility Screen to verify that topical fluoride treatment or fluoride varnish was not applied by another Medicaid dental provider.

Beside each code is a reference chart that indicates whether X-rays are required and when prior authorization (PA) is required for the covered procedure code. If a concise report is required, this information is included in the PA column.

* Revenue code

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the covered service.

** Prior authorization is required for panoramic X-rays performed on children under six years of age (See Section 216.100).

262.200 ADA Procedure Codes Payable to Medically Eligible Beneficiaries Age 21 and Older 2-1-22

The following list shows the procedure code, procedure code description, whether or not prior authorization is required, whether an X-ray should be submitted with a treatment plan and if there is a benefit limit on a procedure.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

The column titled Benefit Limit indicates the benefit limit, if any, and how the limit is to be applied. When the column indicates "Yes, $500.00", then that item, when used in combination with other items listed, cannot exceed the $500.00 Medicaid maximum allowable reimbursement limit for the state fiscal year (July 1 through June 30). Other limitations are also shown in the column (i.e.: 1 per lifetime). If "No" is shown, the item is not benefit limited.

NOTE: The use of the symbol, ***, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

262.400 Billing Instructions - ADA Claim Form - Paper Claims Only 2-1-22

Dental providers must complete the ADA claim form when:

262.500 Special Billing Procedures for ADA Claim Form 2-1-22

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

263.100 CPT Procedure Codes 2-1-22

The provider should carefully read and adhere to the following instructions so that claims may be processed efficiently. Accuracy, completeness and clarity are important. Claims cannot be processed if applicable information is not supplied or is illegible. Claims should be typed whenever possible. Handwritten claims must be completed neatly and accurately.

The claim form CMS-1500 must be used by dentists billing the Medicaid Program for these medical procedures. Each service must be billed on a separate form. See Section 263.300 for complete billing instructions.

263.110 CPT Procedure Codes that Require Prior Authorization Before Performing the Procedure 2-1-22

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

263.310 Completion of CMS-1500 Claim Form 2-1-22

263.400 Special Billing Procedure for the CMS-1500 Claim Form 2-1-22

CPT-4 procedure codes must be billed on the CMS-1500 claim form by dentists enrolled in the Medicaid Program when the procedure is provided to an eligible Medicaid beneficiary and is medically necessary. View a CMS-1500 sample form.These procedure codes and their descriptions are located in the American Medical Association Current Procedural Terminology (CPT). Refer to Section III for information on how to purchase a copy of this publication.

NOTE: Procedure code (Hospital Discharge Day Management) is payable for medical services. Procedure code may not be billed by providers in conjunction with an initial or subsequent hospital care code (procedure codes). Initial hospital care codes and subsequent hospital care codes may not be billed on the day of discharge.

NOTE: Covered CPT-4 procedure codes listed in this section are covered by Medicaid for eligible beneficiaries of all ages. The Arkansas Medicaid ADA Procedure Codes are covered only for eligible beneficiaries under the age of 21 years participating in the Child Health Services (EPSDT) Program.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

263.410 Multiple Quadrants Billing Instructions 2-1-22

When billing for multiple applications of any of the following procedures on the same date of service in varying quadrants of a patient's mouth, indicate the number of quadrants (1, 2, 3, 4) in Field 24G:

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

263.420 Anesthesia Services 2-1-22

Anesthesia services are billed using the CMS-1500 claim format.

263.421 Anesthesia Procedure Codes 2-1-22

Oral surgeons must use the following anesthesia procedure codes when billing on paper.

View or print the Dental services procedure codes for covered beneficiaries.

For dental services provided by dental managed care providers, please see the respective provider's manual.

214.300 Foster Care Intake Physical Examination in the EPSDT Program 2-1-22

Arkansas Medicaid beneficiaries entering the Arkansas foster care system are required to receive an intake physical examination within the first seventy two (72) hours. If the EPSDT provider who performs the screening is not the beneficiary's PCP, the intake physical examination should be billed with procedure codes and modifiers EP and H9.

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

Billing with these procedure codes and modifiers will allow the claim to be submitted for payment without a referral from the beneficiary's PCP and will alert the system not to count the screen toward the beneficiary's yearly EPSDT periodic complete medical screening limits.

If the EPSDT provider who performs the screen is the beneficiary's PCP, the intake physical exam should be billed with procedure codes and modifiers EP and H9. Billing with these procedure codes and modifiers will allow the claim to be submitted for payment and will not count toward the beneficiary's yearly EPSDT periodic complete medical screening limits.

Procedure codes, in conjunction with the EP and H9 modifiers, are to be used only for the required intake physical examination for Medicaid beneficiaries in the Arkansas foster care system.

215.100 Schedule for Child Health Services (EPSDT) Medical/Periodicity Screening 2-1-22

The periodic EPSDT screening schedule has been changed in accordance with the most recent recommendations of the American Academy of Pediatrics.

From birth to 15 months of age, children may receive six (6) periodic screens in addition to the newborn screen performed in the hospital.

Children age 15 months to 24 months of age may receive two (2) periodic screens. Children age 24 months to 30 months may receive one (1) periodic screen, and children 30 months to 3 years old may receive one (1) periodic screen.

When a child has turned 3 years old, the following schedule will apply. There must be at least 365 days between each screen listed below for children age 3 years through 20 years.

Most medical and hearing screens for children require a PCP referral before the screens may occur. Routine newborn care, vision screens, dental screens and immunizations for childhood diseases do not require PCP referral. See Section 242.100for procedure codes.

215.210 Health and Developmental History 2-1-22

A health and developmental history should be obtained from the parent or other responsible adult who is familiar with the child's health history. The child's height and weight should also be recorded and compared with the ranges considered normal for children of that age. See Section 242.100 for procedure codes.

215.220 Unclothed Physical Examination 2-1-22

An unclothed physical examination should be performed to note obvious physical defects including orthopedic, genital, skin, and other observable deviations. If there is evidence that the child has been physically abused, this should be reported to the authorities according to state law requirements. See Section 242.100 for procedure codes.

