Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-053 - Official Notice DMS-2005-W-2 - 2005 HCPCS Procedure Code Conversion

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