016-06-16 Ark. Code R. § 1

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

Rule 016.06.16-001 - Notice of Rule Making 002-15 (CPT) and 003-15 (HCPCS) Conversion Notices

I.General Information

A review of the 2015 HCPCS procedure codes has been completed and the Arkansas Medicaid Program will begin accepting updated Healthcare Common Procedural Coding System Level II (HCPCS) procedure codes on claims with dates of service on and after December 18, 2015. Drug procedure codes require National Drug Code (NDC) billing protocol. Drug procedure codes that represent radiopharmaceuticals, vaccines and allergen immunotherapy are exempt from the NDC billing protocol.

Procedure codes that are identified as deletions in 2015 HCPCS Level II will become non-payable for dates of service on and after December 18, 2015.

Please NOTE: The Arkansas Medicaid website fee schedules will be updated soon after the implementation of the 2015 CPT and HCPCS conversions.

II.2015 HCPCS Payable Procedure Codes Tables Information

Procedure codes are in separate tables. Tables are created for each affected provider type (i.e., prosthetics, home health, etc.).

The tables of payable procedure codes for all affected programs are designed with eight columns of information. All columns may not be applicable for each covered program, but are devised for ease of reference.

Please NOTE: An asterisk indicates that the procedure code requires a paper claim.

1. The first column of the list contains the HCPCS procedure codes. The procedure code may be on multiple lines on the table, depending on the applicable modifier(s) based on the service performed.

2. The second column indicates any modifiers that must be used in conjunction with the procedure code, when billed, either electronically or on paper.

3. The third column indicates that the coverage of the procedure code is restricted based on the beneficiary's age in number of years.

4. Certain procedure codes are covered only when the primary diagnosis is covered within a specific ICD diagnosis range. This information is used, for example, by physicians and hospitals. The fourth column, for all affected programs, indicates the beginning and ending range of ICD CM diagnoses for which a procedure code may be used.

5. The fifth column contains information about the diagnosis list for which a procedure code may be used. (See Section V of this notice for more information about diagnosis range and lists.)

6. The sixth column indicates whether a procedure is subject to medical review before payment. The column is titled "Review." The word "Yes" or "No" in the column indicates whether a review is necessary or not. Providers should consult their program manual to obtain the information that is needed for a review.

7. The seventh column shows procedure codes that require prior authorization (PA) before the service may be provided. The column is titled "PA." The word "Yes" or "No" in the column indicates if a procedure code requires prior authorization. Providers should consult their program manual to ascertain what information should be provided for the prior authorization process.

8. The eighth column indicates a procedure code requires a prior approval letter from the Arkansas Medicaid Medical Director for Clinical Affairs for the Division of Medical Services. The word "Yes" or "No" in the column indicates if a procedure code requires a prior approval letter.

III.Acquisition of Prior Approval Letter

A prior approval letter, when required, must be attached to a paper claim when it is filed. Providers must obtain prior approval in accordance with the following procedures for special pharmacy, therapeutic agents and treatments:

A. Process for Acquisition: Before treatment begins, the Medical Director for Clinical Affairs in the Division of Medical Services (DMS) must approve any drug, therapeutic agent or treatment not listed as covered in a provider manual or in official DMS correspondence. This requirement also applies to any drug, therapeutic agent or treatment with a prior approval letter indicated for coverage in a provider manual or official DMS correspondence.

B. The Medical Director for Clinical Affairs' review is necessary to ensure approval for medical necessity. Additionally, all other requirements must be met for reimbursement.

1. The provider must submit a history and physical examination with the treatment plan before beginning any treatment.

2. The provider will be notified by mail of the DMS Medical Director for Clinical Affairs' decision. No prior authorization number is assigned if the request is approved, but a prior approval letter is issued and must be attached to each paper claim submission.

Any change in approved treatment requires resubmission and a new prior approval letter.

3. Requests for a prior approval letter must be addressed to the attention of the Medical Director for Clinical Affairs. Contact the Medical Director for Clinical Affairs' office for any additional coverage information and instructions.

