Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-027 - DMS-2005-W-1: 2004 HCPCS Final Procedure Code Conversion

Current through Register Vol. 49, No. 6, June, 2024
I.
General
			 Information
A final review of the 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 July 1, 2005.
II.
2004 HCPCS Payable
			 Procedure Code Tables Information
Payable procedures codes have been broken into separate tables.
				Tables have been created for each payable 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 column is the procedure code description.
The third column is the type of service (TOS) code that may be
				used in conjunction with the procedure code. Type of service codes are used
				when billing on paper.
The fourth and fifth columns indicate any modifiers that need
				to be used in conjunction with the procedure code, when billing, either
				electronically or on paper. The columns are titled "Ml" and "M2". This
				information is used in the prosthetics program.
The sixth column indicates the diagnosis list, and is titled
				"Diag. List". The information is used by physicians, hospitals, independent
				radiology, ambulatory surgical centers, area health education centers and nurse
				practitioners. Applicable lists will be discussed in each provider's
				section.
The seventh column indicates whether a review must be completed
				when providing a service. The column is titled "Review Y/N". A "Y" in a column
				means that a review is necessary; 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 payment. The column is titled PA, Y/N". An alpha "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". An alpha "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
The following are the diagnosis lists referred to in column six
				which are used by physicians, hospitals, independent radiology, ambulatory
				surgical centers, area health education centers and nurse practitioners. The
				diagnosis list refers to specific ICD-9 codes and certain procedure codes are
				limited by the diagnosis lists. Not all providers use all the lists, but they
				are shown for clarity of information.
Diagnosis List 003
ICD 9 Codes
042
1400 through 20891
Diagnosis List 006:
ICD-9 Codes: 41010 through 41092 4110 through 41189 4130
				through 4139 41400 through 4149
Diagnosis List 007
ICD-9 Codes:
1622 through 1629
7931
Diagnosis List 008
ICD-9 Codes
1530 through 1539
1540 through 1541
Diagnosis List 009
ICD-9 Codes
20000 through 20008
20010 through 20018
20020 through 20028
20100 through 20198
20200 through 20298
Diagnosis List 010
ICD-9 Codes
1400 through 1409
1410 through 1419
1420 through 1429
1430 through 1439
1440 through 1449
1450 through 1459
1460 through 1469
1470 through 1479
1480 through 1489
1490 through 1499
1600 through 1609
1610 through 1619
1950
1960
Diagnosis List 011
ICD-9 Codes
1500 through 1509
1510
Diagnosis List 012
ICD-9 Codes
34501
34511
Diagnosis List 013
ICD-9 Codes
41000 through 41092
4110 through 41189
4130 through 4139
41400 through 41405
41410 through 41419
Diagnosis List 014
ICD-9 Codes
1740 through 1749
1750
2330
Diagnosis List 015
ICD-9 Codes
193
2374
V1087
IV.
HCPCS Codes Payable for Physicians
HCPCS Code
Description
TOS
M1
M2
Diag. List
Review Y/N
PA Y/N
MP Y/N
G0030
PET myocard perf imag, (after G0030-G0047) single
						  study, rest/stress
C
00
00
006
N
N
N
G0030
PET myocard perf imag, (after G0030-G0047) single
						  study, rest/stress
P
00
00
006
N
N
N
G0030
PET myocard perf imag, (after G0030-G0047) single
						  study, rest/stress
T
00
00
006
N
N
N
G0031
PET myocard perf imag, (after G0030-G0047) mult
						  studies, rest/stress
C
00
00
006
N
N
N
G0031
PET myocard perf imag, (after G0030-G0047) mult
						  studies, rest/stress
P
00
00
006
N
N
N
G0031
PET myocard perf imag, (after G0030-G0047) mult
						  studies, rest/stress
T
00
00
006
N
N
N
G0032
PET myocard perf imag, (after rest, 78464) single
						  study, rest/stress
C
00
00
006
N
N
N
G0032
