016-06-05 Ark. Code R. § 53

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.05-053 - Official Notice DMS-2005-W-2 - 2005 HCPCS Procedure Code Conversion

I.General Information

A review of the 2005 HCPCS procedure codes has been completed and the Arkansas Medicaid Program will begin accepting updated HCPCS procedure codes on claims with dates of service on and after August 1, 2005.

II.2005 HCPCS Payable Procedure Code Tables Information

Payable procedures codes have been broken into separate tables. Tables have been created for each affected provider type (e.g.: physician, hospital, etc.)

The tables are designed with nine columns of information. All columns may not be applicable for each covered program, but have been devised for ease of reference.

The first column contains the HCPCS procedure code. In some instances, the procedure code will be shown in multiples, depending on the number of types of service for which it can be used by a provider.

The second and third columns indicate any modifiers that must be used in conjunction with the procedure code, when billed, either electronically or on paper. The columns are titled ?M1? and ?M2?. This information is used in the prosthetics program.

The fourth column is the description of the procedure code.

The fifth column contains the type of service (TOS) code that may be used in conjunction with the procedure code. TOS codes are used with procedure codes billed on paper.

The sixth column indicates the diagnosis list and is titled ?Diag. List?. This information is used by physicians, hospitals, independent radiology, ambulatory surgical centers, area health education centers and nurse practitioners. Applicable lists will be shown in each provider?s section.

The seventh column indicates whether a procedure undergoes medical review before payment. The column is titled ?Review Y/N.? The letter ?Y? in a column means that a review is necessary; and an ?N? indicates that a review is not necessary. Providers should consult their program manual to obtain the information that is needed for a review.

The eighth column shows procedure codes that require prior authorization (PA) before the service may be provided. The column is titled PA, Y/N.? The letter ?Y? in the column indicates that a procedure code requires prior authorization and an ?N? means that the code does not require prior authorization. Providers should consult their program manual to ascertain what information should be provided for the prior authorization process.

The ninth column shows procedure codes that require manual pricing and is titled ?MP Y/N.? A letter ?Y? in the column indicates that an item is manually priced and an ?N? shows that an item is not manually priced. Providers should consult their program manual to review the process involved in manual pricing.

III.Diagnosis Lists

Below is the diagnosis lists referred to in column six. Certain procedure codes are covered only when the primary diagnosis is on the diagnosis lists. Diagnosis list 003, described below, is the only diagnosis list limiting any of the procedure codes in this notice.

Diagnosis List 003

ICD 9 Codes

042

140.0 through 208.91

IV.HCPCS Procedure Codes Payable to Physicians

* See coverage requirements and billing procedures for this procedure code in section XXI.

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	C		N	N	N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	T		N	N	N
G0329			Electromagnetic ther, 1 or [GREATER THAN] areas, Stg 3 ? 4 ulcers, post 30 days conv care	1		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	C		N	N	Y
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	P		N	N	Y
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	T		N	N	Y
G0363			Irrigation of implanted venous access device for drug delivery systems	1		N	N	N
G0364			Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS	2		N	N	N
G0364			Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS	8		N	Y	N
G0365			Vessel mapping of vessels for hemodialysis access	C		N	N	N
G0365			Vessel mapping of vessels for hemodialysis access	P		N	N	N
G0365			Vessel mapping of vessels for hemodialysis access	T		N	N	N
J0128			Injection, abarelix, 10 mg	1	003	N	N	N
J0180*			Injection, agalsidase beta, I mg	1		Y	N	N
J1457			Injection, gallium nitrate, 1 mg	1	003	N	N	N
J1931*			Injection, laronidase, 0.1 mg	1		Y	N	N
J2469			Injection, palonosetron HCI, 25 mcg	1	003	N	N	N
J3396			Injection, verteporfin, 0.1 mg	1		Y	N	N
J7518			Mycophenolic acid, oral, 180 mg	1	003	N	N	N
J9035			Injection, bevacizumab, 10 mg	1	003	Y	N	N
J9041			Injection, bortezomib, 0.1 mg	1	003	Y	N	N
J9055			Injection, cetuximab, 10 mg	1	003	Y	N	N
J9305			Injection, pemetrexed, 10 mg	1	003	Y	N	N
L8614	EP		Tracheoesophageal puncture dilator, replacement only, each	6		N	Y	Y
L8615	EP		Headset/headpiece for use with cochlear implant device, replacement	6		N	Y	Y
L8616	EP		Microphone for use with cochlear implant device, replacement	6		N	Y	Y
L8617	EP		Transmitting coil for use with cochlear implant device, replacement	6		N	Y	Y
L8618	EP		Transmitter cable for use with cochlear implant device, replacement	6		N	Y	Y
L8620	EP		Lithium ion battery for use with cochlear implant device, replacement, each	6		N	Y	Y
L8621	EP		Lithium ion battery for use with cochlear implant device, replacement, each	6		N	Y	Y
L8622	EP		Alkaline battery for use with cochlear implant device, any size, replacement, each	6		N	Y	Y
S0164			Injection, pantoprazole sodium, 40 mg	1	003	N	N	N
S0168			Injection, azacitidine, 100 mg	1	003	N	N	N
S2348			Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumbar	2		N	N	Y
S2348			Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumbar	8		N	Y	Y

V.HCPCS Procedure Codes Payable to Hospitals

* See coverage requirements and billing procedures for this procedure code in section XXI.

