Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-092 - Child Health Services / Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Provider Manual Update Transmittal #69; Ventilator Equipment Provider Manual Update Transmittal #55; Division of Youth Services (DYS) and Division of Children and Family Services (DCFS) Targeted Case Management Provider Manual Update Transmittal #9; Children's Services Targeted Case Management Provider Manual Update Transmittal #17; DDS Alternative Community Services (ACS) Waiver Program Provider Manual Update Transmittal #57; Prosthetics Provider Manual Update Transmittal #74

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II
Child Health Services/Early and Periodic
				Screening, Diagnosis, and Treatment
242.100
Procedure Codes
See section 212.000 for EPSDT screening terminology.
An EPSDT periodic complete medical screen includes both hearing
				and vision screens. Providers must not bill an EPSDT periodic or interperiodic
				vision or hearing screen on the same day or within 7 days of an EPSDT complete
				medical screen by the same or different providers. The above billing
				combinations represent a duplication of services.
An EPSDT interperiodic full medical screen includes both
				hearing and vision screens. Providers must not bill an EPSDT periodic or
				interperiodic vision screen on the same day or within 7 days of an EPSDT
				interperiodic full medical screen by the same or different providers. The above
				billing combinations represent a duplication of services.
Claims for EPSDT medical screenings must be billed
				electronically or using the DMS-694 EPSDT paper claim form.
View or print a DMS-694 sample claim
				form.
Procedure Code
Modifier 1
Modifier 2
Description
99381-99385
EP
U1
EPSDT Periodic Complete Medical Screen (New
						  Patient)
99391-99395
EP
U2
EPSDT Periodic Complete Medical Screen (Established
						  Patient)
99381-99385
EP
EPSDT Interperiodic Full Medical Screen (New
						  Patient)
99391-99395
EP
EPSDT Interperiodic Full Medical Screen (Established
						  Patient)
99391-99395
EP
UB
Partial Medical Screen/Reassessment EPSDT health and
						  developmental history, including assessment of physical development
						  (Established Patient)
96151
EP
Partial Medical Screen/Reassessment EPSDT health and
						  developmental history, including assessment of mental development
99381-99385
EP
UB
Partial Medical Screen/Reassessment EPSDT unclothed
						  physical assessment (New Patient)
99391-99395
EP
U1
Partial Medical Screen/Reassessment EPSDT unclothed
						  physical assessment (Established Patient)
994311 994321
							 994351
EP EP EP
Initial Newborn Care/EPSDT screen in hospital
991731
EP
EPSDT Periodic Vision Screen
V5008
EP
EPSDT Periodic Hearing Screen
V5008
EP
U1
EPSDT Interperiodic Hearing Screen
D01201
CHS/EPSDT Oral Examination
D01401
EPSDT Interperiodic Dental Screen, with prior
						  authorization
920121
EP
TS
EPSDT Interperiodic Vision Screen
99401
EP
EPSDT Health Education - Preventive Medical
						  Counseling
364152
Collection of venous blood by venipuncture
83655
Lead
1 Exempt from PCP referral
				requirements
2Covered when specimen is referred to an
				independent lab
Immunizations and laboratory tests may be billed separately
				from comprehensive screens.
The verbal assessment of lead toxicity risk is part of the
				complete CHS/EPSDT screen. The cost for the administration of the risk
				assessment is included in the fee for the complete screen.
Laboratory/X-ray and immunizations associated with an EPSDT
				screen may be billed on the DMS-694 EPSDT claim form.
When billing on paper, the EPSDT screening services must be
				billed with a type of service code "6."
For billing on paper, immunizations must be billed with a type
				of service code "1."