PET myocard perf imag, (after rest, 78464) single
						  study, rest/stress
P
00
00
006
N
N
N
G0032
PET myocard perf imag, (after rest, 78464) single
						  study, rest/stress
T
00
00
006
N
N
N
G0033
PET myocard perf imag, (after rest,78464) multi
						  studies, rest/stress
C
00
00
006
N
N
N
G0033
PET myocard perf imag, (after rest,78464) multi
						  studies, rest/stress
P
00
00
006
N
N
N
G0033
PET myocard perf imag, (after rest,78464) multi
						  studies, rest/stress
T
00
00
006
N
N
N
G0034
PET myocard perf imag, (after stress, 78465) single
						  study, rest/stress
C
00
00
006
N
N
N
G0034
PET myocard perf imag, (after stress, 78465) single
						  study, rest/stress
P
00
00
006
N
N
N
G0034
PET myocard perf imag, (after stress, 78465) single
						  study, rest/stress
T
00
00
006
N
N
N
G0035
PET myocard perf imag, (after stress, 78465) multi
						  studies, rest/stress
C
00
00
006
N
N
N
G0035
PET myocard perf imag, (after stress, 78465) multi
						  studies, rest/stress
P
00
00
006
N
N
N
G0035
PET myocard perf imag, (after stress, 78465) multi
						  studies, rest/stress
T
00
00
006
N
N
N
G0036
PET myocard perf imag, (after 93510-93529) single study
						  rest/stress
C
00
00
006
N
N
N
G0036
PET myocard perf imag, (after 93510-93529) single study
						  rest/stress
P
00
00
006
N
N
N
G0036
PET myocard perf imag, (after 93510-93529) single study
						  rest/stress
T
00
00
006
N
N
N
G0037
PET myocard perf imag, (after 93510-93529) mult
						  studies, rest/stress
C
00
00
006
N
N
N
G0037
PET myocard perf imag, (after 93510-93529) mult
						  studies, rest/stress
P
00
00
006
N
N
N
G0037
PET myocard perf imag, (after 93510-93529) mult
						  studies, rest/stress
T
00
00
006
N
N
N
G0038
PET myocard perf imag, (after 78460) single study,
						  rest/stress
C
00
00
006
N
N
N
G0038
PET myocard perf imag, (after 78460) single study,
						  rest/stress
P
00
00
006
N
N
N
G0038
PET myocard perf imag, (after 78460) single study,
						  rest/stress
T
00
00
006
N
N
N
G0039
PET myocard perf imag, (after 78460) mult studies,
						  rest/stress
C
00
00
006
N
N
N
G0039
PET myocard perf imag, (after 78460) mult studies,
						  rest/stress
P
00
00
006
N
N
N
G0039
PET myocard perf imag, (after 78460) mult studies,
						  rest/stress
T
00
00
006
N
N
N
G0040
PET myocard perf imag, (after 93350) single study,
						  rest/stress
C
00
00
006
N
N
N
G0040
PET myocard perf imag, (after 93350) single study,
						  rest/stress
P
00
00
006
N
N
N
G0040
PET myocard perf imag, (after 93350) single study,
						  rest/stress
T
00
00
006
N
N
N
G0041
PET myocard perf imag, (after 93350) mult studies,
						  rest/stress
C
00
00
006
N
N
N
G0041
PET myocard perf imag, (after 93350) mult studies,
						  rest/stress
P
00
00
006
N
N
N
G0041
PET myocard perf imag, (after 93350) mult studies,
						  rest/stress
T
00
00
006
N
N
N
G0042
PET myocard perf imag, (after 78481/78483) single
						  study, rest/stress
C
00
00
006
N
N
N
G0042
PET myocard perf imag, (after 78481/78483) single
						  study, rest/stress
P
00
00
006
N
N
N
G0042
PET myocard perf imag, (after 78481/78483) single
						  study, rest/stress
T
00
00
006
N
N
N
G0043
PET myocard perf imag, (after 78481/78483) mult
						  studies, rest/stress
C
00
00
006
N
N
N
G0043
PET myocard perf imag, (after 78481/78483) mult
						  studies, rest/stress
P
00
00
006
N
N
N
G0043
PET myocard perf imag, (after 78481/78483) mult
						  studies, rest/stress
T
00
00
006
N
N
N
G0044
PET myocard perf imag, (after 93000) single study,
						  rest/stress
C
00
00
006
N
N
N
G0044
PET myocard perf imag, (after 93000) single study,
						  rest/stress
P
00
00
006
N
N
N
G0044
PET myocard perf imag, (after 93000) single study,
						  rest/stress
T
00
00
006
N
N
N
G0045
PET myocard perf imag, (after 93000) mult studies,
						  rest/stress
C
00
00
006
N
N
N
G0045
PET myocard perf imag, (after 93000) mult studies,
						  rest/stress
P
00
00
006
N
N
N
G0045
PET myocard perf imag, (after 93000) mult studies,