2005 Codes	M1	M2	Description	T O S	Diag List	Review Y/N	PA Y/N	MP Y/N
C9218			Injection, azacitidine, per 1 mg	G	003	N	N	Y
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	G		N	N	N
G0329			Electromagnetic ther, 1 or [GREATER THAN] areas, Stg 3 - 4 ulcers, post 30 days conv care	G		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	G		N	N	N
G0363			Irrigation of implanted venous access device for drug delivery systems	G		N	N	N
G0365			Vessel mapping of vessels for hemodialysis access	G		N	N	N
J0128			Injection, abarelix, 10 mg	G	003	N	N	N
J0180*			Injection, agalsidase beta, 1 mg	G		Y	N	N
J0878			Injection, daptomycin, 1 mg	G	003	N	N	N
J1457			Injection, gallium nitrate, 1 mg	G	003	N	N	N
J1931*			Injection, laronidase, 0.1 mg	G		Y	N	N
J2469			Injection, palonosetron HCI, 25 mcg	G	003	N	N	N
J3246			Injection, tirofiban HCI, 0.25 mg	G		N	N	N
J7343			Dermal & epidermal, tissue non-human origin, w/ or w/o bioengin or proc elements, per sq cm	G		Y	N	N
J7344			Dermal tissue, human origin, w/ or w/out other bioengineered or processed elements, per sq cm	G		Y	N	N
J7518			Mycophenelic acid, oral, 180 mg	G	003	N	N	N
J9035			Injection, bevacizumab, 10 mg	G	003	Y	N	N
J9041			Injection, bortezomib, 0.1 mg	G	003	Y	N	N
J9055			Injection, cetuximab, 10 mg	G	003	Y	N	N
J9305			Injection, pemetrexed, 10 mg	G	003	Y	N	N
S0164			Injection, pantoprazole sodium, 40 mg	G	003	N	N	N
S0168			Injection, azacitidine, 100 mg	G	003	N	N	N
S2348			Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumber	G		N	N	Y

VI.HCPCS Procedure Codes Payable to Independent Lab

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Ind	PA Y/N	MP
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	C		N	N	N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	T		N	N	N

VII.HCPCS Procedure Codes Payable to Independent Radiology

2005 Codes	M1	M2	Description	T O S	Diag List	Review Y/N	PA Y/N	MP
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	C		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	P		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	T		N	N	N

VIII.HCPCS Procedure Codes Payable to Home Health

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
A4349	NU		Male external catheter with integral collection compartment, extended wear, each	H		N	N	N
A7045	NU		Exhalation port w/wo swivel used w/accessories for positive airway devices, replacement	H		N	N	N
B4100	NU		Food thickener, administered orally, per oz.	H		N	N	N
T4521	NU		Adult sized disposable incontinence product, brief/diaper, small, each	H		N	N	N
T4522	NU		Adult sized disposable incontinence product, brief/diaper, medium, each	H		N	N	N
T4523	NU		Adult sized disposable incontinence product, brief/diaper, large, each	H		N	N	N
T4524	NU		Adult sized disposable incontinence product, brief/diaper, extra large, each	H		N	N	N
T4526	NU		Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each	H		N	N	N
T4526	EP		Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each	6		N	N	N
T4527	NU		Adult sized disposable incontinence product, protective underwear/pull-on, large size, each	H		N	N	N
T4527	EP		Adult sized disposable incontinence product, protective underwear/pull-on, large size, each	6		N	N	N
T4528	NU		Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea	H		N	N	N
T4528	EP		Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea	6		N	N	N
T4529	EP		Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each	6		N	N	N
T4529	EP	U1	Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each	6		N	N	N
T4530	EP		Pediatric sized disposable incontinence product, brief/diaper, large size, each	6		N	N	N
T4531	EP		Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea	6		N	N	N
T4531	EP	U1	Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea	6		N	N	N
T4532	EP		Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each	6		N	N	N
T4532	EP	U1	Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each	6		N	N	N
T4533	EP		Youth sized disposable incontinence product, brief/diaper, each	6		N	N	N
T4535	NU		Disposable liner/shield/guard/pad/undergarment, for incontinence, each	H		N	N	N
T4535	NU	U1	Disposable liner/shield/guard/pad/undergarment, for incontinence, each	H		N	N	N
T4535	EP		Disposable liner/shield/guard/pad/undergarment, for incontinence, each	6		N	N	N
T4535	EP	U1	Disposable liner/shield/guard/pad/undergarment, for incontinence, each	6		N	N	N