215.230 Developmental Assessment 2-1-22

A developmental assessment should be obtained by history and observation of the child or by one of the developmental tests. This portion of the screening could include assessment of eye hand coordination, gross motor function (walking, hopping, climbing), fine motor skills (use of finger dexterity and hand usage), speech development, daily living personal skills such as dressing, feeding and grooming oneself, behavioral development and proofs of mind with body integration. See Section 242.100 for procedure codes.

215.240 Visual Evaluation 2-1-22

A visual evaluation is required for all children receiving Child Health Services (EPSDT) screening. The age-specific procedures (Section 216.000) may be helpful to determine the necessary procedures according to the child's age. This screening does not require Titmus machine or other ophthalmological testing. Subjective testing may be provided as part of a vision screening. See Section 242.100 for procedure codes.

215.250 Hearing Evaluation 2-1-22

A hearing evaluation is required for all children receiving a Child Health Services (EPSDT) screening. The age-specific procedures (Section 217.000) may be helpful to determine the necessary procedures according to the child's age. This screening does not require machine audiology testing. Subjective testing may be provided as part of a hearing screening. See Section 242.100 for procedure codes.

215.260 Oral Assessment 2-1-22

An oral assessment is considered part of the full Child Health Services (EPSDT) screening. A referral to a dentist for an oral screen is offered beginning at childbirth. See Section 242.100 for procedure codes.

215.270 Laboratory Procedures (CPT Codes) 2-1-22

Laboratory procedures should be performed as appropriate for the child's age and population group. See Sections 215.310 through 215.340 for age and testing recommendations. See Section 219.000 for specific blood lead testing and Section 242.150 for CPT codes.

215.280 Nutritional Assessment 2-1-22

Physical and laboratory determinations carried out in the screening process will usually yield information useful in assessing nutritional status. A child having any detectable nutritional deficiencies should be treated or referred to the proper resource for counseling. This component of the medical screen is included in the full Child Health Services (EPSDT) screening. See Section 242.100 for procedure codes.

215.290 Health Education 2-1-22

Health education is a required component of screening services and includes anticipatory guidance. The developmental assessment, comprehensive physical examination, visual, hearing or dental screening provides the initial opportunity for providing health education. Health education and counseling to parents (or guardians) and children are required. Health education and counseling are designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. See Section 242.100 for procedure codes.

Health education can include but isn't limited to tobacco cessation counseling services to the parent/legal guardian of the child.

216.000 Vision Screen 2-1-22

An EPSDT periodic complete medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic vision or hearing screen on the same day, or within seven (7) days of an EPSDT periodic complete medical screen by the same or different providers. The above combinations represent a duplication of services.

The provider must administer an age-appropriate vision assessment. See Section 242.100 for procedure codes.

Vision services are subject to their own periodicity schedule; however, when the periodicity schedule coincides with the schedule for periodic complete medical screen, vision screens must be included as part of the required minimum periodic complete medical screening services.

Vision screens are exempt from the PCP referral requirement.

See Sections 215.310 through 215.340 for the age-specific vision screening periodicity schedule.

At a minimum, vision services include diagnosis and treatment for defects in vision, including eyeglasses.

218.000 Dental Screening Services 2-1-22

Although an oral assessment may be part of a medical screen, it does not substitute for examination through direct referral to a dentist. A direct dental referral is required for every child once per state fiscal year (July 1 through June 30). See Section 242.100 for procedure codes.

A Child Health Services (EPSDT) interperiodic dental screen may be completed as often as medically necessary, but must be prior authorized in order for the claim to be paid. Refer to Section 220.000 for an explanation of the prior authorization process.

Dental screens are exempt from the primary care provider (PCP) referral requirement.

Dental Services

At a minimum, dental services include relief of pain and infections, restoration of teeth and maintenance of dental health. Dental services may not be limited to emergency services. The periodicity schedule for other EPSDT services may not govern the schedule for dental services.

A child should receive his or her first dental screen examination within 6 months after eruption of the first primary tooth but no later than 12 months of age.

220.000 PRIOR AUTHORIZATION 1-1-22

Prior authorization is required for the interperiodic dental screen and must be requested on the ADA claim form. Refer to the Dental Provider Manual for details regarding the prior authorization process. See Section 242.100 for procedure codes.

242.100 Procedure Codes 2-1-22

The table below contains procedure codes, the associated modifiers to be used with the individual code, and a description of each EPSDT service.

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.

Other coding information found in the chart:

242.110 Newborn Care 2-1-22

For routine newborn care following a vaginal delivery or C-section, procedure code should be used one time to cover all newborn care visits by the attending physician. Payment of these codes is considered a global rate and subsequent visits may not be billed in addition to codes.

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

These procedure codes include the physical exam of the baby and the conference(s) with the newborn's parent(s), which is considered to be the initial newborn care/EPSDT screen in hospital. These procedure codes should not be used for illness care (e.g. neonatal jaundice). Providers may refer to the physician manual for necessary illness codes.

Note the descriptions, modifiers, and required diagnosis range. The newborn care procedure codes require a modifier or modifiers and a primary detail diagnosis for all providers (View ICD Codes.)Refer to the appropriate manual(s) for additional information about newborn screenings.

242.120 Billing Exceptions 2-1-22

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

All EPSDT procedure codes must be billed on the CMS-1500 claim form with the following exceptions.

242.140 Vaccines for Children Program 2-1-22

The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. To enroll in the VFC Program, contact the Arkansas Department of Health. Providers may also obtain the vaccines to administer from the Arkansas Department of Health. View or print Arkansas Department of Health contact information.

Vaccines available through the VFC program are covered for Medicaid-eligible children. Only the administrative fee is reimbursed. When filing claims for administering VFC vaccines, providers must use the CPT procedure code for the vaccine administered. Electronic and paper claims require modifiers EP and TJ.

All procedure codes under the VFC program must be billed electronically or on paper, using either the CMS-1500 claim form or the CMS-1450 claim form.

Medicaid policy regarding immunizations for adults remains unchanged by the VFC program.

Providers may consult the Physician's manual to view the list of vaccines that are non-VFC but are covered for beneficiaries who are 19 and 20 years of age. The following list contains the vaccines available through the VFC program.