242.150
Limitation for Laboratory Procedures Performed as Part of EPSDT
Screens
Child Health Services (EPSDT) screens do not include laboratory
				procedures unless the screen is performed by the recipient'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:
81000 -
Urinalysis, by dip stick or tablet reagent for
						  bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,
						  specific gravity, urobilinogen, any number of these constituents;
						  non-automated, with microscopy
81001 -
Urinalysis, by dip stick or tablet reagent for
						  bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,
						  specific gravity, urobilinogen, any number of these constituents; automated,
						  with microscopy
81002 -
Urinalysis, by dip stick or tablet reagent for
						  bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein,
						  specific gravity, urobilinogen, any number of these constituents;
						  non-automated, without microscopy
83020 -
Hemoglobin, electrophoresis (e.g., AZ, S, C)
83655 -
Lead
85013 -
Blood count; spun microhematocrit
85014 -
Blood count; other than spun hematocrit
85018 -
Blood count, hemoglobin
86580 -
Skin test; tuberculosis, intradermal
86585 -
Tuberculosis, tine test
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:
Procedure Code
Modifier 1
Modifier 2
Description
99381-99385
EP
U1
EPSDT Periodic Complete Medical Screen (New
						  Patient)
99391-99395
EP
U2
EPSDT Periodic Complete Medical Screen (Established
						  Patient)
*99381-99385
EP
EPSDT Interperiodic Full Medical Screen (New
						  Patient)
99391-99395
EP
EPSDT Interperiodic Full Medical Screen (Established
						  Patient)
99391-99395
EP
UB
Partial Medical Screen/Reassessment EPSDT health and
						  developmental history (including assessment of physical development)
						  (Established Patient)
99381-99385
EP
UB
Partial Medical Screen/Reassessment EPSDT unclothed
						  physical assessment (New Patient)
99391-99395
EP
U1
Partial Medical Screen/Reassessment EPSDT unclothed
						  physical assessment (Established Patient)
96151
EP
Partial Medical Screen EPSDT health and development
						  history including assessment of mental development
* Procedure codes
99381
through
99385
(New Patient) with modifier
EP
should only be used to bill
				an EPSDT Interperiodic Full Medical Screen for new patients, ages 0 through 20
				years of age, who have already received an EPSDT Periodic Complete Medical
				Screen by another PCP within the current fiscal year.
Ventilator
				Equipment
242.100
Ventilator Equipment and
			 Supplies Procedure Codes 12-5-05
Procedure codes must be billed either electronically or on
				paper with the modifiers indicated. Additionally, when billed on paper,
				procedure codes must be billed with a type of service (TOS) code "6" for
				individuals under age 21 or TOS code "9" for individuals of all ages.
Prior authorization requirements are shown under the heading
				PA.
1 Code may only be billed for a
			 ventilator patient in his or her home. The code is not covered for a ventilator
			 patient in a nursing facility.
2
			 Bill only for TOS 6.
* Prior authorization is not required when another insurance
				pays at least 50% of the
Medicaid maximum allowable reimbursement amount.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Procedure Code
Modifier(s) Description
PA
Max. Units
Payment Method
A4483
Nasal prosthesis
No
N/A
1 per day
(1 day = 1 unit)
Purchase
E02501
Hospital bed, fixed height, with any type side rails,
						  with mattress
Yes*
Capped Rental
E02551
Hospital bed, variable height, hi-lo, with any type
						  side rails, with mattress
Yes*
1 per day
(1 day = 1 unit)
Capped Rental
E02601
Hospital bed, semi-electric (head and foot adjustment),
						  with any type side rails, without mattress
Yes*
1 per day
(1 day = 1 unit)
Capped Rental
E04241
Stationary compressed gaseous oxygen system, rental;
						  includes container, contents, regulator flowmeter, humidifier, nebulizer,
						  cannula or mask, and tubing
Yes*
1 per day
(1 day = 1 unit)
Rental Only
E04301
Portable gaseous oxygen system, purchase; includes
						  regulator, flowmeter, humidifier, cannula or mask, and tubing
Yes*
1 per day
(1 day = 1 unit)
Rental Only
E04351
Portable liquid oxygen system, purchase; includes
						  portable container, supply reservoir, flowmeter, humidifier, contents gauge,
						  cannula or mask, tubing, and refill adapter