						  rest/stress
T
00
00
006
N
N
N
G0046
PET myocard perf imag, (after 93015) single study,
						  rest/stress
C
00
00
006
N
N
N
G0046
PET myocard perf imag, (after 93015) single study,
						  rest/stress
P
00
00
006
N
N
N
G0046
PET myocard perf imag, (after 93015) single study,
						  rest/stress
T
00
00
006
N
N
N
G0047
PET myocard perf imag, (after 93015) mult studies,
						  rest/stress
C
00
00
006
N
N
N
G0047
PET myocard perf imag, (after 93015) mult studies,
						  rest/stress
P
00
00
006
N
N
N
G0047
PET myocard perf imag, (after 93015) mult studies,
						  rest/stress
T
00
00
006
N
N
N
G0125
PET imag regional/whole body; single pulmonary
						  nodule
C
00
00
007
N
N
N
G0125
PET imag regional/whole body; single pulmonary
						  nodule
P
00
00
007
N
N
N
G0125
PET imag regional/whole body; single pulmonary
						  nodule
T
00
00
007
N
N
N
G0130
Bone density study, 1 or [GREATER THAN] sites;
						  appendicular skeleton
C
00
00
N
N
N
G0130
Bone density study, 1 or [GREATER THAN] sites;
						  appendicular skeleton
P
00
00
N
N
N
G0130
Bone density study, 1 or [GREATER THAN] sites;
						  appendicular skeleton
T
00
00
N
N
N
G0166
External counterpulsation, per treatment
						  session
C
00
00
N
N
N
G0166
External counterpulsation, per treatment
						  session
P
00
00
N
N
N
G0166
External counterpulsation, per treatment
						  session
T
00
00
N
N
N
G0173
Linear accelerator based stereotactic radiosurgery,
						  complete course of therapy/1 session
2
00
00
N
N
Y
G0173
Linear accelerator based stereotactic radiosurgery,
						  complete course of therapy/1 session
8
00
00
N
N
Y
G0186
Destruction localized lesion of choroid, feeder vessel
						  tech, 1 or [GREATER THAN] sess
2
00
00
N
N
Y
G0186
Destruction localized lesion of choroid, feeder vessel
						  tech, 1 or [GREATER THAN] sess
8
00
00
N
N
Y
G0202
Screening mammography, producing direct digital image,
						  bilateral, all views
C
00
00
N
N
N
G0202
Screening mammography, producing direct digital image,
						  bilateral, all views
P
00
00
N
N
N
G0202
Screening mammography, producing direct digital image,
						  bilateral, all views
T
00
00
N
N
N
G0204
Diagnostic mammography, producing direct digital image,
						  bilateral, all views
C
00
00
N
N
N
G0204
Diagnostic mammography, producing direct digital image,
						  bilateral, all views
P
00
00
N
N
N
G0204
Diagnostic mammography, producing direct digital image,
						  bilateral, all views
T
00
00
N
N
N
G0206
Diagnostic mammography, producing direct digital image,
						  unilateral, all views
C
00
00
N
N
N
G0206
Diagnostic mammography, producing direct digital image,
						  unilateral, all views
P
00
00
N
N
N
G0206
Diagnostic mammography, producing direct digital image,
						  unilateral, all views
T
00
00
N
N
N
G0210
PET imaging whole body; diagnosis; lung cancer,
						  non-small cell
C
00
00
007
N
N
N
G0210
PET imaging whole body; diagnosis; lung cancer,
						  non-small cell
P
00
00
007
N
N
N
G0210
PET imaging whole body; diagnosis; lung cancer,
						  non-small cell
T
00
00
007
N
N
N
G0211
PET imaging whole body; initial staging; lung cancer;
						  non-small cell
C
00
00
007
N
N
N
G0211
PET imaging whole body; initial staging; lung cancer;
						  non-small cell
P
00
00
007
N
N
N
G0211
PET imaging whole body; initial staging; lung cancer;
						  non-small cell
T
00
00
007
N
N
N
G0212
PET imaging whole body; restaging; lung cancer;
						  non-small
C
00
00
007
N
N
N
G0212
PET imaging whole body; restaging; lung cancer;
						  non-small
P
00
00
007
N
N
N
G0212
PET imaging whole body; restaging; lung cancer;
						  non-small
T
00
00
007
N
N
N
G0213
PET imaging whole body; diagnosis;
						  colorectal
C
00
00
008
N
N
N
G0213
PET imaging whole body; diagnosis;
						  colorectal
P
00
00
008
N
N
N
G0213
PET imaging whole body; diagnosis;
						  colorectal
T
00
00
008
N
N
N
* Procedure code limited to diagnosis range 1720 through
				1729.