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

242.141 Billing of Multi-Use and Single-Use Vials 2-1-22

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

242.150 Limitation for Laboratory Procedures Performed as Part of EPSDT Screens 2-1-22

Child Health Services (EPSDT) screens do not include laboratory procedures unless the screen is performed by the beneficiary's primary care physician (PCP) or is conducted in accordance with a referral from the PCP.

The following tests are exempt from this limitation and may continue to be billed in conjunction with an EPSDT screen performed in accordance with existing Medicaid policy:

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

Claims for laboratory tests, other than those specified above, performed in conjunction with an EPSDT screen will be denied, unless the screen is performed by the PCP or in accordance with a referral from the PCP.

The following screens will be affected by this policy.

242.300 Billing Instructions - Paper Only 2-1-22

To bill for a Child Health Services (EPSDT) screening service, use the CMS-1500 claim form. The numbered items correspond to numbered fields on the claim form. See Section 242.310 for paper billing instructions. View or print a sample CMS-1500 form.

Each screening should be billed separately, providing the appropriate information for each of the screening components.

View or print the procedure codes and modifiers for Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services.

With the exception of codes (office medical services), (home medical services) and (hospital inpatient medical services), specific procedures may be used at the provider's discretion as long as the federally-mandated components (refer to Section 215.000) have been included in the screening package.

Medical services such as immunizations and laboratory procedures may also be billed on the CMS-1500 when provided in conjunction with a Child Health Services (EPSDT) screening, as well as other treatment services provided.

Claims for Child Health Services (EPSDT) dental services are to be billed on the ADA claim form. For dental screening to be paid, the ADA claim form must be completed and the box marked "child" in Field 2 must be checked.

Claims for Child Health Services (EPSDT) visual services are to be billed on the CMS-1500 claim form. The numbered items correspond to numbered fields on the claim form. See Section 242.310 for paper billing instructions. View or print a sample CMS-1500 form.

Carefully follow these instructions to help the Arkansas Medicaid fiscal agent efficiently process claims. Accuracy, completeness and clarity are essential. Claims cannot be processed if applicable information is omitted. Claims should be typed whenever possible.

Forward completed claim forms to the Claims Department. View or print the Claims Department contact information.

262.110 FQHC Encounter Service 2-1-22

FQHCs bill Medicaid for a core services encounter (which includes all services and supplies incident to the encounter) with procedure code, "FQHC Encounter Service."

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

Use type of service code 9 (paper claims only) with. Medicaid pays the facility's current established rate for each encounter.

262.120 Telemedicine 2-1-22

Use procedure code and type of service code Y (paper claims only) to indicate telemedicine charges.

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

The charge associated with this procedure code should be an amount attributable to the telemedicine service, such as line (or wireless) charges. Medicaid will deny the charge and capture it in the same manner as with ancillary charges.

262.130 Obstetric and Gynecologic Encounters 2-1-22

Bill for the following obstetric and gynecologic procedures with the CPT procedure codes indicated and type of service code 2 (paper claims only).

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.For settlement purposes, each of these procedures is considered an encounter.

262.140 Family Planning 2-1-22

Bill Medicaid for family planning services with applicable procedure codes listed in Sections 262.141through 262.152.

262.141 Family Planning and Post-Sterilization Visits 2-1-22

Bill for family planning visits and post-sterilization visits with type of service code A (paper billing only) and a family planning diagnosis.

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

262.142 Family Planning Procedures 2-1-22

Bill for family planning procedures with a type of service code A (paper billing only) and a family planning diagnosis.

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

262.143 Contraceptives 2-1-22

Bill for contraceptives with type of service code A (paper claims only) and a family planning diagnosis.

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

262.144 Contraceptive Injections-Depo-Provera 2-1-22

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

262.151 Local Procedure Codes 2-1-22

Bill for family planning laboratory procedures with type of service code A (paper claims only) and a family planning diagnosis.

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

262.152 National Procedure Codes 2-1-22

Bill for family planning laboratory procedures with a type of service A (paper claims only) and a family planning diagnosis.

View or print the procedure codes for Federally Qualified Health Center (FQHC) services.

262.442 Billing of Multi-Use and Single-Use Vials 2-1-22

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

242.100 Audiology Procedure Codes 2-1-22

Use the following procedure codes for audiological function tests.

View or print the procedure codes for Hearing (Audiology) services.

[DAGGER] Non-payable to a school district or ESC

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the indicated Arkansas Medicaid description.

Use the following procedure code for hearing screenings for beneficiaries under age 21 in the Child Health Services (EPSDT) Program.

242.110 Hearing Aid Procedure Codes 2-1-22

Use the following procedure codes for hearing aid equipment for beneficiaries under age 21 in the Child Health Services (EPSDT) Program.

View or print the procedure codes for Hearing (Audiology) services.

Medicaid covers up to 2 hearing aids per beneficiary each six-months. Hearing aid procedure codes may be billed electronically or on a paper claim form.

*Repairs require prior authorization

**Accessories

[DAGGER] Non-payable to a school district or ESC

242.400 Special Billing Procedures 2-1-22

Requests for payment of hearing aids, accessories and repairs must be completed on Form CMS-1500 prior to being submitted to the Utilization Review Section.

The following documentation must accompany each request for a hearing aid:

242.110 Home Health Visits 2-1-22

View or print the procedure codes for Home Health services.

242.120 Home Health Physical Therapy 2-1-22

View or print the procedure codes for Home Health services.

242.130 Specimen Collection 2-1-22

View or print the procedure codes for Home Health services.

242.141 Epogen Injections for Renal Failure 2-1-22

View or print the procedure codes for Home Health services.

242.142 Epogen Injections for Diagnosis other than Renal Failure 2-1-22

View or print the procedure codes for Home Health services.

242.144 Billing of Multi-Use and Single-Use Vials 2-1-22

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

242.150 Home Health Medical Supplies 2-1-22

The following Health Care Procedural Coding System (HCPCS) codes must be used when billing the Arkansas Medicaid Program for medical supplies. Providers must use the current HCPCS Book for code descriptions.

View or print the procedure codes for Home Health services.

Listed below are medical supplies that require special billing or need prior authorization. These items are listed with the HCPCS codes and require modifiers. The asterisk denotes these items and the required modifiers.

242.160 Incontinence Supplies 2-1-22

Codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

View or print the procedure codes for Home Health services.