IX.HCPCS Procedure Codes Payable to Prosthetics

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
A4349	NU		Male external catheter with integral collection compartment, extended wear, each	H		N	N	N
A7045	NU		Exhalation port w/wo swivel used w/accessories for positive airway devices, replacement	H		N	N	N
B4100	NU		Food thickener, administered orally, per oz.	H		N	N	Y
B4149	EP		Enteral formula, blenderized natural foods w/intact nutrients, adm with enteral feeding tube	6		N	N	N
B4150	EP	U1	Enteral formula, nutritionally complete w/intact nutrients, adm via enteral feeding tube, 100 cal = 1 unit	6		N	N	N
B4155	EP	U3	Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit	6		N	N	N
B4158	EP		Enteral formula, pediatrics, nutritionally complete adm w/enteral feeding tube, 100 cal = 1 unit	6		N	N	N
B4159	EP		Enteral form/pediatrics/nutritionally comp/soy based, adm w/enteral feeding tube, 100 cal/1 unit	6		N	N	N
B4160	EP		Enteral form/pediatrics/nutritionally comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit	6		N	N	N
B4160	EP	U1	Enteral form/pediatrics/nutrition comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit	6		N	N	N
B4161	EP		Enteral formula, pediatrics, administered through an enteral feeding tube, 100 cal = 1 unit	6		N	N	N
B4162	EP		Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit	6		N	N	N
B4162	EP	U1	Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit	6		N	N	N
B9998	EP	U1	NOC for enteral supplies	6		N	Y	N
B9998	EP	U2	NOC for enteral supplies	6		N	Y	N
B9998	EP	U3	NOC for enteral supplies	6		N	Y	N
B9998	EP	U4	NOC for enteral supplies	6		N	Y	N
B9998	EP	U5	NOC for enteral supplies	6		N	Y	N
B9998	EP	U6	NOC for enteral supplies	6		N	Y	N
B9998	EP	U7	NOC for enteral supplies	6		N	Y	N
B9998	EP	U8	NOC for enteral supplies	6		N	Y	N
E2206	NU		Manual wheelchair accessory, wheel lock assembly, complete, each	H		N	N	N
E2206	EP		Manual wheelchair accessory, wheel lock assembly, complete, each	6		N	N	N
E2291	EP		Back, planar, for pediatric size wheelchair including fixed attaching hardware	6		N	N	Y
E2292	EP		Seat, planar, for pediatric size wheelchair including fixed attaching hardware	6		N	N	Y
E2293	EP		Back, contoured, for pediatric size wheelchair including fixed attaching hardware	6		N	N	Y
E2294	EP		Seat, contoured, for pediatric size wheelchair including fixed attaching hardware	6		N	N	Y
E2368	NU		Power wheelchair component, motor, replacement only	H		N	N	N
E2368	EP		Power wheelchair component, motor, replacement only	6		N	N	N
E2369	NU		Power wheelchair component, gear box, replacement only	H		N	N	N
E2369	EP		Power wheelchair component, gear box, replacement only	6		N	N	N
E2601	NU		General use wheelchair seat cushion, width less than 22 in., any depth	H		N	N	N
E2601	NU		General use wheelchair seat cushion, width less than 22 in., any depth	H		N	N	N
E2601	UE		General use wheelchair seat cushion, width less than 22 in., any depth	U		N	N	N
E2601	EP		General use wheelchair seat cushion, width less than 22 in., any depth	6		N	N	N
E2602	NU		General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2602	NU		General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2602	UE		General use wheelchair seat cushion, width 22 in. or greater, any depth	U		N	N	N
E2602	EP		General use wheelchair seat cushion, width 22 in. or greater, any depth	6		N	N	N
E2611	NU		General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2611	NU		General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2611	UE		General use wheelchair seat cushion, width 22 in. or greater, any depth	U		N	N	N
E2611	EP		General use wheelchair seat cushion, width 22 in. or greater, any depth	6		N	N	N
E2612	NU		General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2612	NU		General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2612	UE		General use wheelchair seat cushion, width 22 in. or greater, any depth	U		N	N	N
E2612	EP		General use wheelchair seat cushion, width 22 in. or greater, any depth	6		N	N	N
E2618	NU		PO WC access., solid seat suppbase, use w/ man WC or lightweight power WC, w/mounting hw	H		N	N	Y
E2618	EP		PO WC access., solid seat suppbase, use w/ man WC or lightweight power WC, w/mounting hw	6		N	N	Y
E2619	NU		Replacement cover for wheelchair seat cushion or back cushion, each	H		N	N	N
E2619	EP		Replacement cover for wheelchair seat cushion or back cushion, each	6		N	N	N
E8000	EP		Gait trainer, pediatric size, posterior support, w/all accessories and components, 14 in.	6		N	N	N
E8000	EP	U1	Gait trainer, pediatric size, posterior support, w/all accessories and components, 19 in.	6		N	Y	N
E8000	EP	U2	Gait trainer, pediatric size, posterior support, w/all accessories and components, intermediate	6		N	Y	N
E8001	EP		Gait trainer, pediatric size, upright support, w/all accessories and components, 14 in.	6		N	N	N
E8001	EP	U1	Gait trainer, pediatric size, upright support, w/all accessories and components, 19 in.	6		N	Y	N
E8001	EP	U2	Gait trainer, pediatric size, upright support, w/all accessories and components, intermediate	6		N	Y	N
E8002	EP		Gait trainer, pediatric size, anterior support, w/all accessories and components, 14 in.	6		N	N	N
E8002	EP	U1	Gait trainer, pediatric size, anterior support, w/all accessories and components, 19 in.	6		N	Y	N
E8002	EP	U2	Gait trainer, pediatric size, anterior support, w/all accessories and components, intermediate	6		N	Y	N
K0630	NU		SO, flexible, pelvic-sacral supp, w/straps, closures, prefab, including fitting & adjustment	H		N	N	N
K0630	EP		SO, flexible, pelvic-sacral supp, w/straps, closures, prefab, including fitting & adjustment	6		N	N	N
K0631	NU		SO, flexible, pelvic-sacral supp, including straps, closures, prefab, including fitting & adjustment	H		N	N	N
K0631	EP		SO, flexible, pelvic-sacral supp, including straps, closures, prefab, including fitting & adjustment	6		N	N	N
K0632	NU		SO, flexible, pelvic-sacral supp, panels over sac & abd, w/straps, closures, prefab, fit & adjust	H		N	N	N
K0632	EP		SO, flexible, pelvic-sacral supp, panels over sac & abd, w/straps, closures, prefab, fit & adjust	6		N	N	N
K0633	NU		SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab	H		N	N	Y
K0633	EP		SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab	6		N	N	Y
K0634	NU		SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab	H		N	N	N