Mailing address: Attention: Arkansas Medicaid Medical Director for Clinical Affairs 1020 West 4th Street, Suite 300 Little Rock, AR 72201

Fax: 501-212-8741 Phone: 501-212-8663

IV.Process for Obtaining Prior Authorization

When obtaining a prior authorization from the Arkansas Foundation for Medical Care, please send your request to the following:

In-state and out-of-state toll free for inpatient reviews, prior authorizations for surgical procedures and assistant surgeons only	1-800-426-2234
General telephone contact, local or long distance - Fort Smith	(479) 649-8501 1-877-650 -2362
Fax for CHMS only	(479) 649-0776
Fax for Molecular Pathology only	(479) 649-9413
Fax	(479) 649-0799
Web portal	http://review.afmc.org/MedicaidReview/iEXCHANGE%c2%ae.aspx
Mailing address	Arkansas Foundation for Medical Care, Inc. P.O. Box 180001 Fort Smith, AR 72918-0001
Physical site location	5111 Rogers Avenue, Suite 476 Fort Smith, AR 72903
Office hours	8:00 a.m. until 4:30 p.m. (Central Time), Monday through Friday, except holidays

V.International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), Diagnosis Range and Diagnosis Lists

Diagnosis is documented using the International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM). Certain procedure codes are covered only for a specific primary diagnosis or a particular diagnosis range. Diagnosis list 103 is specified here (View ICD Codes.). For any other diagnosis restrictions, reference the table for each individual program.

VI.Dental

The following 2015 ADA Dental procedure codes are not covered by Arkansas Medicaid.

D0171	D0351	D1353	D6110	D6111	D6112	D6113	D6114
D6115	D6116	D6117	D6549	D9219	D9931	D9986	D9987

VII.HCPCS Procedure Codes Payable to End-Stage Renal Disease Providers

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

Procedure Code	Modifier	Age Restriction	Diagnosis Diagnosis List	Review	PA	Prior Approval Letter
J0887	No	21y & up	Yes; see No	No	No	No

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

J0888

No

21y & up

View ICDNo Codes.

No

No

No

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

VIII.HCPCS Procedure Codes Payable to Home Health Providers

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

Procedure Code	Modifier	Age Restriction	Diagnosis Diagnosis List	Review	PA	Prior Approval Letter
J0887	No	21y & up	Yes; see No below	No	No	No

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

J0888

No

21y & up

View ICDNo Codes.

No

No

No

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

IX.HCPCS Procedure Codes Payable to Hospitals

The following information is related to procedure codes payable to Hospital providers:

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
C9025 C9026	No No	18y & up 18y & up	No View ICD Codes.	103 No	No Yes	No No	No Yes

NOTE: Entyvio is an integrin receptor antagonist for adult ulcerative colitis (UC). For adults with UC it must be moderately to severely active and have had an inadequate response with, or lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids:

1) inducing and maintaining clinical response;

2) inducing and maintaining clinical remission;

3) improving endoscopic appearance of the mucosa; or

4) achieving corticosteroid-free remission. Patient must have tried and failed Enbrel, Humiraand Cimzia. For adults with Crohn's disease, it must be moderately to severely active with an inadequate response with, lost response to, or were intolerant to a TNF blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids:

1) achieving clinical response;

2) achieving clinical remission; or

3) achieving corticosteroid-free remission. Patient must have tried and failed Enbrel, Humiraand Cimzia. Physician must submit a history and physical exam with the Prior Approval Letter to the Medical Director for Clinical Affairs.

C9027

No

18y & up

Yes

103

Yes

No

Yes

NOTE: Keytruda is a human programmed death receptor-1 (PD-1)-blocking antibody indicated for the treatment of patients with unresectable or metastatic melanoma (View ICD Codes.) and disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor, in adult patients. The maximum dose is 2mg/kg. There will not be approvals for over this dose. If the patient is on high dose corticosteroids, Keytruda should be discontinued. If the patient has disease progression, Keytruda should be discontinued. Medical records documenting a history and physical exam showing use of ipilimumab first or a BRAF inhibitor should be forwarded to the Medical Director for Clinical Affairs. The patient should have a prognosis of 6 months. All treatments should be included in the medical records. Prior surgeries or other chemotherapeutics should be documented. A letter of Prior Approval will be approved for the length of treatment.

C9136	No	No	View ICD Codes.	No	No	No	No
C9349	No	No	No	No	No	No	No
C9442	No	18y & up	View ICD Codes.	No	Yes	No	Yes

NOTE: Beleodaqis a histone decacetylase inhibitor indicated for the treatment of adult patients with relapsed or refractory peripheral T-cell lymphoma (PTCL). All previous treatments should be documented. A complete history and physical exam documenting previous treatments and results should be submitted to the Medical Director for Clinical Affairs for a Prior Approval letter. Length of treatment should be specified.