Reimbursement is based on a per unit basis with one unit equaling one item (diaper or underpad). When billing for these services that are benefit limited to a dollar amount per month, providers must bill according to the calendar month.

Providers must not span calendar months when billing for diapers and/or underpads. The date of delivery is the date of service. Provider may not bill "from" and "through" dates of services.

216.300 Hysteroscopy for Foreign Body Removal 2-1-22

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Procedure code requires paper billing and clinical documentation for justification.

216.540 Family Planning Procedures 2-1-22

The following procedure code table lists family planning procedures payable to hospitals. These codes require a primary diagnosis of family planning on the claim.

Sterilization procedures require paper billing with DMS-615 attached. View or print form DMS-615. View or print form DMS-615 Spanish.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

*CPT code represents a procedure to treat medical conditions as well as for elective sterilizations.

Family planning laboratory codes are found in Section 216.550.

216.550 Family Planning Lab Procedures 2-1-22

Family planning services are covered for beneficiaries in full coverage for Aid Category 61 (PW-Pl). For additional information on Family Planning Services, see Sections 216.100-216.110, 216.130-216.132, 216.515, and 216.540-216.550.

Collection fees for laboratory procedures are included in the reimbursement for the laboratory procedure.

The following procedure codes table lists payable family planning laboratory procedure codes that require a primary diagnosis of Family Planning on the claim form:

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.*Procedure codes are limited to one unit per beneficiary per state fiscal year.

217.062 Corneal Transplants 2-1-22

217.090 Bilaminate Graft or Skin Substitute Coverage Restriction 2-1-22

217.113 Gastrointestinal Tract Imaging with Endoscopy Capsule 2-1-22

217.141 Computed Tomographic Colonography (CT Colonography) 2-1-22

244.000 Procedures that Require Prior Authorization 2-1-22

245.031 Prior Authorization of Hyaluronon (Sodium Hyaluronate) Injection 2-1-22

Prior authorization is required for coverage of the Hyaluronon (sodium hyaluronate) injection. Providers must specify the brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization for the following procedure codes:

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

A written request must be submitted to Division of Medical Services Utilization Review Section. View or print the Division of Medical Services Utilization Review Section address.

The request must include the patient's name, Medicaid ID number, physician's name, physician's provider identification number, patient's age, 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.

252.117 Reimbursement of Burn Dressing Changes in Outpatient Hospitals 2-1-22

272.115 Observation Bed Billing Information 2-1-22

Use code 760* to bill for Observation Bed. One unit of service on the CMS-1450 (UB-04) outpatient claim equals 1 hour of service. Medicaid will cover up to 8 hours of hospital observation per date of service.

When a physician admits a patient to observation subsequent to providing emergency or nonemergency services in the emergency department, the hospital may bill the observation bed code 760* and the appropriate procedure code for emergency room 450* or non-emergency room 459*. Condition code 88 must be billed to indicate an emergency claim.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

You may not bill 622* or 250*:

272.131 Non-Emergency Charges 2-1-22

The following procedure codes may be billed in conjunction with procedure code 459* ("Other non-emergency service", which includes room charge). See Section 272.510 for billing requirements.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

*Refer to Section 272.510 for additional criteria.

NOTE: Arkansas Medicaid reimburses for medically necessary vaccines, laboratory services, X-Rays and machine tests in addition to standalone revenue code 0459.

272.132 Procedure Codes Requiring Modifiers 2-1-22

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.404 Hyperbaric Oxygen Therapy (HBOT) Procedures 2-1-22

272.405 Billing of Gastrointestinal Tract Imaging with Endoscopy Capsule 2-1-22

Gastrointestinal Tract Imaging with Endoscopy Capsule, billed as, is payable for all ages and must be billed by using the primary diagnosis of (View ICD Codes.).

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

This procedure code should be billed with no modifiers when performed in the outpatient hospital place of service.

CPT code is payable on electronic and paper claims. For coverage policy, see Section 217.113.

272.421 Dialysis Procedure Codes 2-1-22

The facility providing the hemodialysis and peritoneal dialysis service must use the following HCPCS procedure codes when billing for the dialysis treatment:

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

The codes listed in CPT-4 must not be used.

*Revenue code

272.435 Tissue Typing 2-1-22

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.436 Billing for Corneal Transplant 2-1-22

For processing, preserving and transporting corneal tissue, use procedure code

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Requires paper billing and a manufacturer's invoice attached to the claim. See Section 217.062 for coverage information.

272.437 Vascular Embolization and Occlusion 2-1-22

The following procedure codes require paper billing and documentation attached that describes the procedure code and supports medical necessity:

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.440 Factor VIIa 2-1-22

Arkansas Medicaid covers Factor VIIa (coagulation factor, recombinant) for treatment of bleeding episodes in hemophilia A or B patients with inhibitors to Factor VIII or Factor IX. Factor VIIa coverage is restricted to diagnosis codes: (View ICD Codes.).

Providers must bill Medicaid for Factor VIIa with HCPCS procedure code. One unit equals 1.2 milligrams.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.441 Factor VIII 2-1-22

HCPCS procedure code must be used when billing for all anti-hemophiliac Factor VIII, including Monoclate.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Anti-hemophiliac Factor VIII is covered by the Arkansas Medicaid Program when administered in the outpatient hospital setting, physician's office or beneficiary's home. When billing for this procedure, enter the brand name and the dosage in the description area of the claim form. The provider must bill the cost per unit and the number of units administered. The number of units administered must be entered in the units column of the claim form.

272.442 Factor IX 2-1-22

HCPCS procedure code must be used when billing for Factor IX Complex (Human).

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Factor IX Complex (Human) is covered by the Arkansas Medicaid Program when administered in the outpatient hospital setting, physician's office or beneficiary's home. When billing for this procedure, enter the brand name and the dosage in the description area of the claim form. The provider must bill the cost per unit and the number of units administered. The number of units administered must be entered in the units column of the claim form.

272.443 Factor VIII and Factor IX 2-1-22

Anti-hemophiliac Factor VIII is covered by the Arkansas Medicaid Program when administered in the outpatient hospital, physician's office or in the patient's home. The following procedure codes must be used:

Factor VIII [antihemophilic factor (porcine)], per IU

Factor VIII [antihemophilic factor (recombinant)], per IU

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

The provider must bill his/her cost per unit and the number of units administered.