HCPCS Code
Description
TOS
M1
M2
Diag. List
Review Y/N
PA Y/N
MP Y/N
G0214
PET imaging whole body; initial staging; initial
						  staging; colorectal
C
00
00
008
N
N
N
G0214
PET imaging whole body; initial staging; initial
						  staging; colorectal
P
00
00
008
N
N
N
G0214
PET imaging whole body; initial staging; initial
						  staging; colorectal
T
00
00
008
N
N
N
G0215
PET imaging whole body; restaging; colorectal
						  cancer
C
00
00
008
N
N
N
G0215
PET imaging whole body; restaging; colorectal
						  cancer
P
00
00
008
N
N
N
G0215
PET imaging whole body; restaging; colorectal
						  cancer
T
00
00
008
N
N
N
*G0216
PET imaging whole body; diagnosis; melanoma
C
00
00
N
N
N
*G0216
PET imaging whole body; diagnosis; melanoma
P
00
00
N
N
N
*G0216
PET imaging whole body; diagnosis; melanoma
T
00
00
N
N
N
*G0217
PET imaging whole body; initial staging;
						  melanoma
C
00
00
N
N
N
*G0217
PET imaging whole body; initial staging;
						  melanoma
P
00
00
N
N
N
*G0217
PET imaging whole body; initial staging;
						  melanoma
T
00
00
N
N
N
*G0218
PET imaging whole body; restaging; melanoma
C
00
00
N
N
N
*G0218
PET imaging whole body; restaging; melanoma
P
00
00
N
N
N
*G0218
PET imaging whole body; restaging; melanoma
T
00
00
N
N
N
G0220
PET imaging whole body; diagnosis; lymphoma
C
00
00
009
N
N
N
G0220
PET imaging whole body; diagnosis; lymphoma
P
00
00
009
N
N
N
G0220
PET imaging whole body; diagnosis; lymphoma
T
00
00
009
N
N
N
G0221
PET imaging whole body; initial staging;
						  lymphoma
C
00
00
009
N
N
N
G0221
PET imaging whole body; initial staging;
						  lymphoma
P
00
00
009
N
N
N
G0221
PET imaging whole body; initial staging;
						  lymphoma
T
00
00
009
N
N
N
G0222
PET imaging whole body; restaging; lymphoma
C
00
00
009
N
N
N
G0222
PET imaging whole body; restaging; lymphoma
P
00
00
009
N
N
N
G0222
PET imaging whole body; restaging; lymphoma
T
00
00
009
N
N
N
G0223
PET imag whole body/region; diag; head/neck ca;
						  ex/thyroid/CNS ca
C
00
00
010
N
N
N
G0223
PET imag whole body/region; diag; head/neck ca;
						  ex/thyroid/CNS ca
P
00
00
010
N
N
N
G0223
PET imag whole body/region; diag; head/neck ca;
						  ex/thyroid/CNS ca
T
00
00
010
N
N
N
G0224
PET imag whole body/region; init stag; head/neck ca; ex
						  thyroid/CNS ca
C
00
00
010
N
N
N
G0224
PET imag whole body/region; init stag; head/neck ca; ex
						  thyroid/CNS ca
P
00
00
010
N
N
N
G0224
PET imag whole body/region; init stag; head/neck ca; ex
						  thyroid/CNS ca
T
00
00
010
N
N
N
G0225
PET imag whole body/region; restag; head/neck ca; ex
						  thyroid/CNS ca
C
00
00
010
N
N
N
G0225
PET imag whole body/region; restag; head/neck ca; ex
						  thyroid/CNS ca
P
00
00
010
N
N
N
G0225
PET imag whole body/region; restag; head/neck ca; ex
						  thyroid/CNS ca
T
00
00
010
N
N
N
G0226
PET imaging whole body; diagnosis; esophageal
						  cancer
C
00
00
011
N
N
N
G0226
PET imaging whole body; diagnosis; esophageal
						  cancer
P
00
00
011
N
N
N
G0226
PET imaging whole body; diagnosis; esophageal
						  cancer
T
00
00
011
N
N
N
G0227
PET imaging whole body; initial staging; esophageal
						  cancer
C
00
00
011
N
N
N
G0227
PET imaging whole body; initial staging; esophageal
						  cancer
P
00
00
011
N
N
N
G0227
PET imaging whole body; initial staging; esophageal
						  cancer
T
00
00
011
N
N
N
G0228
PET imaging whole body; restaging; esophageal
						  cancer
C
00
00
011
N
N
N
G0228
PET imaging whole body; restaging; esophageal
						  cancer
P
00
00
011
N
N
N
G0228
PET imaging whole body; restaging; esophageal
						  cancer
T
00
00
011
N
N
N
G0229
PET imaging; metabolic brain imag/pre-surg eval,
						  refractory seizures
C
00
00
012
N
N
N
G0229
PET imaging; metabolic brain imag/pre-surg eval,
						  refractory seizures
P
00
00
012
N
N
N
G0229