C9443 No 18y & up	No	No	No	No	No
C9444 No 18y & up	No	No	No	No	No
C9446 No 18y & up	No	No	No	No	No
C9739 No No	No	No	No	No	No
NOTE: Covered for males only.
C9740 No No	No	No	No	No	No
NOTE: Covered for males only.
G6015 No No	No	No	No	No	No
J0153 No No	No	No	No	No	No
J0887 No 21y & up	Yes; see	No	No	No	No

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

Procedure Code	Modifier Age Restriction	Diagnosis	Diagnosis List	Review PA	Prior Approval Letter
J0888	No 21y & up	View ICD Codes.	No	No No	No

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

J1071 No	No	No	View ICD Codes.	No	No	No
J1439 No	18y & up	View ICD Codes.	No	No	No	No
J2274 No	No	No	No	No	No	No
J2704 No	3y & up	No	No	No	No	No
J3121 No	No	No	103	No	No	No
NOTE: Covered for males only.
J3145 No	No	No	103	No	No	No
NOTE: Covered for males only.
J7181 No	No	View ICD Codes.	No	No	No	No
J7201 No	No	No	No	No	No	No
J7327 No	18y & up	No	No	No	Yes	No

NOTE: Prior authorization is required for coverage of the Hyaluronon injection in the physician's office for procedure codes J7321, J7323, J7324, J7325 and J7327. Providers must specify the brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization for this procedure code. A written request must be submitted to the Division of Medical Services Utilization Review Section. Refer to the Utilization Review prior authorization information in the provider manual. The request must include the patient's name, Medicaid ID number, physician's name, physician's Arkansas Medicaid provider identification number, patient's date of birth and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one injection or series of injections per knee, per beneficiary, per lifetime.

J9267	No	No	No	103	No	No	No
J9301	No	18y &up	View ICD Codes.	No	Yes	No	Yes

NOTE: Gazyvais a CD-20 directed cytolytic antibody and is indicated, in combinations witii ciilorambucil, fertile treatment of adult patients with previously untreated chronic lymphocytic leukemia. Patients should have a protocol with chlorambucil and a history and physical exam covering all treatments including failures to submit to the Medical Director for Clinical Affairs for a Prior Approval Letter. Dates of Service need to be included.

Q4150	No	No	No	No	No	No	No
Q4152	No	No	No	No	No	No	No
Q4157	No	No	No	No	No	No	No
Q4160	No	No	No	No	No	No	No

X.HCPCS Procedure Codes Payable to Independent Radiology

The following information is related to procedure codes payable to Independent Radiology providers:

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
G6015	No	No	No	No	No	No	No

XI.HCPCS Procedure Codes Payable to Nurse Practitioners

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

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
G6015 J0887	No No	No 21y & up	No Yes; see	No No	No No	No No	No No

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

J0888

No

21y & up

View ICD Codes.

No

No

No

No

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 1 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

J3121	No	No	No	103	No	No	No
NOTE: Covered for males only.
J3145	No	No	No	103	No	No	No
NOTE: Covered for males only.
J9267	No	No	No	103	No	No	No

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

The following information is related to procedure codes payable to Physician and AHEC providers:

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
C9025 C9026	No No	18y & up 18y & up	No View ICD Codes.	103 No	No Yes	No No	No Yes

NOTE: Entyvio is an integrin receptor antagonist for adult ulcerative colitis (UC). For adults with UC it must be moderately to severely active and have had an inadequate response with, or lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids:

1) inducing and maintaining clinical response;

2) inducing and maintaining clinical remission;

3) improving endoscopic appearance of the mucosa; or

4) achieving corticosteroid-free remission. Patient must have tried and failed Enbrel, Humira and Cimzia. For adults with Crohn's disease, it must be moderately to severely active with an inadequate response with, lost response to, or were intolerant to a TNF blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids:

1) achieving clinical response;

2) achieving clinical remission; or

3) achieving corticosteroid-free remission. Patient must have tried and failed Enbrel, Humira and Cimzia. Physician must submit a history and physical exam with the Prior Approval Letter to the Medical Director for Clinical Affairs.