HCPCS procedure code must be used when billing for Factor IX Complex (human). Factor IX Complex (human) is covered by Medicaid when administered in the physician's office or the patient's home (residence). The provider must bill his/her cost per unit and the number of units administered.

For the purposes of Factor VIII and Factor IX coverage, the patient's home is defined as where the patient resides. Institutions, such as a hospital or nursing facility, are not considered a patient's residence.

272.447 Bone Stimulation 2-1-22

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Procedure codes are payable when provided in the physician's office, ambulatory surgical center or outpatient hospital setting to Medicaid beneficiaries of all ages. Procedure codes will require prior authorization and are payable only for non-union of bone. When provided in the outpatient setting, the provider must submit an invoice with the claim if providing the device.

272.448 Vascular Injection Procedures 2-1-22

Effective for claims with dates of service on or after December 1, 1993, in accordance with Medicare guidelines, the Arkansas Medicaid Program implemented the following policy regarding vascular injection procedures:

If a provider bills procedure code and one or all of the following procedure codes on the same date of service, the Medicaid Program will reimburse for procedure code and the other codes will be denied.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.450 Special Billing Requirements for Laboratory and X-Ray Services 2-1-22

The following codes have special billing requirements for laboratory and X-Ray procedures.

272.453 Hysterectomy for Cancer or Dysplasia 2-1-22

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Hospitals may use procedure code when billing for a total hysterectomy procedure when the diagnosis is cancer or severe dysplasia.

Procedure code does not require prior authorization (PA). All hysterectomies require paper billing using claim form CMS-1450. Form DMS-2606 must be properly signed and attached to the claim form.

Procedure code is covered for emergency hysterectomy immediately following C-section. It requires no PA but does require form DMS-2606 and an operative report/discharge summary to confirm the emergency status.

272.461 Verteporfin (Visudyne) 2-1-22

Verteporfin (Visudyne), HCPCS procedure code, is payable to outpatient hospitals when furnished to Medicaid beneficiaries of any age when the requirements identified in Section 217.140 are met.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.462 Billing Protocol for Computed Tomographic Colonography (CT) 2-1-22

272.500 Influenza Virus Vaccines 2-1-22

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

272.501 Medication Assisted Treatment and Opioid Use Disorder Treatment Drugs 2-1-22

Effective for dates of service on and after September 1, 2020, Medication Assisted Treatment for Opioid Use Disorders is available to all qualifying Medicaid beneficiaries when provided by providers who possess an X-DEA license on file with Arkansas Medicaid Provider Enrollment for billing purposes. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.

Effective for dates of services on and after October 1, 2018, the following Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes are payable:

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

To access prior approval of these HCPCS procedure codes when necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms found at the DHS contracted Pharmacy vendor website.

272.510 Injections, Radiopharmaceuticals and Therapeutic Agents 2-1-22

Intravenous administration of therapeutic agents is payable only if provided in an outpatient setting. Therapeutic injections should only be provided by facilities that have the capacity to treat patients who may experience adverse reactions. The capability to treat infusion reactions with appropriate life support techniques should be immediately available. Reimbursement for supplies is included in the administration fee.

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services.

Use procedure code for IV infusion therapy. For additional hours, sequential and/or concurrent infusions, bill revenue code 0760 (for observation), up to 8 hours maximum per day. For monoclonal antibody intravenous infusion use procedure code.

Multiple units may be billed for drug procedure codes, if appropriate. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as take home drugs.

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

242.110 Parenteral Hyperalimentation Services 2-1-22

One unit of service equals a half-liter of fluid and includes fluids and the equipment and supplies necessary for the administration of the fluids in the beneficiary's place of residence.

View or print the procedure codes for Hyperalimentation services.

242.120 Enteral (Sole Source) Formulae 2-1-22

The following pages provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions, and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

Modifiers in this section are indicated by the headings M1, M2, and M3.

Enteral formulae are divided into several categories. Each unit of service equals one-hundred (100) calories of formula. All supplies and equipment necessary to administer the nutrients in the beneficiary's place of residence, except the infusion pump and pump supply kit, are included in the unit description.

For beneficiaries from birth through four (4) years of age, the use of modifier U8, as well as additional documentation, will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP's medical rationale for prescribing a formula, as well as medical records documenting the beneficiary's failed trials of WIC formula, must be submitted for review. Flavor preference for formulae will not be considered for medical necessity.

A separate prior authorization must be obtained for the enteral infusion pump and the pump supply kit. The enteral infusion pump and the pump supply kit may be billed separately.

View or print the procedure codes for Hyperalimentation services.

Exceptions to Use of Formula

The following exceptions must be followed in order to use formulae listed in this section.

NOTE: The Women, Infant, and Children program (WIC) must be accessed before the Medicaid Program for children from birth to five (5) years of age.

The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulae. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged zero (0) to five (5) years, prior to requesting supplemental amounts of WIC-approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.

242.130 Pedia-Pop 2-1-22

The following procedure code must be utilized when billing for Pedia-Pop.

View or print the procedure codes for Hyperalimentation services.

Reimbursement for this product is the provider's cost plus ten percent (10%). Pedia-Pop is covered for eligible Medicaid beneficiaries of all ages. Pedia-Pop is only for oral consumption in frozen form and may not be appropriate for a hyperalimentation diet.

242.142 Equipment and Supplies for Enteral (Sole Source) Nutrition Therapy 2-1-22

Equipment and supplies necessary for the administration of enteral (sole source) nutrition therapy in the beneficiary's place of residence are included in the unit reimbursement price. Prior authorization is required for the enteral infusion pump and the pump supply kit and may be billed separately. The prior authorization request for the pump must contain supporting documentation to establish medical necessity (e.g., gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome, etc.).

Prior authorization is indicated by the heading PA. If prior authorization is required, that information is indicated with a "Y" in the column; if not, an "N" is shown.

View or print the procedure codes for Hyperalimentation services.