PET imaging; metabolic brain imag/pre-surg eval,
						  refractory seizures
T
00
00
012
N
N
N
G0230
PET imag, metab assess/myocardial viability after
						  inconclu SPECT
C
00
00
013
N
N
N
G0230
PET imag, metab assess/myocardial viability after
						  inconclu SPECT
P
00
00
013
N
N
N
G0230
PET imag, metab assess/myocardial viability after
						  inconclu SPECT
T
00
00
013
N
N
N
G0231
PET, whole body, recurrence colorectal cancer; gamma
						  cameras only
C
00
00
008
N
N
N
G0231
PET, whole body, recurrence colorectal cancer; gamma
						  cameras only
P
00
00
008
N
N
N
G0231
PET, whole body, recurrence colorectal cancer; gamma
						  cameras only
T
00
00
008
N
N
N
G0232
PET, whole body, recurrence of lymphoma; gamma cameras
						  only
C
00
00
009
N
N
N
G0232
PET, whole body, recurrence of lymphoma; gamma cameras
						  only
P
00
00
009
N
N
N
G0232
PET, whole body, recurrence of lymphoma; gamma cameras
						  only
T
00
00
009
N
N
N
*G0233
PET, whole body, recurrence of melanoma; gamma cameras
						  only
C
00
00
N
N
N
*G0233
PET, whole body, recurrence of melanoma; gamma cameras
						  only
P
00
00
N
N
N
*G0233
PET, whole body, recurrence of melanoma; gamma cameras
						  only
T
00
00
N
N
N
G0234
PET, regional/whole body, pul nodule, lung ca, gamma
						  cameras only
C
00
00
007
N
N
N
G0234
PET, regional/whole body, pul nodule, lung ca, gamma
						  cameras only
P
00
00
007
N
N
N
G0234
PET, regional/whole body, pul nodule, lung ca, gamma
						  cameras only
T
00
00
007
N
N
N
G0242
Multi-source photon stereotactic radiosurg, per course
						  oftx
2
00
00
N
N
Y
G0242
Multi-source photon stereotactic radiosurg, per course
						  oftx
8
00
00
N
N
Y
G0243
Multi-source photon stereotactic radiosurg, complete
						  course oftx
2
00
00
N
N
Y
G0243
Multi-source photon stereotactic radiosurg, complete
						  course oftx
8
00
00
N
N
Y
G0251
Linear accel based stereotactic radiosurg, all lesions,
						  max 5 sessions
2
00
00
N
N
Y
G0251
Linear accel based stereotactic radiosurg, all lesions,
						  max 5 sessions
8
00
00
N
N
Y
G0253
PET imaging, breast cancer recurrence or distant
						  metastases
C
00
00
014
N
N
N
G0253
PET imaging, breast cancer recurrence or distant
						  metastases
P
00
00
014
N
N
N
G0253
PET imaging, breast cancer recurrence or distant
						  metastases
T
00
00
014
N
N
N
G0254
PET imag breast cancer, eval response to tx during
						  course oftx
C
00
00
014
N
N
N
G0254
PET imag breast cancer, eval response to tx during
						  course oftx
P
00
00
014
N
N
N
G0254
PET imag breast cancer, eval response to tx during
						  course oftx
T
00
00
014
N
N
N
G0255
Curr percep threshold/sensory nerve conduct test, per
						  limb, any nerve
C
00
00
N
N
Y
G0255
Curr percep threshold/sensory nerve conduct test, per
						  limb, any nerve
P
00
00
N
N
Y
G0255
Curr percep threshold/sensory nerve conduct test, per
						  limb, any nerve
T
00
00
N
N
Y
G0256
Prostate brachytherapy, Palladium seeds, perm
						  interstitial rad source
C
00
00
N
N
Y
G0256
Prostate brachytherapy, Palladium seeds, perm
						  interstitial rad source
P
00
00
N
N
Y
G0256
Prostate brachytherapy, Palladium seeds, perm
						  interstitial rad source
T
00
00
N
N
Y
G0267
Bone marrow/perip stem cell harvest mod or tx to elim
						  cell type
2
00
00
N
N
Y
G0267
Bone marrow/perip stem cell harvest mod or tx to elim
						  cell type
8
00
00
N
N
Y
G0269
Placement occlusive device venous/arterial access site,
						  post surg
2
00
00
N
N
Y
G0269
Placement occlusive device venous/arterial access site,
						  post surg
8
00
00
N
N
Y
G0269
Placement occlusive device venous/arterial access site,
						  post surg
G
00
00
N
N
Y
G0275
Renal angiography, unilat or bilat, perf at time of
						  cardiac cath, w/radiologic super & interpret
C
00
00
N
N
N
G0275