K0634	EP		SO, flexible, pelvic-sacral supp, w/panels over sac & abdom, w/straps, closures, cust fab	6		N	N	N
K0635	NU		LO, sagittal control, rigid panels, L1 to L5 vert, prod intracavitary pressure, prefab, fit & adjust	H		N	N	N
K0635	EP		LO, sagittal control, rigid panels, L1 to L5 vert, prod intracavitary pressure, prefab, fit & adjust	6		N	N	N
K0636	NU		LO, sagittal control, w/rigid ant-pos panel, L1to L5 vert, prod intracavitary press, prefab, fit & adjust	H		N	N	N
K0636	EP		LO, sagittal control, w/rigid ant-pos panel, L1to L5 vert, prod intracavitary press, prefab, fit & adjust	6		N	N	N
K0637	NU		LSO, flex, lumbar suppt, sacro-coccygeal junc-T9 Vert, w/straps, clsrs, pad, stays, prefab, fit & adjust	H		N	N	N
K0637	EP		LSO, flex, lumbar suppt, sacro-coccygeal junc-T9 Vert, w/straps, clsrs, pad, stays, prefab, fit & adjust	6		N	N	N
K0638	NU		LSO, flex, lumbar suppt, sacrococcygeal junc-T9 Vert, w/stay, straps, pend abdom dsgn, cusfab	H		N	N	Y
K0638	EP		LSO, flex, lumbar suppt, sacrococcygeal junc-T9 Vert, w/stay, straps, pend abdom dsgn, cusfab	6		N	N	Y
K0639	NU		LSO, sagittal ctrl, w/panels, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust	H		N	N	N
K0639	EP		LSO, sagittal ctrl, w/panels, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust	6		N	N	N
K0640	NU		LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust	H		N	N	N
K0640	EP		LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust	6		N	N	N
K0641	NU		LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, cust fab	H		N	N	Y
K0641	EP		LSO, sagittal ctrl, w/ant-pos panel, sacrococcygeal junc-T9 Vert, w/stay, straps, cust fab	6		N	N	Y
K0642	NU		LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust	H		N	N	N
K0642	EP		LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, w/stay, straps, prefab, fit & adjust	6		N	N	N
K0643	NU		LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigd, w/stay, straps, custfab	H		N	N	Y
K0643	EP		LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigd, w/stay, straps, custfab	6		N	N	Y
K0644	NU		LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigid, w/stay, straps, prefab, fit & adj	H		N	N	N
K0644	EP		LSO, sagittal ctrl, w/pos panl, sacrococcygeal junc-T9 Vert, rigid, w/stay, straps, prefab, fit & adj	6		N	N	N
K0645	NU		LSO, sagittal-coronal control, lumbar flex, rigid, sacrococcygeal junc-T9 Vert, w/straps, cust fab	H		N	N	N
K0645	EP		LSO, sagittal-coronal control, lumbar flex, rigid, sacrococcygeal junc-T9 Vert, w/straps, cust fab	6		N	N	N
K0646	NU		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, w/straps, prefab & fitting	H		N	N	N
K0646	EP		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, w/straps, prefab & fitting	6		N	N	N
K0647	NU		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft pad, cust fab	H		N	N	N
K0647	EP		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft pad, cust fab	6		N	N	N
K0648	NU		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, prefab/fitting	H		N	N	N
K0648	EP		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, prefab/fitting	6		N	N	N
K0649	NU		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, cust fab	H		N	N	N
K0649	EP		LSO, sagittal-coronal cntrl, rigid, sacrococcygeal junc-T9 Vert, may incld soft interface, cust fab	6		N	N	N
L1932	NU		AFO, rigid anterior tibial section, total Carbon fiber or = material, prefab, w/fitting and adjustment	H		N	N	N
L1932	EP		AFO, rigid anterior tibial section, total Carbon fiber or = material, prefab, w/fitting and adjustment	6		N	N	N
L2005	NU		KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab	H		N	N	N
L2005	EP		KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab	6		N	N	N
L2232	NU		KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab	H		N	N	Y
L2232	EP		KAFO, any material, single/double upright stance ctrl, w/ankle joint, any type, cust fab	6		N	N	Y
L4002	NU		Replacement strap, any orthosis, includes all components, any length, any type	H		N	N	Y
L4002	EP		Replacement strap, any orthosis, includes all components, any length, any type	6		N	N	Y
L5685	NU		Add to lower extremity prosthesis, below knee, suspension/sealing sleeve, w/ or w/out valve, ea	H		N	N	Y
L5685	EP		Add to lower extremity prosthesis, below knee, suspension/sealing sleeve, w/ or w/out valve, ea	6		N	N	Y
T4521	NU		Adult sized disposable incontinence product, brief/diaper, small, each	H		N	N	N
T4522	NU		Adult sized disposable incontinence product, brief/diaper, medium, each	H		N	N	N
T4523	NU		Adult sized disposable incontinence product, brief/diaper, large, each	H		N	N	N
T4524	NU		Adult sized disposable incontinence product, brief/diaper, extra large, each	H		N	N	N
T4526	NU		Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each	H		N	N	N
T4526	EP		Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each	6		N	N	N
T4527	NU		Adult sized disposable incontinence product, protective underwear/pull-on, large size, each	H		N	N	N
T4527	EP		Adult sized disposable incontinence product, protective underwear/pull-on, large size, each	6		N	N	N
T4528	NU		Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea	H		N	N	N
T4528	EP		Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, ea	6		N	N	N
T4529	EP		Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each	6		N	N	N
T4529	EP	U1	Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each	6		N	N	N
T4530	EP		Pediatric sized disposable incontinence product, brief/diaper, large size, each	6		N	N	N
T4531	EP		Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea	6		N	N	N
T4531	EP	U1	Pediatric disposable incont product, protective underwear/pull-on, reusable, sm/med size, ea	6		N	N	N
T4532	EP		Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each	6		N	N	N
T4532	EP	U1	Pediatric disposable incont product, protective underwear/pull-on, reusable, large size, each	6		N	N	N
T4533	EP		Youth sized disposable incontinence product, brief/diaper, each	6		N	N	N
T4535	NU		Disposable liner/shield/guard/pad/undergarment, for incontinence, each	H		N	N	N
T4535	NU	U1	Disposable liner/shield/guard/pad/undergarment, for incontinence, each	H		N	N	N
T4535	EP		Disposable liner/shield/guard/pad/undergarment, for incontinence, each	6		N	N	N
T4535	EP	U1	Disposable liner/shield/guard/pad/undergarment, for incontinence, each	6		N	N	N