Yes*
1 per day
(1 day = 1 unit)
Rental Only
E04391
Stationary liquid oxygen system, rental; includes
						  container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or
						  mask, and tubing
Yes*
1 per day
(1 day = 1 unit)
Rental Only
E0450
***(New equipment) Volume control ventilator without
						  pressure support mode, may include pressure control mode, used with invasive
						  interface, e.g., tracheostomy tube
Yes
1 per day
(1 day = 1 unit)
Rental Only
E04501 UB
***(Positive pressure ventilator supplies -Includes
						  suction catheter kits, trach kits, trach tubes, sterile water and
all
respiratory care supplies) Volume control
						  ventilator, may include pressure control mode, used with invasive interface,
						  e.g., tracheostomy tube
Yes
1 per day
(1 day = 1 unit)
Purchase
E0450 UE
***(Used equipment) Volume control ventilator without
						  pressure support mode, may include pressure control mode, used with invasive
						  interface, e.g., tracheostomy tube
Yes
1 per day
(1 day = 1 unit)
Rental Only
E0500
IPPB machine, all types, with built-in nebulization;
						  manual or automatic valves; internal or external power source
Yes
1 per day
Rental Only
E05701
Nebulizer with compressor
Yes*
1 per day
(1 day = 1 unit)
Purchase Only
E06001
Respiratory suction pump, home model, portable or
						  stationary, electric
No
1 per day
(1 day = 1 unit)
Rental Only
E06001 U1
Suction pump, home model, portable (used
						  equipment)
Yes
1 per day
(1 day = 1 unit)
Rental Only
E1390
Oxygen concentrator, Yes* single delivery port, capable
						  of delivering 85 percent or greater oxygen concentration at the prescribed flow
						  rate
1 per day
Rental Only
G02372
							 G02382
EP, UA EP, UA
Respiratory therapy Yes services for
						  ventilator-dependent patients
Frequency of visits as prescribed
N/A
Division of Youth Services (DYS) and Division of Children
and Family Services (DCFS) Targeted Case
				Management
262.200
DYS Procedure Codes
Procedure Code
Required Modifier
Required Modifier
Description
262.300
DCFS Procedure Codes
Procedure Code
Required Modifier
Required Modifier
Description
T1017
U3
UA
DCFS targeted case management
CS Targeted Case
				Management
262.100
Children's Services Targeted
			 Case Management Procedure Code 12-5-05
Providers of Children's Services targeted case management (TCM)
				must bill for services provided using the procedure code shown in the list
				below. Providers must use this code and the indicated modifiers when billing
				either electronically or on paper for Children's Services TCM services.
				Additionally, when billing on paper, the procedure code must be billed with a
				type of service code "9."
Procedure Code
Modifier 1
Modifier 2
Type of Service
Description
Benefit Limit
T1017
U2
UA
9
Targeted case management, each 15 minutes (Children's
						  Services targeted case management)
One (1) unit per client per day.
DDS Alternative Community Services (ACS)
				Waiver
272.100
DDS ACS Waiver Procedure
			 Codes
The following procedure codes and any associated modifier(s)
				must be billed for DDS ACS Waiver Services. Prior authorization is required for
				all services.
Procedure Code
M1
M2 P A
Description
Unit of Service
POS for
Paper
Claims
POS for
Electronic
Claims
A0080
Y
ACS Non-Medical Transportation
1 Year
0
99
H2016
Y
ACS Supportive Living (Individual)
1 Year
4, 0
12, 99
H2016
UB
Y
ACS Supportive Living (Group)
1 Year
4, 0
12, 99
H20231
Y
Supported Employment
15 Minutes
0
99
S5151
Y
ACS Respite Care
1 Year
4, 0
12, 99
T2020
Y
Community Experiences
1 Year
4, 0
12, 99
T2020
UA
Y
Community Experiences
1 Year
4, 0
12, 99
T2022
Y
Case Management Services
1 Month
4, 0
12, 99
T2024
Y
ACS Waiver Coordination
1 Year
4, 0
12, 99
T20252
Y
Consultation Services
1 Hour
4, 0
12, 99
T20283
Y
ACS Specialized Medical Supplies
1 Year
4, 0
12, 99
T2034
Y
Crisis Center
1 Year
0, 4
99, 12
T20344
U1
UA Y
ACS Crisis Intervention Services
1 Hour
0, 4
99, 12
1 Individuals are
			 limited to a maximum of 32 units (8 hours) of supported employment services per
			 date of service.
A breakdown of the supported employment units of service
				includes:
One unit = 15 minutes to 21 minutes Two units = 22 minutes to
				37 minutes Three units = 38 minutes to 52 minutes Four units = 53 minutes to 67
				minutes
2 Beneficiaries may
			 receive twenty-five (25) hours of ACS consultation services per waiver-eligible
			 year.