Renal angiography, unilat or bilat, perf at time of
						  cardiac cath, w/radiologic super & interpret
P
00
00
N
N
N
G0278
Iliac artery angiography, at same time of cardiac cath,
						  radiologic supervision & intepret
C
00
00
N
N
N
G0278
Iliac artery angiography, at same time of cardiac cath,
						  radiologic supervision & intepret
P
00
00
N
N
N
G0279
Extracorporeal shock wave therapy; involving elbow
						  epicondylitis
2
00
00
N
N
Y
G0279
Extracorporeal shock wave therapy; involving elbow
						  epicondylitis
8
00
00
N
N
Y
G0280
Extracorp Shockwave ther; involv oth than elbow
						  epicon/plant fascitis
2
00
00
N
N
Y
G0280
Extracorp Shockwave ther; involv oth than elbow
						  epicon/plant fascitis
8
00
00
N
N
Y
G02961
Pet imaging, restaging thyroid cancer
C
00
00
015
N
N
Y
G02961
Pet imaging, restaging thyroid cancer
P
00
00
015
N
N
Y
G02961
Pet imaging, restaging thyroid cancer
T
00
00
015
N
N
Y
J0200
Injection, alatrofloxacin mesylate, 100mg
1
00
00
003
N
N
N
J0275
Alprostadil urethral suppository
1
00
00
003
N
N
N
J0287
Injection, amphotericin B cholesteryl
						  sulfate
1
00
00
003
N
N
N
J0288
Injection, amphotericin B cholesteryl sulfate complex,
						  10mg
1
00
00
003
N
N
N
J0289
Injection, amphotericin B liposome, 10 mg
00
00
003
N
N
N
J0456
Injection, azithromycin, 500 mg
00
00
003
N
N
N
J0476
Injection, baclofen, 50 meg for intrathecal
						  trial
00
00
003
N
N
N
J0592
Injection, buprenorphine hydrochloride, 0.1
						  mg
00
00
003
N
N
N
J0637
Injection, caspofungin acetate, 5 mg
00
00
N
N
N
J0692
Injection, cefepime HCI, 500 mg
00
00
003
N
N
N
J0706
Injection, caffeine citrate, 5 mg
00
00
003
N
N
N
J0744
Injection, ciprofloxacin for intravenous infusion, 200
						  mg
00
00
003
N
N
N
J0880
Injection, darbepoetin alfa, 5 meg
00
00
Y
N
N
J1270
Injection, doxercalciferol, 1 meg
00
00
003
N
N
N
J1450
Injection, fluconazole, 200 mg
00
00
003
N
N
N
J1452
Injection, omivirsen sodium, intraocular, 1.65
						  mg
00
00
003
N
N
N
J1590
Injection, gatifloxacin, 10 mg
00
00
003
N
N
N
J1652
Injection, fondaparinux sodium, 0.5 mg
00
00
003
N
N
N
J1655
Injection, tinzaparin sodium, 1000 IU
00
00
003
N
N
N
J1835
Injection, itraconazole, 50 mg
00
00
003
N
N
N
J1956
Injection, levofloxacin, 250 mg
00
00
003
N
N
N
J2020
Injection, linezolid, 200 mg
00
00
003
N
N
N
J2271
Injection, morphine sulfate, 100 mg
00
00
003
N
N
N
J2355
Injection, oprelvekin, 5 mg
00
00
003
N
N
N
J2501
Injection, paricalcitol, 1 meg
00
00
003
N
N
N
J2543
Inject, piperacillin sodium/tazobactam sodium, 1
						  g/0.125 g (1.125 g)
00
00
003
N
N
N
J2770
Injection, quinupristin/dalfopristin, 500 mg
						  (150/350)
00
00
003
N
N
N
J2780
Injection, ranitidine HCI, 25 mg
00
00
003
N
N
N
J2792
Inject, Rho D immune globulin, IV, human, solvent
						  detergent, 100 IU
00
00
N
N
N
J2941
Injection, somatropin, 1 mg
00
00
003
N
N
N
J3315
Injection, triptorelin pamoate, 3.75 mg
00
00
003
N
N
N
J3395
Injection, verteporfin, 15 mg
00
00
Y
N
N
J3485
Injection, zidovudine, 10 mg
00
00
003
N
N
N
J3487
Injection, zoledronic acid, 1 mg
00
00
Y
N
J3590
Unclassified biologies
00
00
Y
N
Y
J7193
Factor IX, (antihemophilic factor, purified,
						  non-recombinant) perlU
00
00
N
N
N
J7195
Factor IX, (antihemophilic factor, recombinant) per
						  IU
00
00
N
N
J7198
Anti-inhibitor, per IU
00
00
003
N
N
N
J7308
Aminolevulinic acid HCI, top adm, 20%, sgl unit dose
						  form (354 mg)
00
00
003
N
N
N
J7330
Autologous cultured chondrocytes, implant
00
00
003
N
Y
N
J7350
Dermal tissue, human, inj, w/o metabolized active elem,
						  per 10 mg
00
00
N
N
Y
J7502
Cyclosporine, oral, 100 mg
00
00
Y
N
N
J7511
Lymphocyte immune glob, antithymocyte glob, rabbit,
						  paren, 25 mg
00
00
003
N
N
N
J7513
Daclizumab, parenteral, 25 mg
00
00
003
N
N
N
J7515
Cyclosporine, oral, 25 mg
00
00
Y
N
N
J7516