X.HCPCS Procedure Codes Payable to Rehabilitation Centers

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
03 G28			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	G		N	N	N

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

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
C9218			Injection, azacitidine, per 1 mg	G	003	N	0	Y
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	T		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	T		N	N	N
G0363			Irrigation of implanted venous access device for drug delivery systems	G		N	N	N
G0365			Vessel mapping of vessels for hemodialysis access	T		N	N	N
J7344			Dermal tissue, human origin, w/ or w/out other bioengineered or processed elements, per sq cm	G		Y	N	N
J7518			Mycophenelic acid, oral, 180 mg	G	003	N	N	N
S2348			Decomp proc, percu, nucleas pulposus intervert disc, radiofreq energy, single/multiple lvls, lumbar	G		N	N	N

XII.HCPCS Procedure Codes Payable to Hyperalimentation

Effective for dates of service on and after August 1, 2005, providers of hyperalimentation services may bill electronically, using the procedure codes shown below. For instructions on electronic billing, providers may consult section III of their program manual.

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
B4035			Enteral feeding supply kit; pump, fed, per day	9		N	Y	N
B4149	U9		Enteral formula, blenderized natural foods w/intact nutrients, adm with enteral feeding tube	9		N	Y	N
B4150	U9		Enteral formula, nutritionally complete w/intact nutrients, adm via enteral feeding tube, 100 cal = 1 unit	9		N	Y	N
B4152	U9		Enteral formula, nutritionally complete, calorically dense, adm via enteral feeding tube, 100 cal = 1 unit	9		N	Y	N
B4153	U9		Enteral formula, nutritionally complete, hydrolyzed proteins, adm via enteral feeding tube, 100 cal = 1 unit	9		N	Y	N
B4154	U9		Enteral formula, nutritionally complete, special metabolic needs, adm via enteral feeding tube, 100 cal = 1 unit	9		N	Y	N
B4155	U9		Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit	9		N	N	N
B4155	U9	U1	Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit	9		N	Y	N
B4155	U9	U2	Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit	9		N	Y	N
B4155	U9	U3	Enteral formula, nutritionally incomplete/modular nutrients via enteral tube, 100 cal = 1 unit	9		N	Y	Y
B4158	U9		Enteral formula, pediatrics, nutrition complete adm w/enteral feeding tube, 100 cal = 1 unit	9		N	Y	N
B4159	U9		Enteral form/pediatrics/nutrition comp/soy based, adm w/enteral feeding tube, 100 cal/1 unit	9		N	Y	N
B4160	U9		Enteral form/pediatrics/nutrition comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit	9		N	Y	N
B4160	U9	U1	Enteral form/pediatrics/nutrition comp/cal dense, adm w/enteral feeding tube, 100 cal/1 unit	9		N	Y	N
B4161	U9		Enteral formula, pediatrics, administered through an enteral feeding tube, 100 cal = 1 unit	9		N	Y	N
B4162	U9		Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit	9		N	Y	N
B4162	U9	U1	Enteral form/pediatrics, special metabolic needs, adm by enteral feed tube, 100 cal/1 unit	9		N	Y	N
B9000	U9		Enteral nutrition infusion pump, w/o alarm	9		N	Y	N
B9002	U9		Enteral nutrition infusion pump, w/alarm	9		N	Y	N
E1340	U9		Repair or nonroutine svc for DME, labor component	9		N	Y	N

