Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-041 - ARKids First B Update Transmittal #36

Current through Register Vol. 49, No. 6, June, 2024
Section II ARKids First-B
224.200
Coinsurance
Refer to Section
				221.100 of this manual for
				services that require coinsurance.
262.110
Medical Supplies Procedure
			 Codes
The following medical supplies procedure codes may be billed by
				Medicaid-enrolled Home Health and Prosthetics providers for ARKids First-B
				participants.
Type of service (TOS) codes are used only when billing on
				paper.
A4206
A4221
A4222
A4253 U1
A4256
A4259 U2
A4265
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4322
A4326
A4327
A4328
A4330
A4338
A4340
A4344
A4346
A4348
A4351
A4352
A4354
A4355
A4356
A4357
A4358
A4359
A4361
A4362
A4364
A4367
A4369
A4371
A4397
A4398
A4399
A4400
A4402
A4404
A4405
A4406
A4450
A4452
A4455
A4558
A4561
A4562
A4623
A4624
A4625
A4626
A4628
A4629
A4772
A4927
A5051
A5052
A5053
A5054
A5055
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5093
A5102
A5105
A5112
A5113
A5114
A5120
A5121
A5122
A5126
A5131
A6154
A6234
A6241
A6242
A6248
A7520
B4086
E0776
Procedure Code
Required Modifier(s)
TOS Code
Description
A6257
-
Transparent film, each (16 square inches or
						  less)
A6258
-
Transparent film, each (more than 16, but less than 48
						  square inches)
A6259
-
Transparent film, each (more than 48 square
						  inches)
A6216 A6219 A6228
"
Gauze pads medicated or non-medicated, each (16 square
						  inches or less)
A6217 A6220 A6229
--
Gauze pads medicated or non-medicated, each (more than
						  16, but less than 48 square inches)
A6403
A6204 A6218 A6221 A6230
Gauze pads medicated or non-medicated, each (more than
						  48 square inches)
A6441 A6446
-
Gauze, non-elastic, per roll (1 linear
						  yard)
A6242 A6245
-
Hydrogel dressing, each (16 square inches or
						  less)
A6243 A6246
-
Hydrogel dressing, each (more than 16, but less than 48
						  square inches)
A6244 A6247
-
Hydrogel dressing, each (more than 48 square
						  inches)
A6248
-
Hydrogel dressing, each (1 ounce)
A6234 A6237
-
Hydrocolloid dressing, each (16 square inches or
						  less)
A6235 A6238
-
Hydrocolloid dressing, each (more than 16, but less
						  than 48 square inches)
A6238
U1
Hydrocolloid dressing, each (more than 48 square
						  inches)
A6196
-
Alginate dressing, each (16 square inches or
						  less)
A6197
-
Alginate dressing, each (more than 16, but less than 48
						  square inches)
A6198
-
Alginate dressing, each (more than 48 square
						  inches)
A6197
-
Alginate dressing, each (1 linear yard)
A6209 A6212
-
Foam dressing, each (16 square inches or
						  less)
A6210 A6213
-
Foam dressing, each (more than 16, but less than 48
						  square inches)
A6211
-
Foam dressing, each (more than 48 square
						  inches)
A6200 A6203
-
Composite dressing, each (16 square inches or
						  less)
A6201 A6204
-
Composite dressing, each (more than 16, but less than
						  48 square inches)
A6202 A6205
-
Composite dressing, each (more than 48 square
						  inches)
A4253
-
Blood glucose test or reagent strips for home blood
						  glucose monitor, per 50 strips
A4353
-
Urinary intermittent catheter with insertion
						  supplies
A4394
-
Ostomy deodorant, all types, per ounce
A4365
-
Adhesive remover wipes, any type, per 50
A4368
-
Ostomy filters, any type, each
A6449 A6452
-
Gauze elastic, all types, per roll (linear
						  yard)
A4483
-
Moisture exchange/agreer, disposable, for use with
						  invasive mech
B4100
-
H
Food thickener, administered orally, peroz.