Cyclosporine, parenteral, 250 mg
00
00
Y
N
N
J7517
Mycophenolate mofetil, oral, 250 mg
00
00
Y
N
N
J7520
Sirolimus, oral, 1 mg
00
00
Y
N
N
J7525
Tacrolimus, parenteral, 5 mg
00
00
Y
N
N
J9017
Arsenic trioxide, 1 mg (Trisenox)
00
00
003
N
N
N
J9151
Daunorubicin citrate, liposomal formulation, 10
						  mg
00
00
003
N
N
N
J9357
Valrubicin, intravesical, 200 mg
00
00
003
N
N
N
Q2006
Injection, digoxin immune fab (ovine), per
						  vial
00
00
003
N
N
N
Q2008
Injection, fomepizole, 15 mg
00
00
003
N
N
N
Q2009
Injection, fosphenytoin, 50 mg
00
00
003
N
N
N
Q2011
Injection, hemin, per 1 mg
00
00
003
N
N
N
Q2012
Injection, pegademase bovine, 25 IU
00
00
003
N
N
N
Q2013
Injection, pentastarch, 10% solution, per 100
						  ml
00
00
003
N
N
Y
Q2017
Injection, teniposide, 50 mg
00
00
003
N
N
N
Q2019
Injection, basiliximab, 20 mg
00
00
003
N
N
N
Q2020
Injection, histrelin acetate, 10 mg
00
00
003
N
N
Y
Q2021
Injection, lepirudin, 50 mg
00
00
003
N
N
N
Q2022
von Willebrand factor complex, human, per
						  IU
00
00
003
N
N
N
Q3025
Injection, interferon beta-1A, 11mcg for IM
						  use
00
00
003
N
N
N
Q3026
Injection, interferon beta-1A, 11mcg for subcu
						  use
00
00
003
N
N
N
S0016
Injection, amikacin sulfate, 500 mg
00
00
003
N
N
Y
S0017
Injection, aminocaproic acid, 5 grams
00
00
003
N
N
Y
S0021
Injection, ceftoperazone sodium, 1 gram
00
00
003
N
N
Y
S0023
Injection, cimetidine HCI, 300 mg
00
00
003
N
N
Y
S0028
Injection, famotidine, 20 mg
00
00
003
N
N
Y
S0030
Injection, metronidazole, 500 mg
00
00
003
N
N
Y
S0032
Injection, nafcillin sodium, 2 grams
00
00
003
N
N
Y
S0034
Injection, ofloxacin, 400 mg
00
00
003
N
N
Y
S0039
Injection, sulfamethoxazole and trimethoprim, 10
						  ml
00
00
003
N
N
Y
S0040
Injection, ticarcillin disodium and clavulanate
						  potassium, 3.1 grams
00
00
003
N
N
Y
S0071
Injection, acyclovir sodium, 50 mg
00
00
003
N
N
Y
S0072
Injection, amikacin sulfate, 100 mg
00
00
003
N
N
Y
S0073
Injection, aztreonam, 500 mg
00
00
003
N
N
Y
S0074
Injection, cefotetan disodium, 500 mg
00
00
003
N
N
Y
S0077
Injection, clindamycin phosphate, 300 mg
00
00
003
N
N
Y
S0080
injection, pentamidine isethionate, 300 mg
00
00
003
N
N
Y
S0081
Injection, piperacillin sodium, 500 mg
00
00
003
N
N
Y
S0092
Injection, hydromorphone hydrochloride, 250
						  mg
00
00
003
N
N
Y
S0093
Injection, morphine sulfate, 500 mg
00
00
003
N
N
Y
S0610
Annual gynecological examination; new
						  patient
00
00
N
N
Y
S0610
Annual gynecological examination; new
						  patient
N
00
00
N
N
Y
S0612
Annual gynecological examination; established
						  patient
1
00
00
N
N
Y
S2112
Arthroscopy, knee, surgical for harvesting of
						  cartilage
2
00
00
N
Y
Y
S2112
Arthroscopy, knee, surgical for harvesting of
						  cartilage
8
00
00
N
Y
Y
S2115
Osteotomy, periacetabular, with internal
						  fixation
2
00
00
N
N
Y
S2115
Osteotomy, periacetabular, with internal
						  fixation
8
00
00
N
N
Y
S2202
Echosclerotherapy
1
00
00
N
N
Y
S2342
Nasal endoscopy for post-op debridement, unilateral or
						  bilateral
2
00
00
N
N
Y
S2342
Nasal endoscopy for post-op debridement, unilateral or
						  bilateral
8
00
00
N
N
Y
S2350
Diskectomy, anterior; lumbar, single
						  interspace
2
00
00
N
N
Y
S2350
Diskectomy, anterior; lumbar, single
						  interspace
8
00
00
N
N
Y
S2351
Diskectomy, anterior; lumbar, each additional
						  interspace
2
00
00
N
N
Y
S2351
Diskectomy, anterior; lumbar, each additional
						  interspace
8
00
00
N
N
Y
S2400
Repair, congenital diaphragmatic hernia in the fetus,
						  in utero
2
00
00
Y
N
Y
S2400
Repair, congenital diaphragmatic hernia in the fetus,
						  in utero
8
00
00
Y
N
Y
S2401
Repair, urinary tract obstruction in fetus, in
						  utero
2
00
00
Y
N
Y
S2401
Repair, urinary tract obstruction in fetus, in
						  utero
8
00
00
Y
N
Y
S2402