XIII.HCPCS Procedure Codes Payable to Private Duty Nursing

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
A4349			Male external catheter with integral collection compartment, extended wear, each	1		N	N	N
B4100			Food thickener, administered orally, per oz.	1		N	N	N

XIV.HCPCS Procedure Codes Payable to Nurse Practitioner

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	N		N	N	N
J0128			Injection, abarelix, 10 mg	N	003	N	N	N
J1457			Injection, gallium nitrate, 1 mg	N	003	N	N	N
J7518			Mycophenelic acid, oral, 180 mg	N	003	N	N	N
J9035			Injection, bevacizumab, 10 mg	N	003	Y	N	N
J9041			Injection, bortezomib, 0.1 mg	N	003	Y	N	N
J9055			Injection, cetuximab, 10 mg	N	003	Y	N	N
J9305			Injection, pemetrexed, 10 mg	N	003	Y	N	N
S0164			Injection, pantoprazole sodium, 40 mg	N	003	N	N	N
S0168			Injection, azacitidine, 100 mg	N	003	N	N	N

XV.HCPCS Procedure Codes Payable to Area Health Education Centers

(AHEC)

* See coverage requirements and billing procedures for this procedure code in section XXI.

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	C		N	N	N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	T		N	N	N
G0329			Electromagnetic ther, 1 or [GREATER THAN] areas, Stg 3 - 4 ulcers, post 30 days conv care	1		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	C		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	P		N	N	N
G0336			PET imag, brain imag, differential dx Alzheimer's dz w/aberrant features vs. fronto-temp dementia	T		N	N	N
G0363			Irrigation of implanted venous access device for drug delivery systems	1		N	N	N
G0364			Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS	2		N	N	N
G0364			Bone marrow aspiration with bone marrow biopsy through the same incision on the same DOS	8		N	Y	N
G0365			Vessel mapping of vessels for hemodialysis access	C		N	N	N
G0365			Vessel mapping of vessels for hemodialysis access	P		N	N	N
G0365			Vessel mapping of vessels for hemodialysis access	T		N	N	N
J0128			Injection, abarelix, 10 mg	1	003	N	N	N
J0180*			Injection, agalsidase beta, I mg	1		Y	N	N
J1457			Injection, gallium nitrate, 1 mg	1	003	N	N	N
J1931*			Injection, laronidase, 0.1 mg	1		Y	N	N
J2469			Injection, palonosetron HCI, 25 mcg	1	003	N	N	N
J3396			Injection, verteporfin, 0.1 mg	1		Y	N	N
J7518			Mycophenelic acid, oral, 180 mg	1	003	N	N	N
J9035			Injection, bevacizumab, 10 mg	1	003	Y	N	N
J9041			Injection, bortezomib, 0.1 mg	1	003	Y	N	N
J9055			Injection, cetuximab, 10 mg	1	003	Y	N	N
J9305			Injection, pemetrexed, 10 mg	1	003	Y	N	N
L8614	EP		Tracheoesophageal puncture dilator, replacement only, each	6		N	Y	Y
L8615	EP		Headset/headpiece for use with cochlear implant device, replacement	6		N	Y	Y
L8616	EP		Microphone for use with cochlear implant device, replacement	6		N	Y	Y
L8617	EP		Transmitting coil for use with cochlear implant device, replacement	6		N	Y	Y
L8618	EP		Transmitter cable for use with cochlear implant device, replacement	6		N	Y	Y
L8620	EP		Lithium ion battery for use with cochlear implant device, replacement, each	6		N	Y	Y
L8621	EP		Lithium ion battery for use with cochlear implant device, replacement, each	6		N	Y	Y
L8622	EP		Alkaline battery for use with cochlear implant device, any size, replacement, each	6		N	Y	Y
S0164			Injection, pantoprazole sodium, 40 mg	1	003	N	N	N
S0168			Injection, azacitidine, 100 mg	1	003	N	N	N
S2348			Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumber	2		N	N	N
S2348			Decomp proc, percu, nucleus pulposus intervert disc, radiofreq energy, single/multiple lvls, lumber	8		N	Y	N

XVI.HCPCS Procedure Codes Payable to Benefit Arkansas and Others

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
G0328			Colorectal CA screening; fecal-occult bld test, immunoassay, 1-3 simultaneous determinations	9		N	N	Y

XVII.HCPCS Procedure Codes Payable to ARKids First-B

2005 Codes	M1	M2	Description	T O S	Diag. List	Review Y/N	PA Y/N	MP Y/N
E2601			General use wheelchair seat cushion, width less than 22 in., any depth	H		N	N	N
E2602			General use wheelchair seat cushion, width 22 in. or greater, any depth	H		N	N	N
E2611			General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware	H		N	N	N
E2612			General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware	H		N	N	N

XVIII.Miscellaneous Changes

Several previously payable HCPCS codes have been deleted in the 2005 HCPCS conversion. Also, within some programs, local ?Z? codes had remained payable when there was no HCPCS code to replace it. Some of those codes are being replaced by a HCPCS code because during the 2005 conversion, a code has been developed that will cover the procedure or item.