242.143 Reimbursement for the Enteral (Sole Source) Nutrition Infusion Pump 2-1-22

Reimbursement for the enteral (sole source) nutrition infusion pump is based on a rent-to-purchase methodology. Each unit reimbursed by Medicaid will apply towards the purchase price established by Medicaid. Reimbursement will only be approved for new equipment. Used equipment will not be prior authorized.

View or print the procedure codes for Hyperalimentation services.

Procedure codes each represent a new piece of equipment being reimbursed by Medicaid on the rent-to-purchase plan. Both codes are reimbursed on a per unit basis with 1 day equaling 1 unit of service.

The provider may bill for the infusion pump at a maximum of one (1) unit of service per day. Medicaid will reimburse on the rent-to-purchase plan for a total of 304 units of service. After reimbursement has been made for 304 units, the equipment will become the property of the Medicaid beneficiary.

Prior authorization is required for procedure codes. The prior authorization request must include the serial number of the infusion pump being provided to the beneficiary.

242.145 Equipment Repairs for the Enteral Nutrition Infusion Pump 2-1-22

Reimbursement for repairs of the enteral nutrition infusion pump requires prior authorization. Repairs will be approved only on equipment purchased by Medicaid. Therefore, no repairs are covered before the equipment becomes the property of the Medicaid beneficiary.

Requests for prior authorization for enteral pump repairs must be mailed to the Utilization Review Section, Division of Medical Services as detailed in Section 220.000 of this manual. The repair invoice and the serial number of the equipment must accompany the prior authorization request form. Total repair costs to an infusion pump may not exceed $290.93.

Medicaid will not reimburse for additional repairs of an infusion pump after the provider has billed repair invoices totaling $290.93. If, after billing the Medicaid maximum allowed for repairs, the equipment is still not in proper working order, the provider must supply the beneficiary with a new infusion pump and may bill either procedure code after receiving prior authorization for the new piece of equipment.

To bill the Medicaid Program for repairs made to the enteral infusion pump, use the following procedure code.

View or print the procedure codes for Hyperalimentation services.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product. When using a procedure code with this symbol, the product must meet the Arkansas Medicaid description.

242.402 Billing of Multi-Use and Single-Use Vials 2-1-22

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

214.500 Laboratory and X-Ray Services Referral Requirements 2-1-22

A nurse practitioner referring a Medicaid beneficiary for laboratory, radiology or machine testing services must specify an ICD diagnosis code for each test ordered, and include in the order, pertinent supplemental diagnosis supporting the need for the test(s).

214.620 Risk Management Services for High Risk Pregnancy 2-1-22

A nurse practitioner may provide risk management services if he or she employs the professional staff indicated in service descriptions below. If a nurse practitioner does not choose to provide high-risk pregnancy services but believes the patient would benefit from such services, he or she may refer the patient to a clinic that offers the services.

Covered risk management services described in parts A through E below are considered as one service with a benefit limit of 32 cumulative units. The early discharge home visit described in part F is considered as a separate service.

214.630 Fetal Non-Stress Test 2-1-22

The fetal non-stress test is limited to 2 per pregnancy per beneficiary. If it is necessary to exceed this limit, the nurse practitioner must request an extension of benefits and submit documentation that establishes medical necessity. Refer to Section 214.900 of this manual for procedures to request extension of benefits. Refer to Section 252.451of this manual for billing instructions and the procedure code.

The post-procedural visits are covered within the 10-day period following the fetal non-stress test.

215.000 Fluoride Varnish Treatment 2-1-22

Arkansas Medicaid covers fluoride varnish application, ADA code, performed by physicians who have completed the online training program approved by the Arkansas Department of Health, Office of Oral Health.

View or print the procedure codes for Nurse Practitioner services.

Eligible physicians may delegate the application to a nurse or other licensed health care professional under his or her supervision that has also completed the online training. The online training course can be accessed http://ar.train.org. Each provider must maintain documentation to establish his or her successful completion of the training and submit a copy of the certificate of completion to Provider Enrollment.

252.110 Billing Protocol for Computed Tomographic Colonography (CT) 2-1-22

252.130 Special Billing Instructions 2-1-22

252.131 Molecular Pathology 2-1-22

The following Molecular Pathology codes require prior authorization from the Arkansas Foundation for Medical Care. See Sections 221.000 through 221.300 for prior authorization procedures.

View or print the procedure codes for Nurse Practitioner services.

252.132 Special Billing Requirements for Lab and X-Ray Services 2-1-22

For consideration of payable unlisted CPT/HCPCS drug procedure codes:

252.410 Clinic or Group Billing 2-1-22

Providers who wish to have payment made to a group practice or clinic must enroll as a group practice. When billing, enter the Clinic/Group pay-to Provider Identification Number in Field 33 after "GRP#." Enter the performing provider identification number in Field 24K. If more than one nurse practitioner in a group practice provides services for a beneficiary, the clinic may bill for all their services on the same claim limited only by the size of the claim format.

Procedure code is payable when provided in the inpatient hospital setting by a nurse practitioner.

View or print the procedure codes for Nurse Practitioner services.

252.422 Detention Time (Standby Service) 2-1-22

View or print the procedure codes for Nurse Practitioner services.

Procedure code must be used by nurse practitioners when billing for detention time.

One unit equals 30 minutes. A maximum of 1 unit per date of service may be billed.

Procedure code is payable when provided in the inpatient hospital setting by a nurse practitioner.

252.424 Hospital Discharge Day Management 2-1-22

View or print the procedure codes for Nurse Practitioner services.

Procedure code, hospital discharge day management, may not be billed by providers on the same date of service as an initial or subsequent hospital care code, procedures. Initial hospital care codes and subsequent hospital care codes may not be billed on the day of discharge.

252.426 Specimen Collections 2-1-22

The policy in regard to collection, handling and/or conveyance of specimens is:

252.428 Services Not Considered a Separate Service from an Office Visit 2-1-22

Some services (e.g., pelvic examinations, prostatic massages, removal of sutures, etc.) are not considered a separate service from an office visit. The charge for such services should be included in the office visit charge. Billing should be under the office visit procedure code that reflects the appropriate level of care. Procedure code should never be used for billing routine pelvic examinations, but should be used only when a pelvic examination is done under general anesthesia.

View or print the procedure codes for Nurse Practitioner services.