3 Reimbursement cannot exceed
			 $300 per month.
4 Crisis
			 intervention services may require a maximum of 24 hours of service during any
			 one day.
The following list contains the procedure codes used for ACS
				physical adaptations. Physical adaptations have a benefit limit of $7500 per
				year.
Procedure Code
M1
M2 P A
Description
POS for
Paper
Claims
POS for
Electronic
Claims
K0108
Y
***(ACS environmental modifications) Other
						  accessories
4
12
S5160
Y
***(Adaptive equipment, personal emergency response
						  system [PERS], installation and testing) Emergency response system;
						  installation and testing
4
12
S5161
Y
***(Adaptive equipment, personal emergency response
						  system [PERS], service fee, per month, excludes installation and testing)
						  Emergency response system; service fee, per month (excludes installation and
						  testing)
4
12
S5162
Y
***(Adaptive equipment, personal emergency response
						  system [PERS], purchase only) Emergency response system; purchase only
4
12
S5165
U1
Y
***(ACS adaptive equipment) Home modifications, per
						  service
4
12
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Refer to section 272.200 for definitions of the place of
				service codes listed above.
Prosthetics
233.000
Orthotic and
			 Prosthetic Reimbursement for Repairs 12-5-05
Providers must bill for the repair of orthotic appliances and
				prosthetic devices utilizing the procedure codes listed in the table below. One
				unit of service equals 15 minutes. A maximum of 20 units of service is allowed
				per date of service.
Any applicable pages from the manufacturer's
				catalog and the manufacturer's invoice for parts must be attached to all repair
				claims
.
National Code
Required Modifier
Description
L4205
-
Repair of orthotic appliances and prosthetic devices
						  (non-EPSDT)
L4210
-
L7510
-
L7520
-
L4205
EP
Repair of orthotic appliances and prosthetic devices
						  (EPSDT)
L4210
EP
L7510
EP, UB
L7520
-
Reimbursement for orthotic appliances and prosthetic devices
				requiring
manual pricing
will be calculated using the
				manufacturer's invoice price plus 10%.
The manufacturer invoice
				must be attached to all repair claims
.
E. Providers may be reimbursed for capped
			 rental and rental-only items if the equipment is used fewer than 30 consecutive
			 days from the first day of rental. This ensure the provider of adequate
			 reimbursement for equipment used fewer than 30 days.
F. A rent-to-purchase item is an item for
			 which Arkansas Medicaid reimburses a provider for the Medicaid-established
			 purchase price of the item. After reimbursement has reached the maximum
			 allowed, the equipment will become the property of the Medicaid beneficiary.
			 Reimbursement is only approved for new equipment.
G. Initial rental transactions are those for
			 which equipment is used in a beneficiary's home for fewer than 30 consecutive
			 days. Initial rental transactions must not be used by the provider to bill a
			 month in advance. Arkansas Medicaid will only pay after services are rendered.
			 An example of an initial rental transaction is that of a hospital bed delivered
			 on July 2 and removed from the home after 10 days.
H. Manually priced items are those for which
			 Arkansas Medicaid pays the manufacturer's invoice price plus 10 percent. The
			 provider must attach the invoice with their claim for services
			 rendered.
I. A used item is any
			 item that has been rented for 90 days or longer by anyone prior to the current
			 Medicaid "rental only" or capped rental" transaction. The provider must
			 maintain documentation that certifies a used item is reconditioned and in good
			 working order and has no defect in workmanship or material.
J. Repair of a "rental only" item is covered
			 in the rental fee. Repair of "purchased" items is covered separately. Total
			 (cumulative) repair costs must not exceed 50% of the item's total purchase
			 cost.
242.110
Respiratory and Diabetic Equipment, All Ages 12-5-05
When billed either electronically or on paper, procedure codes
				found in this section must be billed 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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "6" for individuals under age 21 or
				TOS "H" for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. Prior authorization
				requirements are shown under the heading PA. If prior authorization is needed,
				the information is indicated with a "Y" in the column; if not, an "N" is
				shown.
* Prior authorization is not required when another insurance
				pays at least 50% of the
Medicaid maximum allowable reimbursement amount.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Respiratory and Diabetic Equipment, All Ages (section
				242.110)
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
A4230
NU
H
Infusion set for external insulin pump, nonneedle
						  cannula type (each)
Y*
Purchase
Providers will be reimbursed for a minimum of 30 days of rental
				when the equipment is used less than 30 days. Initial rental codes should only
				be billed when equipment is used less than 30 days during the first month of
				rental.