A6549*
-
Stocking (Jobst)
*NOTE: A6549 must be prior authorized. Form DMS-699 must
				be used for the request for prior authorization.
View or print form
				DMS-699 and instructions for completion.
The costs of B4100 and
				A6549 are not subject to the $125 medical supplies monthly benefit
				limit.
The following procedure code must be utilized when billing for
				Pedia-Pop. Reimbursement for this product is provider's cost plus ten percent.
				Pedia-Pop is only for oral consumption, and only in frozen form.
Z2487
Pedia-Pop
1 unit = 1 box
Maximum = 2 units per date of service
NOTE: Pedia-Pop must be billed on paper.
262.120
Durable Medical Equipment
			 (DME) Procedure Codes
The following DME HCPCS procedure codes may be billed by
				Medicaid-enrolled prosthetics providers for ARKids First-B participants. On
				paper claims, these procedure codes may be billed with type of service (TOS)
				code (paper only) code "H", "U" (used equipment) orT (initial rental).
HCPCS code
TOS Code (paper only)
Capped rental, purchase or rental
						  only
A4635
H, U
Purchase only
A4636
H, U
Purchase only
A4637
H, U
Purchase only
E0100
H
Purchase only
E0105
H, U
Purchase only
E0110
H, U
Purchase only
E0111
H, U
Purchase only
E0112
H, U
Purchase only
E0113
H, U
Purchase only
E0114
H, U
Purchase only
E0116
H, U
Purchase only
E0130
H, U
Purchase only
E0135
H, U
Purchase only
E0140
H, U
Purchase only
E0143
H, U
Purchase only
E0147
H, U
Purchase only
E0153
H, U
Purchase only
E0154
H, U
Purchase only
E0155
H, U
Purchase only
E0157
H, U
Purchase only
E0158
H, U
Purchase only
E0161
H, U
Purchase only
E0163
H, U
Purchase only
E0164
H, U
Purchase only
E0166
H, I, U
Purchase only
E0167
H, U
Purchase only
E0175
H, U
Purchase only
E0180
H, U
Purchase only
E0181
H, I
Capped rental
E0182
H, U
Purchase only
E0184
H, U
Purchase only
E0185
H, U
Purchase only
E0189
H, U
Purchase only
E0190
H
Purchase only
E0191
H, U
Purchase only
E2601 E2602
H, U
Capped rental
E0196
H
Purchase only
E0197
H, U
Purchase only
E0200
H, I, U
Capped rental
E0202
H
Rental only
E0205
H, I, U
Capped rental
E0217
H, I, U
Capped rental
E0225
H, I, U
Capped rental
E0235
H, U
Purchase only
E0236
H, I, U
Capped rental
E0238
H, U
Purchase only
E0239
H, I, U
Capped rental
E0249
H, U
Purchase only
E0250
H, I
Capped rental
E0255
H, I, U
Capped rental
E0260
H, I, U
Capped rental
E0271
H, I, U
Capped rental
E0272
H, I
Capped rental
E0273
H, U
Purchase only
E0275
H, U
Purchase only
E0276
H, U
Purchase only
E0280
H, U
Purchase only
E0325
H, U
Purchase only
E0326
H, U
Purchase only
E0424
H, I
Rental only
E0430
H, I
Rental only
E0435
H, I
Rental only
E0439
H, I
Rental only
E0443
H
Purchase only
E0444
H
Purchase only
E0480
H, I, U
Capped rental
E0560
H, U
Purchase only
E0565
H, I, U
Capped rental
E0570
H, U
Purchase only
E0575
H, U
Capped rental
E0585
H, I, U
Capped rental
E0600
H, U
Rental only
E0605
H, U
Purchase only
E0606
H, I, U
Capped rental
E0607 U1
H, U
Purchase only
E0630
H, I, U
Capped rental
E0650
H, I, U
Capped rental
E0667
H, I
Capped rental
E0668
H, I
Capped rental
E0691
H, I
Rental only
E0692
H, I
Rental only
E0693
H, I
Rental only
E0694
H, I
Rental only
E0720
H, I, U
Capped rental
E0730
H, I, U
Capped rental
E0740
H, U
Purchase only
E0745
H, I, U
Capped rental
E0747
H, I, U
Rental only
E0840
H, U
Purchase only
E0850
H, U
Purchase only
E0860
H
Purchase only