252.430 Family Planning Services Program Procedure Codes 2-1-22

252.431 Family Planning Laboratory Procedure Codes 2-1-22

Family planning services are covered for beneficiaries in full coverage aid categories and Aid Category 61 (PW-PL). For information regarding additional aid categories, see Section 124.000. For eligible beneficiaries, these codes are payable when used for purposes other than family planning. Claims require modifier FP when the service diagnosis indicates family planning.

252.439 Billing of Multi-Use and Single-Use Vials 2-1-22

Arkansas Medicaid follows the billing protocol per the Federal Deficit Reduction Act of 2005 for drugs.

252.441 Family/Group Psychotherapy 2-1-22

The following psychotherapy procedure codes are payable by the Arkansas Medicaid Program for family/group psychotherapy:

View or print the procedure codes for Nurse Practitioner services.

Procedure codes are payable when the place of service is the beneficiary's home, the physician's office, a hospital or a nursing home. Procedure code is payable only when the patient is present during the treatment. Procedure codes are payable when the patient is not present; however, the patient may be present during the session, when appropriate.

252.443 Other Covered Injections 2-1-22

Nurse practitioners billing the Arkansas Medicaid Program for injections for treatment or immunization purposes should bill the appropriate CPT or HCPCS procedure code for the specific injection provided. The immunization procedure codes and descriptions may be found in the CPT coding book and in this section of this manual.

Providers may bill the immunization procedure codes on either the Child Health Services (EPSDT) DMS-694 claim form or the CMS-1500 form.

If the patient is scheduled for immunization only, the provider will not be permitted to bill for an office visit, but for the immunization only.

The following is an alphabetized list of injections with special instructions for coverage and billing.

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* Procedure code requires paper billing.

NOTE: Where both a national code and a local code ("Z code") are available, the local code can be used only for dates of service through October 15, 2003; the national code must be used for both electronic and paper claims for dates of service after October 15, 2003. Where only a local code is available, it can be used indefinitely, but it can be billed only on a paper claim. Where only a national code is available, it can be used indefinitely for both electronic and paper claims.

252.444 Billing Procedures for Rabies Immune Globulin and Rabies Vaccine 2-1-22

The following CPT procedure codes are covered for all ages without diagnosis restrictions.

View or print the procedure codes for Nurse Practitioner services.

These procedure codes require billing on a paper claim with the dosage entered in the units column of the claim form for each date of service. The manufacturer's invoice must be attached to each claim. Reimbursement for each of these procedure codes includes an administrations fee. Medical policy and billing procedures have not changed for these procedure codes.

252.448 Medication Assisted Treatment and Opioid Use Disorder Treatment Drugs 2-1-22

Effective for dates of service on and after September 1, 2020, Medication Assisted Treatment for Opioid Use Disorders is available to all qualifying Medicaid beneficiaries when provided by providers who possess an X-DEA license on file with Arkansas Medicaid Provider Enrollment for billing purposes. All rules and regulations promulgated within the Physician's provider manual for provision of this service must be followed.

Effective for dates of services on and after October 1, 2018, the following Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes are payable:

View or print the procedure codes for Nurse Practitioner services.

To access prior approval of these HCPCS procedure codes when necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms found at the DHS contracted Pharmacy vendor website.

252.449 Influenza Virus Vaccine 2-1-22

View or print the procedure codes for Nurse Practitioner services.

252.450 Obstetrical Care and Risk Management Services for Pregnancy 2-1-22

Covered nurse practitioner obstetrical services are limited to antepartum and postpartum care only. Claims for antepartum and postpartum services are filed using the appropriate office visit CPT procedure code.

A nurse practitioner may provide risk management services listed below if he or she receives a referral from the patient's physician or certified nurse-midwife and if the nurse practitioner employs the professional staff required. Complete service descriptions and coverage information may be found in Section 214.620 of this manual. The services in the list below are considered to be one service and are limited to 32 cumulative units.

View or print the procedure codes for Nurse Practitioner services.

For an early discharge home visit, use one of the applicable CPT procedure codes.

252.451 Fetal Non-Stress Test 2-1-22

The Fetal Non-Stress Test (procedure code) is limited to 2 per pregnancy. If it is necessary to exceed this limit, the nurse practitioner must request an extension of benefits and submit documentation that establishes medical necessity.

View or print the procedure codes for Nurse Practitioner services.

252.452 Newborn Care 2-1-22

All newborn services must be billed under the newborn's own Medicaid identification number.

The parent(s) of the newborn will be responsible for applying for and meeting eligibility requirements for a newborn to be certified eligible. If the newborn is not certified as Medicaid eligible, the parent(s) will be responsible for the charges incurred by the newborn.

View or print the procedure codes for Nurse Practitioner services.

For routine newborn care following a vaginal delivery or C-section, procedure codes must be used one time to cover all newborn care visits by the attending physician, certified nurse-midwife or, if applicable, a nurse practitioner.

The newborn care procedure codes represent the initial Child Health Services (EPSDT) newborn care/screen. This screening includes the physical exam of the baby and the conference(s) with the newborn's parent(s). Payment of these codes is considered a global rate, and subsequent visits may not be billed in addition to these codes.

Procedure codes may be billed on the EPSDT screening paper form DMS-694 or on the electronic claim transaction format. These codes may also be filed on the CMS-1500; paper or electronically. For information on the Child Health Service (EPSDT) Program, call the Provider Assistance Center. View or print Provider Assistance Center contact information.

For illness care (e.g., neonatal jaundice), use procedure codes. Do not use procedure codes in addition to these codes.

Note the descriptions, modifiers and required diagnosis range. The newborn care procedure codes require a modifier and a primary detail diagnosis of V30.00-V37.21 for all providers. Refer to the appropriate manual(s) for additional information about newborn screenings.

ARKids A (EPSDT) requires an EPSDT claim form or CMS-1500 claim form and may be billed electronically or on paper.

ARKids First B requires a CMS-1500 claim form and may be billed electronically or on paper.

252.453 Fluoride Varnish Treatment 2-1-22

View or print the procedure codes for Nurse Practitioner services.