C9027

No

18y & up

Yes

103

Yes

No

Yes

NOTE: Keytruda is a human programmed death receptor-1 (PD-1)-blocking antibody indicated for the treatment of patients with unresectable or metastatic melanoma (View ICD Codes.) and disease progression following ipilimumab and, if BRAF V600 mutation positive, a BRAF inhibitor, in adult patients. The maximum dose is 2mg/kg. There will not be approvals for over this dose. If the patient is on high dose corticosteroids, Keytruda should be discontinued. If the patient has disease progression, Keytruda should be discontinued. Medical records documenting a history and physical exam showing use of ipilimumab first or a BRAF inhibitor should be forwarded to the Medical Director for Clinical Affairs. The patient should have a prognosis of 6 months. All treatments should be included in the medical records. Prior surgeries or other chemotherapeutics should be documented. A letter of Prior Approval will be approved for the length of treatment.

C9136	No	No	View ICD Codes.	No	No	No	No
C9349	No	No	No	No	No	No	No
C9442	No	18y & up	View ICD Codes.	No	Yes	No	Yes

NOTE: Beleodaq is a histone decacetylase inhibitor indicated for the treatment of adult patients with relapsed or refractory peripheral T-cell lymphoma (PTCL). All previous treatments should be documented. A complete history and physical exam documenting previous treatments and results should be submitted to the Medical Director for Clinical Affairs for a Prior Approval letter. Length of treatment should be specified.

C9443	No	18y & up	No	No	No	No	No
C9444	No	18y & up	No	No	No	No	No
C9446	No	18y & up	No	No	No	No	No
C9739	No	No	No	No	No	No	No
NOTE: Covered for males only.
C9740	No	No	No	No	No	No	No
NOTE: Covered for males only.
G6015	No	No	No	No	No	No	No
J0153	No	No	No	No	No	No	No
J0887	No	21y & up	Yes; see below	No	No	No	No

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

J0888

No

21y & up

View ICD Codes.

No

No

No

No

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

J1071	No	No	No	103	No	No	No
J1439	No	18y & up	View ICD Codes.	No	No	No	No
J2274	No	No	No	No	No	No	No
J3121	No	No	No	103	No	No	No
NOTE: Covered for males only.
J3145	No	No	No	103	No	No	No
NOTE: Covered for males only.
J7181	No	No	View ICD Codes.	No	No	No	No
J7201	No	No	No	No	No	No	No
J7327	No	18y & up	No	No	No	Yes	No

NOTE: Prior authorization is required for coverage of the Hyalurononinjection in the physician's office for procedure codes J7321, J7323, J7324, J7325 and J7327. Providers must specify the brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization for this procedure code. A written request must be submitted to the Division of Medical Services Utilization Review Section. Refer to the Utilization Review prior authorization information in the provider manual. The request must include the patient's name, Medicaid ID number, physician's name, physician's Arkansas Medicaid provider identification number, patient's date of birth and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one injection or series of injections per knee, per beneficiary, per lifetime.

J9267

No

No

No

103

No

No

No

J9301

No

18y &up

View ICD Codes.

No

Yes

No

Yes

NOTE: Gazyvais a CD-20 directed cytolytic antibody and is indicated, in combinations witii ciilorambucil, fertile treatment of adult patients with previously untreated chronic lymphocytic leukemia Patients should have a protocol with chlorambucil and a history and physical exam covering all treatments including failures to submit to the Medical Director for Clinical Affairs for a Prior Approval Letter. Dates of Service need to be included.

Q4150	No	No	No	No	No	No	No
Q4152	No	No	No	No	No	No	No
Q4157	No	No	No	No	No	No	No
Q4160	No	No	No	No	No	No	No

XIII.HCPCS Procedure Codes Payable to Podiatrists

The following information is related to procedure codes payable to Podiatrist providers:

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
C9349	No	No	No	No	No	No	No
Q4150	No	No	No	No	No	No	No
Q4152	No	No	No	No	No	No	No
Q4157	No	No	No	No	No	No	No
Q4160	No	No	No	No	No	No	No

XIV.HCPCS Procedure Codes Payable to Prosthetics Providers

The following information is related to procedure codes payable to Prosthetics providers:

Procedure codes in the table must be billed with appropriate modifiers. For procedure codes that require a prior authorization, the written PA request must be submitted to the Utilization Review Section of the Division of Medical Services (DMS) for wheelchairs and wheelchair related equipment and services.