E0870
H, U
Purchase only
E0880
H, U
Purchase only
E0890
H, U
Purchase only
E0900
H, U
Purchase only
E0910
H, I, U
Capped rental
E0920
H, I, U
Capped rental
E0930
H, I, U
Capped rental
E0935
H, I, U
Capped rental
E0940
H, I, U
Capped rental
E0941
H, I, U
Capped rental
E0942
H, U
Purchase only
E0944
H, U
Purchase only
E0945
H, U
Purchase only
E0946
H, U
Purchase only
E0947
H, U
Purchase only
E0948
H, U
Purchase only
E1130
H, I, U
Capped rental
E1140
H
Capped rental
E1150
H
Capped rental
E1160
H
Capped rental
E1224
H, I, U
Capped rental
E1390
H, I
Rental only
E1391
H, I
Rental only
E2611
H
Purchase only
E2612
H
Purchase only
Procedure Code
Required Modifier
TOS Code (paper only)
Description
Capped rental, purchase or rental
						  only
E1340
NU
H
Durable medical equipment repairs/parts only repairs
						  will not be approved for more than the allowed purchase price of new equipment.
						  (The manufacturer's invoice must be attached to the repair claim for all
						  parts.)
Manually priced
Bill on paper
H
Unlisted durable medical equipment, $500.00 and over.
						  (The manufacturer's invoice must be attached to the claim form.)
Manually priced
E0779 E0779
RR
H I
Ambulatory infusion device, payable only when services
						  are provided to patients receiving chemotherapy, pain management or antibiotic
						  treatment in the home
Rental only
A7034 A7034
RR
H I
CPAP (continuous positive airway pressure) device,
						  nasal (includes necessary accessory items)
Note: Complete medical data pertinent to the
						  request must be submitted with a prior authorization
						  request.
Rental only
E0445
-
H, I
Pulse oximeter (including 4 disposable
						  probes)
Rental only
E1340
EP, U3
6
Unlisted repairs/wheelchairs
Manually priced
E0483 E0483
UB RR
H H
High-frequency chest-wall oscillation air-pulse
						  generator system, incl
Rental only
E0483
"
H
Pulmonary vest (The manufacturer's invoice must be
						  attached to the claim form.)
Purchase only
E1340
U4
H
Maintenance for capped rental items
N/A
E1340
NU, U1
H
Labor only (a maximum of twenty (20) units per date of
						  service is allowed) (20 units = 5 hours of labor)
Manually priced
E1340
6
Labor only (a maximum of twenty (20) units per date of
						  service is allowed) (20 units = 5 hours of labor)
Manually priced
A4670
-
H
Electronic blood pressure monitor and cuff
Rental only
A4230
-
H
Infusion set for external insulin pump, non-needle
						  cannula type
Purchase only
A4213
-
H
Syringes, sterile, 20 cc or greater, each
Purchase only
Bill on paper
-
H
Power kit/batteries
Purchase only
A6021 A6022 A6023 A6024
H
Polyskin dressing
Purchase only
A4627
UB
H
Spacer bag or reservoir, with or without mask, for use
						  with metered dose inhaler
Purchase only
A4627
"
H
Spacer bag or reservoir, with mask, for use with
						  metered inhaler
Purchase only
262.140
Speech-Language Pathology Procedure Codes
Procedure Code
Required Modifier
Description
92506
Evaluation for Speech Therapy
92507
-
Individual Speech Session
92507
UB
Individual Speech Therapy by Speech Language Pathology
						  Assistant
92508
-
Group Speech Session
92508
UB
Group Speech Therapy by Speech Language Pathology
						  Assistant
Occupational, physical and speech-language pathology procedure
				codes are payable when billed using type of service (TOS) code
				B.