The American Dental Association (ADA) procedure code is covered by the Arkansas Medicaid Program. This code is payable for beneficiaries under the age of twenty-one (21). Topical fluoride varnish application benefit is covered every six (6) months plus one (1) day for beneficiaries under age twenty-one (21).

A new specialty code, FC-Fluoride Certification will be tied to provider types 01, 03, 58 and 69. These providers must send proof of their fluoride varnish certification to DHS or its designated vendor before the specialty code will be added to their file in the MMIS. View or print contact information to obtain the DHS or designated vendor step-by-step process for provider enrollment. After the specialty code, FC-Fluoride Certification, is added to the provider's file, the provider will be able to bill for procedure code, Topical Application of Fluoride Varnish.

Providers must check the Supplemental Eligibility Screen to verify that topical fluoride varnish benefit of two (2) per State Fiscal Year (SFY) has not been exhausted. If further treatment is needed due to severe periodontal disease, then the beneficiary must be referred to a Medicaid dental provider.

NOTE: This service is billed on form CMS-1500 with ADA procedure code (Topical application of fluoride varnish (prophylaxis not included) - child (ages 0-20)). View a form CMS-1500 sample form.

252.454 Tobacco Cessation Products and Counseling Services 2-1-22

252.455 Physical Therapy Services Billing 2-1-22

Occupational therapy evaluations and services are payable only to a qualified occupational therapist. Physical therapy evaluations are payable to the nurse practitioner. Physical therapy may be payable to the physician when directly provided in accordance with the Occupational, Physical, Speech Therapy Services Manual. The following procedure codes must be used when filing claims for physician provided therapy services. See Glossary - Section IV - for definitions of "group" and "individual" as they relate to therapy services.

View or print the procedure codes for Nurse Practitioner services.

A provider must furnish a full unit of service to bill Medicaid for a unit of service. Partial units are not reimbursable. Extended therapy services may be requested for physical and speech therapy, if medically necessary, for eligible Medicaid beneficiaries of all ages.

252.456 Laboratory Procedures for Highly Active Antiretroviral Therapy (HAART) 2-1-22

The following CPT procedure codes are covered for Medicaid beneficiaries.

View or print the procedure codes for Nurse Practitioner services.

252.457 Procedures That Require Prior Authorization 2-1-22

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252.462 Non-Emergency Services 2-1-22

Procedure code should be billed for a non-emergency nurse practitioner visit.

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252.484 Injections, Therapeutic and/or Diagnostic Agents 2-1-22

Nurse practitioners shall administer injections, therapeutic and diagnostic agents in accordance with the rules set forth in the Arkansas Medicaid Physician's policy manual and within the scope of their practice guidelines.

View or print the procedure codes for Nurse Practitioner services.

213.000 Outpatient Behavioral Health Services Program Entry 2-1-22

Prior to continuing provision of Counseling Level Services, the provider must document medical necessity of Outpatient Behavioral Health Counseling Services. The documentation of medical necessity is a written intake assessment that evaluates the beneficiary's mental condition and, based on the beneficiary's diagnosis, determines whether treatment in the Outpatient Behavioral Health Services Program is appropriate. This documentation must be made part of the beneficiary's medical record.

The intake assessment, either the Mental Health Diagnosis, Substance Abuse Assessment, or Psychiatric Assessment, must be completed prior to the provision of Counseling Level Services in the Outpatient Behavioral Health Services program. This intake will assist providers in determining services needed and desired outcomes for the beneficiary. The intake must be completed by a mental health professional qualified by licensure and experienced in the diagnosis and treatment of behavioral health and/or substance use disorders.

View or print the procedure codes for OBHS services.

231.100 Prior Authorization 2-1-22

Prior Authorization is required for certain Outpatient Behavioral Health Services provided to Medicaid-eligible beneficiaries.

Prior Authorization requests must be sent to the DMS contracted entity to perform prior authorizations for beneficiaries under the age of 21 and for beneficiaries age 21 and over for services that require a Prior Authorization. View or print current contractor contact information.Information related to clinical management guidelines and authorization request processes is available at current contractor's website.

Procedure codes requiring prior authorization:

View or print the procedure codes for OBHS services.

231.300 Substance Abuse Covered Codes 2-1-22

Certain Outpatient Behavioral Health Services are covered by Arkansas Medicaid for an individual whose primary diagnosis is substance abuse. Independently Licensed Practitioners may provide Substance Abuse Service within the scope of their practice. Behavioral Health Agency sites must be licensed by the Divisions of Provider Services and Quality Assurance in order to provide Substance Abuse Services. Allowable substance abuse services are listed below:

View or print the procedure codes for OBHS services.

Beneficiaries being treated by an Outpatient Behavioral Health Service provider for a mental health disorder who also have a co-occurring substance use disorder(s), this (these) substance use disorder(s) is (are) listed as a secondary diagnosis. Outpatient Behavioral Health Service Agency providers that are certified to provide Substance Abuse services may also provider substance abuse treatment to their behavioral health clients. In the provision of Outpatient Behavioral Health mental health services, the substance use disorder is appropriately focused on with the client in terms of its impact on and relationship to the primary mental health disorder.

A Behavioral Health Agency and Independently Licensed Practitioner may provide substance abuse treatment services to beneficiaries who they are also providing mental health/behavioral health services to. In this situation, the substance abuse disorder must be listed as the secondary diagnosis on the claim with the mental health/behavioral health diagnosis as the primary diagnosis.

252.111 Individual Behavioral Health Counseling 2-1-22

252.112 Group Behavioral Health Counseling 2-1-22

252.113 Marital/Family Behavioral Health Counseling with Beneficiary Present 2-1-22

252.114 Marital/Family Behavioral Health Counseling without Beneficiary Present 2-1-22

252.115 Psychoeducation 2-1-22

252.116 Multi-Family Behavioral Health Counseling 2-1-22

252.117 Mental Health Diagnosis 2-1-22

252.118 Interpretation of Diagnosis 2-1-22

252.119 Substance Abuse Assessment 2-1-22

252.120 Psychological Evaluation 2-1-22

252.121 Pharmacologic Management 2-1-22

252.122 Psychiatric Assessment 2-1-22

255.001 Crisis Intervention 2-1-22

255.003 Acute Crisis Units 2-1-22