For other durable medical equipment (DME), a written request must be submitted to the Arkansas Foundation for Medical Care. Please refer to your Arkansas Medicaid Prosthetics Provider Manual for details on requesting a DME prior authorization.

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
K0901	EP	0-20y	No	No	No	No	No
K0901	No	21y & up	No	No	No	Yes	No
K0902	EP	0-20y	No	No	No	No	No
K0902	No	21y & up	No	No	No	Yes	No
L3981	EP	0-20y	No	No	No	No	No
L3981	No	21y & up	No	No	No	No	No
L7259	EP	0-20y	No	No	No	No	No
L7259	No	21y & up	No	No	No	Yes	No

XV.HCPCS Procedure Codes Payable to Transportation Providers

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

Procedure Code	Modifier	Age Restriction	Diagnosis Diagnosis List	Review	PA	Prior Approval Letter
J0153	No	No	No No	No	No	No

XVI.Miscellaneous Information

An asterisk (*) after the procedure code denotes the requirement of a paper claim.

A. Existing HCPCS procedure codes A6208, A6250, A6266 and A6457 are payable to Prosthetics and Home Health providers:

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
A6208	NU	No	No	No	No	No	No
A6250	NU	No	No	No	No	No	No
A6266	NU	No	No	No	No	No	No
A6457	NU	No	No	No	No	No	No

B. Effective July 1, 2015, for beneficiaries age 21 and over, a benefit limit of $60,000 per State Fiscal Year (July 1 through June 30) has been established for reimbursement for prosthetic devices. When the Medicaid maximum allowable for a prosthetic device item is $1,000 or more, prior authorization is required.

C. ICD code (View ICD Codes.) has been added to existing HCPCS procedure code J0490. All other criteria remain unchanged:

Procedure Code	Modifier	Age Restriction	Diagnosis Diagnosis List	Review	PA	Prior Approval Letter
J0490	No	18y & up	View ICDNo Codes.	Yes	No	Yes

NOTE: This drug is indicated for treatment of patients age 18 years and above with active,

autoantibody-positive, systemic lupus erythematosus who are receiving standard therapy, such as non-steroidal anti-inflammatory drugs, hydroxychloroquine, corticosteroids or immunosuppressive drugs. Use of this drug is not recommended for use in combination with other biologics or intravenous cyclophosphamide, or patients with severe active lupus nephritis, or severe active central nervous system lupus. This drug administration requires a prior approval letter which must include a history and physical exam documenting all prior treatment and documented failure of treatment. The patient should continue to receive the standard therapy. This drug should be administered by healthcare providers prepared to manage anaphylaxis and must be prescribed by a rheumatologist.

D. Existing HCPCS procedure code J1446 is now payable to Hospital, Physician, and Nurse Practitioner providers:

Procedure Code	Modifier	Age Restriction	Diagnosis Diagnosis List	Review	PA	Prior Approval Letter
J1446	No	21y & up	No No	No	No	No

E. Existing HCPCS procedure code J9228will require ICD diagnosis as listed below in the Diagnosis table:

Procedure Code	Modifier	Age Restriction	Diagnosis Diagnosis List	Review	PA	Prior Approval Letter
J9228	No	18y & up	View ICDNo Codes.	Yes	No	Yes

NOTE: Iplimumabis indicated for treatment of unresectable or metastatic melanoma. It should be given every 3 weeks for a total of four doses. Liver function tests, thyroid function and clinical chemistries must be monitored before each dose. Iplimumabshould only be prescribed by physicians who are prepared to treat immune mediated complications. Participation in the risk evaluation and mitigation program is essential. Use of Iplimumabrequires a detailed history and physical exam including all previous treatments and clear documentation that the melanoma is not treatable by surgery or has metastasized. Patients considered for treatment should be at least 18 years old and have a life expectancy of at least 4 months. It should not be used if patient had previous autoimmune disease requiring systemic therapy. A Prior Approval Letter with a history and physical exam must be sent to the Medical Director of Clinical Affairs.