The table below lists the deleted HCPCS code, any replacement code and the program(s) affected.

Deleted Code	Replacement Code	Program(s) Affected
A4347	N/A	Physician
A4521	T4521	Prosthetics
A4522	T4522	Prosthetics
A4523	T4523	Prosthetics
A4524	T4524	Prosthetics
A4526	T4526	Prosthetics
A4527	T4527	Prosthetics
A4528	T4528	Prosthetics
A4531	T4531	Prosthetics
A4532	T4532	Prosthetics
A4533	T4533	Prosthetics
A4535	T4535	Prosthetics
B4151	N/A	Prosthetics
B4156	N/A	Prosthetics
C9208	J0180	Physician, Outpatient Hospital
C9209	J1931	Physician, Outpatient Hospital
D7281	N/A	Dental
E0176	N/A	Prosthetics
E0178	N/A	Prosthetics
E0192	E2601-E2602	Prosthetics
E0962	E2611-E2612	Prosthetics
E0963	E2611-E2612	Prosthetics
E0964	E2611-E2612	Prosthetics
E0965	E2511-E2612	Prosthetics
E1013	E2293-E2294	Prosthetics
K0023	E2291	Prosthetics
K0024	N/A	Prosthetics
K0059	N/A	Prosthetics
K0081	N/A	Prosthetics
K0114	N/A	Prosthetics
K0115	N/A	Prosthetics
K0116	N/A	Prosthetics
L0476	N/A	Prosthetics
L0478	N/A	Prosthetics
L0500	K0637	Prosthetics
L0510	N/A	Prosthetics
L0515	K0635	Prosthetics
L0520	K0642	Prosthetics
L0530	NA	Prosthetics
L0540	K0644	Prosthetics
L0550	K0649	Prosthetics
L0560	N/A	Prosthetics
L0565	K0648	Prosthetics
L0600	K0630	Prosthetics
L0610	K0631	Prosthetics
L0620	K0632	Prosthetics
L2435	N/A	Prosthetics
L5674	N/A	Prosthetics
L5675	N/A	Prosthetics
L5846	N/A	Prosthetics
L8490	N/A	Prosthetics
Q0182	N/A	Physician, Podiatry, Outpatient Hospital
S0115	N/A	Physician, Outpatient Hospital, Nurse Practitioner
S2113	N/A	Surgery, Assistant Surgeons, Outpatient Hospital

The following table lists the deleted local code and the HCPCS code that has been assigned to replace the code. The third column lists the program affected.

Deleted Code	Replacement Code	Program(s) Affected
Z2090	E8000	Prosthetics
Z2091	E8001	Prosthetics
Z2092	E8002	Prosthetics
Z2157	E2619	Prosthetics
Z2158	E2619	Prosthetics
Z2699	B9998, EP, U1	Hyperalimentation
Z2700	B9998, EP, U2	Hyperalimentation
Z2702	B9998, EP, U3	Hyperalimentation
Z2703	B9998, EP, U4	Hyperalimentation
Z2704	B9998, EP, U5	Hyperalimentation
Z2705	B9998, EP U6	Hyperalimentation
Z2706	B9998, EP, U7	Hyperalimentation
Z2714	B9998, EP, U8	Hyperalimentation

NOTE: One CPT procedure code, 69949, is being replaced by HPCPS procedure code L8614, described as ?cochlear device/system.? The CPT procedure code remains payable for other than the cochlear implant device.

XIX.Non-Covered HCPCS Procedure Codes

The following codes are not covered by Arkansas Medicaid.

A4520	D5226	E2603	G9018	L7181
A7040	D6094	E2604	G9019	L8515
A7041	D6190	E2605	G9020	S0109
A7527	D6194	E2606	G9035	S0117
A9152	D6205	E2607	G9036	S0160
A9153	D6214	E2608	G9037	S0162
A9180	D6624	E2609	J0135	S0166
B4102	D6634	E2610	J2357	S0167
B4103	D6710	E2613	J2794	S0194
B4104	D6794	E2614	J3110	S0196
C9211	D7283	E2615	J7304	S0515
C9212	D7288	E2616	J7611	S0618
C9704	D7311	E2617	J7612	S2082
D0416	D7321	E2620	J7613	S2083
D0421	D7511	E2621	J7614	S2215
D0431	D7521	G0110	J7616	S3890
D0475	D7953	G0111	J7617	S4042
D0476	D7963	G0112	J7674	S8093
D0477	D9942	G0113	J8501	S8301
D0478	E0118	G0114	J8565	S9976
D0479	E0464	G0115	K0628	S9977
D0481	E0637	G0116	K0629	S9988
D0482	E0639	G0330	K0630	T4525
D0483	E0640	G0331	K0669	T4534
D0484	E0849	G0339	L5856	T4536
D0485	E1039	G0340	L5857	T4537
D2915	E1229	G0341	L6694	T4538
D2934	E1239	G0342	L6695	T4539
D2971	E1841	G0343	L6696	T4540
D2975	E2205	G0344	L6697	T4541
D5225	E2370	G9017	L6698	T4542
				V2702

XX.Non-Covered Procedure Codes with Elements of CPT or Other Codes

The following codes are non-covered because they contain elements of CPT procedure codes or other HCPCS procedure codes already covered by Arkansas Medicaid.