Arkansas Medicaid will only reimburse for one initial minimum
				30 days of rental per state fiscal year period per beneficiary per procedure
				code. The provider will not be reimbursed for the same procedure code utilizing
				another modifier and type of service for the same time period.
242.112
Home Blood Glucose Monitor and
			 Supplies - Pregnant Women Only, All Ages
Procedure codes found in this section must be billed either
				electronically or on paper with modifier NU for individuals of all ages. When a
				second modifier is listed, that modifier must be used in conjunction with the
				NU modifier.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "H" for individuals of all ages.
				Modifiers in the section are indicated by the headings M1 and M2. Type of
				service is indicated by the heading TOS. Prior authorization is indicated by
				the heading PA.
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
E0607
NU
U1
H
Home Blood Glucose Monitor
N
Purchase
A4253
NU
U1
H
Blood glucose test or reagent strips for home glucose
						  monitor, per 50 strips
N
Purchase
A4259
NU
U2
H
Lancets, per box of 100
N
Purchase
242.120
Medical Supplies, All Ages 12-5-05
Procedure codes found in this section must be billed either
				electronically or on paper with modifier NU for individuals of all ages. When a
				second modifier is listed, that modifier must be used in conjunction with the
				modifier NU.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "H" for individuals of all
				ages.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
1 These supplies must be prior authorized.
			 Form DMS-679 may be used for the request for prior authorization.
View or print form DMS-679 and instructions for completion.
Please note: Compression burn garments are manually priced.
Medical Supplies, All Ages (section
				242.120)
Procedure Code
M1
M2
TOS Description
A4206
NU
H Syringe with needle, sterile, 1 cc, ea
A4207
NU
Syringe with needle, sterile, 2 cc, ea
242.180
Orthotic Appliances, All Ages
			 12-5-05
Procedure 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
				older. When a second modifier is listed, that modifier must be used in
				conjunction with either
EP
or
NU
.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "6" for individuals under age 21 or
				TOS code "H" for individuals age 21 and older.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading
				PA. If prior authorization is needed for individuals age 21 and older, that
				information is indicated with a "Y" in the column; if not, an "N" is shown.
				When prior authorization is not applicable (for U21) that information is shown
				with an "N/A" in the column.
When codes are payable for all ages, "All" is indicated in the
				column, "U21" is shown when the code is payable only for individuals under age
				21 and "21+" is shown when the code is payable only for those individuals age
				21 and older.
** This item is not a covered service for the diagnosis of
				Carpal Tunnel Syndrome prior to surgery.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Orthotic Appliances, All Ages (section
				242.180)
Procedure Code
M1 M2
TOS
Description
All
U21
21+
PA 21+
Payment Method
A5500
NU
H
For diabetics only, fitting (including follow-up)
						  custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to
						  accommodate multi-density insert(s), per shoe
21+
Y
Purchase
A5501
NU
H
For diabetics only, fitting (including follow-up)
						  custom preparation and supply of molded from cast(s) of patient's foot (custom
						  molded shoe), per shoe
21+
Y
Purchase
A5503
NU
H
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid
						  rocker bottom, per shoe
21+
Y
Purchase
A5504
NU
H
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per
						  shoe
21+
Y
Purchase
A5505
NU
H
For diabetics only, modification (including fitting) of
						  off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per
						  shoe
21+
Y
Purchase
Orthotic Appliances, All Ages (section
				242.180)
Procedure Code
M1
M2
TOS
Description
All
U21
21+
PA 21+
Payment Method
L7499
NU EP
H 6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.
) Upper
						  extremity prosthesis, not otherwise specified
All
Y
Manually Priced
Manually Priced
L7510
NU EP
UB
H 6
Repair of prosthetic device, hourly rate
All
Y
Manually Priced
Purchase
L7520
NU EP
H 6
Repair prosthetic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L8499
NU EP
H 6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.
)
						  Unlisted procedure for miscellaneous prosthetic services
All
Y
Manually Priced
Purchase
242.190
Prosthetic Devices, All Ages 12-5-05
Procedure 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 individuals age 21 and
				older. When a second modifier is listed, that modifier must be used in
				conjunction with either
EP
or
NU
.