F. Existing HCPCS procedure code J9047 no longer requires a Prior Approval letter. All other criteria remain unchanged:

Procedure Code	Modifier	Age Restriction	Diagnosis	Diagnosis List	Review	PA	Prior Approval Letter
J9047*	No	18y & up	View ICD Codes.	No	No	No	No

NOTE: Kyprolisis indicated for the treatment of adult patients with multiple myeloma, who have received at least two prior therapies including Velcade and an immunomodulary agent and have demonstrated disease progression on or within 60 days of completion of the last therapy. Approval is based upon response rate. A physical exam and history documenting the above requirements must be included. All monitoring and warnings and precautions from the Federal Drug Administration must be complied with for this drug to be approved. Females should avoid becoming pregnant. Consideration will be on a case-by-case basis.

XVII.Non-Covered 2015 HCPCS with Elements of CPT or Other Procedure Codes

The following new 2015 HCPCS procedure codes are not payable because these services are covered by a CPT code, another HCPCS code or a revenue code.

A9606

C2624

C2644

C9742

XVIII.Non-Covered 2015 HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

A4459	A4602	A7048
G0464	G0466	G0467
G0473	G6001	G6002
G6008	G6009	G6010
G6017	G6018	G0619
G6025	G6027	G6028
G6036	G6037	G6038
G6044	G6045	G6046
G6052	G6053	G6054
G9363	G9364	G9365
G9376	G9377	G9378
G9384	G9385	G9386
G9394	G9395	G9396
G9404	G9405	G9406
G9412	G9413	G9414
G9420	G9421	G9422
G9428	G9429	G9430
G9436	G9437	G9438
G9448	G9449	G9450
G9456	G9457	G9458
G9466	G9467	G9468
J0572	J0573	J0574
L6026	L8696	Q2052
Q4158	Q4159	S1034

C9447	C9741	G0276	G0277	G0279
G0468	G0469	G0470	G0471	G0472
G6003	G6004	G6005	G6006	G6007
G6011	G6012	G6013	G6014	G6016
G0620	G0621	G6022	G6023	G6024
G6030	G6031	G6032	G6034	G6035
G6039	G6040	G6041	G6042	G6043
G6047	G6048	G6049	G6050	G6051
G6055	G6056	G6057	G6058	G9362
G9366	G9367	G9368	G9369	G9370
G9379	G9380	G9381	G9382	G9383
G9389	G9390	G9391	G9392	G9393
G9399	G9400	G9401	G9402	G9403
G9407	G9408	G9409	G9410	G9411
G9415	G9416	G9417	G9418	G9419
G9423	G9424	G9425	G9426	G9427
G9431	G9432	G9433	G9434	G9435
G9439	G9440	G9441	G9442	G9443
G9451	G9452	G9453	G9454	G9455
G9459	G9460	G9463	G9464	G9465
G9469	G9470	G9471	G9472	J0571
J0575	J1322	J7182	J7200	J7336
Q4151	Q4153	Q4154	Q4155	Q4156
S1035	S1036	S1037	S8032	S9901

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

If you need this material in an alternative format, such as large print, please contact the Program Development and Quality Assurance Unit at (501) 320-6429.

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

Thank you for your participation in the Arkansas Medicaid Program.

____________________________________________________

Dawn Stehle Director

Summary for 2015 CPT and HCPCS Procedure Code Conversion

To comply with federal regulation 45 CFR Subpart J, Section 162.1002, these Notices of Rulemaking informs providers of the implementation of the annual Current Procedure Codes, (CPT), and the annual Healthcare Common Procedure Codes Systems, (HCPCS). These data sets are created and published by the American Medical Association and the Centers for Medicare and Medicaid on an annual basis. This Rule is necessary for consistency with the utilization of procedure codes used by Medicare and other third party payers of medical claims. These data sets are standardized and are used nationally for claims processing. This emergency notice will help expedite claims processing. Payable procedure codes will be added to the provider fee schedules and policy manuals will be updated as necessary. This will ensure that additional claims system testing will not be needed before implementation, resulting in subsequent delays and further lost efficiency of time. It will also help to put 2016 CPT/HCPCS planning, programming, testing, and promulgation processes back on its regular timelines.

Emergency filing is necessary to allow providers to bill on the 2015 codes. Due to the implementation of ICD-10, work could not begin on implementing these codes until August 2015. The work will not be completed until December 2015.

016.06.16 Ark. Code R. § 001

3/18/2016