Repair, congenital cystic adenomatoid malformation in
						  fetus, in utero
2
00
00
Y
N
Y
S2402
Repair, congenital cystic adenomatoid malformation in
						  fetus, in utero
8
00
00
Y
N
Y
S2403
Repair, extralobar pulmonary sequestration in fetus, in
						  utero
2
00
00
Y
N
Y
S2403
Repair, extralobar pulmonary sequestration in fetus, in
						  utero
8
00
00
Y
N
Y
S2404
Repair, myelomeningocele in fetus, in utero
2
00
00
Y
N
Y
S2404
Repair, myelomeningocele in fetus, in utero
8
00
00
Y
N
Y
S2405
Repair of sacrococcygeal teratoma in fetus, in
						  utero
2
00
00
Y
N
Y
S2405
Repair of sacrococcygeal teratoma in fetus, in
						  utero
8
00
00
Y
N
Y
S2409
Repair, congenital malformation of fetus, in utero,
						  NOC
2
00
00
Y
N
Y
S2409
Repair, congenital malformation of fetus, in utero,
						  NOC
8
00
00
Y
N
Y
S2411
Fetoscopic laser therapy for tx of twin-to-twin
						  transfusion syndrome
2
00
00
Y
N
Y
S2411
Fetoscopic laser therapy for tx of twin-to-twin
						  transfusion syndrome
8
00
00
Y
N
Y
S3620
Newborn metabolic screening panel
C
00
00
N
N
Y
S3620
Newborn metabolic screening panel
T
00
00
N
N
Y
S3701
Immunoassay for nuclear matrix protein 22,
						  quantitative
C
00
00
N
N
Y
S3701
Immunoassay for nuclear matrix protein 22,
						  quantitative
P
00
00
N
N
Y
S3701
Immunoassay for nuclear matrix protein 22,
						  quantitative
T
00
00
N
N
Y
S3831
Single-mutation analysis for HNPCC genetic
						  testing
C
00
00
N
N
Y
S3831
Single-mutation analysis for HNPCC genetic
						  testing
P
00
00
N
N
Y
S3831
Single-mutation analysis for HNPCC genetic
						  testing
T
00
00
N
N
Y
S3835
Complete gene seq analysis for cystic fibrosis genetic
						  testing
C
00
00
N
N
Y
S3835
Complete gene seq analysis for cystic fibrosis genetic
						  testing
P
00
00
N
N
Y
S3835
Complete gene seq analysis for cystic fibrosis genetic
						  testing
T
00
00
N
N
Y
S3837
Complete gene sequence analy for hemochromatosis
						  genetic testing
C
00
00
N
N
Y
S3837
Complete gene sequence analy for hemochromatosis
						  genetic testing
P
00
00
N
N
Y
S3837
Complete gene sequence analy for hemochromatosis
						  genetic testing
T
00
00
N
N
Y
S3904
Masters two step
C
00
00
N
N
Y
S3904
Masters two step
P
00
00
N
N
Y
S3904
Masters two step
T
00
00
N
N
Y
S8030
Scleral app of tantalum ring(s) for local lesions for
						  proton beam therapy
2
00
00
N
N
Y
S8030
Scleral app of tantalum ring(s) for local lesions for
						  proton beam therapy
8
00
00
N
N
Y
S8037
Magnetic resonance cholangiopancreatography
C
00
00
N
N
Y
S8037
Magnetic resonance cholangiopancreatography
P
00
00
N
N
Y
S8037
Magnetic resonance cholangiopancreatography
T
00
00
N
N
Y
S8075
Computer analy full-field dig mammogram & phy
						  review for interpretation
C
00
00
N
N
Y
S8075
Computer analy full-field dig mammogram & phy
						  review for interpretation
P
00
00
N
N
Y
S8075
Computer analy full-field dig mammogram & phy
						  review for interpretation
T
00
00
N
N
Y
S8110
Peak expiratory flow rate (physician
						  services)
C
00
00
N
N
Y
S8110
Peak expiratory flow rate (physician
						  services)
P
00
00
N
N
Y
S8110
Peak expiratory flow rate (physician
						  services)
T
00
00
N
N
Y
S9015
Automated EEG monitoring
C
00
00
N
N
Y
S9015
Automated EEG monitoring
P
00
00
N
N
Y
S9015
Automated EEG monitoring
T
00
00
N
N
Y
S9024
Paranasal sinus ultrasound
C
00
00
N
N
Y
S9024
Paranasal sinus ultrasound
P
00
00
N
N
Y
S9024
Paranasal sinus ultrasound
T
00
00
N
N
Y
S9109
CHF telemonitoring, equip rent, and maintenance, per
						  month
1
00
00
N
N
Y
V2623
Prosthetic eye, plastic, custom
D
00
00
N
N
Y
V2629
Prosthetic eye, other type
D
00
00
N
N
Y
1 Please note:
			 For claims received on July 1, 2005 and after, procedure code G0296 will be
			 restricted to a detail diagnosis included in List 015.