Additionally, when billed on paper, procedure codes must be
				billed with type of service (TOS) code "6" for individuals under age 21 or TOS
				code "H" for beneficiaries age 21 and older.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading
				PA. If prior authorization is needed for individuals age 21 and older, that
				information is indicated with a "Y" in the column; if not, an "N" is shown.
				When codes are payable for all ages, "All" is indicated in the column, "U21" is
				shown when the code is payable only for individuals under age 21 and "21+" is
				shown when the code is payable only for those individuals age 21 and
				older.
* Replacement only
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Prosthetic Devices, All Ages (section
				242.190)
Procedure Code
M1
M2
TOS
Description
All
U21
21+
PA Payment 21+ Method
L8600
NU EP
H 6
Implantable breast prosthesis, silicone or equal
All
N Manually Priced
242.191
Specialized Wheelchairs and Wheelchair Seating Systems 12-5-05
for Individuals Age Two Through Adult
Procedure 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
				older. When a second modifier is listed, that modifier must be used in
				conjunction with either
EP
or
NU
.
Additionally, when billed on paper, procedure codes found in
				this section must be billed with a type of service (TOS) code "6" for
				individuals under age 21 or TOS code "H" for individuals age 21 and
				older.
Modifiers in this section are indicated by the headings M1 and
				M2. The type of service code is indicated by the heading TOS. Prior
				authorization requirements are shown under the heading PA. If prior
				authorization is needed, that information is indicated with a "Y" in the
				column; if not, an "N" is shown.
Other coding information found in the chart:
1 The purchase of this wheelchair component
			 for individuals age 21 and older is limited to one per five-year
			 period.
2 The purchase of this
			 wheelchair component for individuals under age 21 is limited to one per
			 two-year period.
* The purchase of wheelchairs for individuals age 21 and older
				is limited to one per five-year period.
** Bill only for TOS code "6."
# This procedure code is payable for individuals ages 2 through
				20, using TOS code "6." Prior authorization is required through Utilization
				Review.
**** Items listed require prior authorization (PA) when used in
				combination with other items listed and the total combined value exceeds the
				$1,000.00 Medicaid maximum allowable reimbursement limit.
* Prior authorization is not required when another insurance
				pays at least 50% of the Medicaid maximum allowable reimbursement
				amount.
Note: W/C or w/c indicates wheelchair.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
242.192
Specialized Rehabilitative Equipment, All Ages 12-5-05
Procedure 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.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "6" for individuals under 21 years of
				age or TOS code "H" for individuals age 21 or over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. Prior authorization
				requirements are shown under the heading PA. If prior authorization is needed,
				that information is indicated with a "Y" in the column; if not, an "N" is
				shown.
** Indicates that providers may bill only for individuals under
				age 21.
* Prior authorization is not required when another insurance
				pays at least 50% of the
Medicaid maximum allowable reimbursement amount.
***
(...) This symbol, along with text in
				parentheses, indicates the Arkansas Medicaid description of the product.
Specialized Rehabilitative Equipment, All Ages (section
				242.192 )
Procedure Code
M1
M2
TOS
Description
PA
Payment Method
E0149
NU EP
H 6
***
(4 Wheel Reverse Walker) Walker, heavy
						  duty, wheeled, rigid or folding, any type
N
Purchase
E0163
EP
6
***(Potty Chair - Sm) Commode chair, stationary, with
						  fixed arms
Y
Purchase
E0166
EP
U1
6
***(Potty Chair - Lg) Commode chair, mobile, with
						  detachable arms
Y
Purchase
E0168
NU
U1
H
***(Rehab Shower/Commode Chair) Commode chair, extra
						  wide and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
Y*
Purchase
E0168
EP
6
***(Rehab Shower/Commode Chair) Commode chair, extra
						  wide and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
Y*
Purchase
E0168
NU
H
***(Adaptive Commode Chair) Commode chair, extra wide
						  and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
N
Purchase
E0168
EP
UB
6
***(Adaptive Commode Chair) Commode chair, extra wide
						  and/or heavy duty, stationary or mobile, with or without arms, any type,
						  each
N
Purchase