A4223	C1772	C2620	C9430	G0349
A4605	C1773	C2621	C9431	G0350
A4644	C1776	C2622	C9432	G0351
A4645	C1777	C2625	C9433	G0353
A4646	C1778	C2626	C9435	G0354
B9999	C1779	C2627	C9437	G0355
C1093	C1780	C2628	C9438	G0356
C1305	C1781	C2629	C9439	G0357
C1713	C1782	C2630	C9713	G0358
C1714	C1784	C2631	C9716	G0359
C1715	C1785	C2634	C9718	G0360
C1721	C1786	C2635	C9719	G0361
C1722	C1787	C2636	C9720	G0362
C1724	C1788	C9205	C9721	G0366
C1725	C1789	C9206	C9722	G0367
C1726	C1813	C9220	E0769	G0368
C1727	C1815	C9221	G0260	G9013
C1728	C1816	C9222	G0308	G9014
C1729	C1817	C9399	G0309	G9021
C1730	C1874	C9400	G0310	G9022
C1731	C1875	C9401	G0311	G9023
C1732	C1876	C9402	G0312	G9024
C1733	C1877	C9403	G0313	G9025
C1750	C1878	C9404	G0314	G9026
C1751	C1879	C9405	G0315	G9027
C1752	C1880	C9410	G0316	G9028
C1753	C1881	C9411	G0317	G9029
C1754	C1882	C9413	G0318	G9030
C1755	C1883	C9414	G0319	G9031
C1756	C1885	C9415	G0320	G9032
C1757	C1887	C9417	G0321	G9034
C1758	C1891	C9418	G0322	K0628
C1759	C1892	C9419	G0323	K0629
C1760	C1893	C9420	G0324	S0116
C1762	C1894	C9421	G0325	S0158
C1763	C1895	C9422	G0326	S0159
C1764	C1896	C9423	G0327	S0161
C1766	C1897	C9424	G0337	S0257
C1767	C1898	C9425	G0338	S2152
C1768	C1899	C9426	G0345	S9097
C1769	C2615	C9427	G0346	S9482
C1770	C2617	C9428	G0347	T2049
C1771	C2619	C9429	G0348

XXI.Coverage and Billing Requirements for Procedure Codes J0180 and J1931

Coverage Requirements

Special criteria for coverage of these two injections apply.

Procedure code J0180 ? Adgalsidase beta, per 1 mg is covered for treatment of Fabry?s disease, ICD-9-CM diagnosis code 272.7.

Procedure code J1931 ? Laronidase, per 2.9 mg is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5.

The injections may be provided in the outpatient hospital or emergency room. If the physician provides the service in the office, the following conditions apply:

The provider must have nursing staff available to monitor the patient?s vital signs during the infusion.

The provider must be able to treat anaphylactic shock in the treatment area where the drugs are infused.

Prior Approval and Billing Procedures

Providers must obtain prior approval for the use of J0180 and J1931 in accordance with the following procedures:

When the physician determines the injection is needed for a Medicaid-eligible patient, he or she must obtain prior approval from the Medical Director for the Division of Medical Services (DMS) before beginning therapy.

The Medical Director?s prior approval is necessary to ensure payment of the provider?s charges.

The provider must submit a history and physical examination with the treatment protocol before beginning the treatment.

Send all requests for prior approval to: Division of Medical Services P. O. Box 1437, Slot S472

Attention: Medical Director

The provider will be notified by mail of the DMS Medical Director?s decision.

Claims for prior-approved therapeutic agents must be submitted to EDS on paper.

Each claim must reflect, in the description of service field, the number in the treatment series of each administration for which you are billing Medicaid.

No prior approval authorization number is issued; therefore, a copy of the Medical Director?s approval letter must be attached to each claim filed.

The physician must supply the hospital a copy of the Medical Director?s approval letter if the administration is to be provided at the outpatient hospital (POS 22) or the emergency room (POS 23).

Paper versions of this update transmittal have updated pages attached to file in your provider manual. See Section I for instructions on updating the paper version of the manual. For electronic versions, these changes will be automatically incorporated.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 or 1-877-708 -8191. Both telephone numbers are voice and TDD.

If you have questions regarding this transmittal, please contact the EDS Provider Assistance Center at 1-800-457 -4454 (Toll-Free) within Arkansas or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals (including update transmittals), official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

_______________________________________________

Roy Jeffus, Director

016.06.05 Ark. Code R. § 053

7/14/2005