Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.05-088 - Transportation Provider Manual Update Transmittal #73; Vision Care Provider Manual Update Transmittal #68; Private Duty Nursing Provider Manual Update Transmittal #61

Current through Register Vol. 49, No. 6, June, 2024
252.100
Ambulance Procedure Codes
93041*
A0380
A0382
A0390
A0398
A0422
A0426
A0427
A0429
J0150*
J1940*
J2270*
J3490*
J0152*
J0170*
J0280*
J0460*
J1094*
J1100*
J1160*
J1200*
J2060*
J2175*
J2310*
J2550*
J2560*
J3360*
J3410*
J3475*
J3480*
Q4076*
* Procedure code can be billed
only
in
				conjunction with procedure code
A0427.
Procedure Code
Required Modifier
Description
A0436
Emergency, per mile, loaded, helicopter air
						  ambulance
A0422
U1
Emergency, oxygen, helicopter air ambulance
A0431
Ambulance service, emergency, basic pick-up,
						  helicopter, one unit per day
A0428
Ambulance service, ILS intermediate transport, mileage
						  and disposable supplies billed separately
A0380
TF
ILS mileage (per mile)
T2002**
Non-emergency ground ambulance transportation, hospital
						  to nursing facility
A0435
U1, UB U2, UB U3, UB U4, UB
U5, UB
U6, UB
Piston propelled fixed air ambulance per mile
Turboprop fixed wing air ambulance per mile
Jet (fixed wing) one unit equals one mile
Piston propelled fixed wing air ambulance per hour
						  (Round to the nearest hour.)
Turboprop fixed wing air ambulance per hour (Round to
						  the nearest hour.)
Jet (fixed wing) one unit equals one hour (Round to the
						  nearest hour.)
A0434
Air Ventilator/Respiratory Therapist, one unit equals
						  one hour (Round to the nearest hour.)
** Procedure code must be billed on a paper CMS-1500 claim form
				with the supporting documentation listed in section
				213.100.
242.110
Visual Procedure Codes
The following services are covered under the Arkansas Medicaid
				Program.
Procedure Code
Required Modifier
Description
Coverage
Under 21
Over 21
DIAGNOSTIC AND ANCILLARY
						  SERVICES
S0620 S0621
VISION ANALYSIS AND DIAGNOSIS (SINGLE VISION)
This service must include the following: case history,
						  general health observation, external exam of the eye and adnexa,
						  ophthalmoscopic examination, determination of refractive state, basic
						  sensorimotor and binocularity examination. It may also include initiation of
						  diagnostic and treatment programs or referral.
yes
yes
92340
PRESCRIPTION SERVICES This service includes
						  determination of prescription, sizing, ordering, verification, dispensing of
						  spectacles and follow-up services for the life of the prescription.
yes
yes
99173
UB
PRELIMINARY EVALUATION (MODIFIED SCREENING) This
						  procedure must include at minimum three of the services listed under procedure
						  code V0100. This code may not be billed in conjunction with procedure code
						  V0100.
yes
yes
CONTACT LENS SERVICES
S0592
VISION ANALYSIS AND CONTACT LENS EXAM
This service must include the following: biomicroscopy,
						  multiple ophthalmometry, case history, tear flow, measurement of ocular adnexa,
						  initial tolerance evaluation, and may include other tests. This procedure does
						  not include contact lens and should be billed in conjunction with other contact
						  lens procedure codes. If billing this code,
DO NOT
bill V0100.
						  Contacts and glasses may be ordered using this code.
yes W/PA
yes W/PA
S0512
SUPPLYING AND FITTING OF CONTACT LENS (HARD) Spherical,
						  aphakic, lenticular, toric, prism ballast (per lens)
yes W/PA
yes W/PA
S0512
SUPPLYING AND FITTING OF CONTACT LENS (SOFT) Spherical,
						  aphakic, lenticular, toric, hydrophilic (per lens)
yes W/PA
yes W/PA
S0512
SUPPLYING AND FITTING OF CONTACT LENS (GAS PERMEABLE)
						  Spherical, aphakic, lenticular, toric, prism ballast (per lens)
yes W/PA
yes W/PA
V2501
UA
SUPPLYING AND FITTING OF KERATOCONUS LENS (HARD OR GAS
						  PERMEABLE) - per lens
yes W/PA
yes W/PA
S0512
SUPPLYING AND FITTING OF MONOCULAR LENS (HARD OR GAS
						  PERMEABLE)-per lens
yes W/PA
yes W/PA
V2501
U1
SUPPLYING AND FITTING OF MONOCULAR LENS (SOFT LENS)
						  -per lens
yes W/PA
yes W/PA
LOW VISION SERVICES
92002
UB
LOWVISION EVALUATION
yes W/PA
yes W/PA
SUPPLEMENTAL PROCEDURES
92081
U1
VISUAL FIELD - Electronic or Goldmann
yes
yes
92081
U1
VISUAL FIELD - Confrontation Perimetry
yes
yes
MISCELLANEOUS SERVICES
92100
UB
TONOMETRY
This procedure will only be covered when medically
						  necessary. These conditions include, but are not limited to,
diabetes, hypertension and age of the
						  patient.
yes
yes
92393
OCULAR PROSTHESIS
This procedure must include fitting,
prescriptions and supplying of stock artificial eyes
						  with medical supervision of adaptation.
yes W/PA
no
V2624
-
CLEANING OF PROSTHESIS
yes W/PA
no
REPAIRS AND MATERIAL SERVICES
V2025
FRAME REPLACEMENT This procedure is for professional
						  services only when replacing the whole frame. This procedure may be billed in
						  conjunction with procedure code 92390 (Z0146) for material cost or the material
						  may be ordered through the current optical contractor.
yes
no
PROFESSIONAL SERVICES FOR LENS
						  REPLACEMENT
S0504
RP
LENS REPLACEMENT - SINGLE
VISION
This procedure is for professional services only. It
						  may be billed in conjunction with procedure code 92390
(Z0146) or through the current optical
						  contractor.
yes
yes W/PA
S0506
RP
LENS REPLACEMENT - BIFOCAL This procedure is for
						  professional services only. It may be billed in conjunction with procedure code
						  92390 (Z0146) or through the current optical contractor.
yes
yes W/PA
CONTACT LENS REPLACEMENT
92326
"
HARD LENS (PER LENS)
This procedure code does not include a professional
						  fee.
yes W/PA
no
92326
"
SOFT LENS (PER LENS)
This procedure code does not include a professional
						  fee.
yes W/PA
no
92326
"
GAS PERMEABLE (PER LENS)
This procedure code does not include a professional
						  fee.
yes W/PA
no
92396
-
APHAKIC LENS Post-operative cataract.
yes
yes W/PA
92390
SPECTACLE MATERIAL Cost of material for replacing
						  frame, front, temple. This procedure code may be billed in conjunction with
						  V2025 (Z0124), S0504 (Z0134) and S0506 (Z0136). This price may not exceed our
						  maximum rates established with our current optical contractor. When this code
						  is used, an invoice must be attached.
yes
no
V2799
-
UNSPECIFIED PROCEDURE
yes
yes
W/PA
=
Coverage with prior
				authorization.
242.120
Simultaneous Care of Two
			 Patients
When a private duty nurse is caring for two patients
				simultaneously in the same location, the following procedure codes are to be
				used for the care provided to the second patient:
Procedure Code
Required Modifier
Description
S9123
UB
Private duty nurse, RN, 2nd
						  patient. Medicaid maximum allowable is 50% of the rate for S9123.
S9124
UB
Private duty nurse, LPN, 2nd
						  patient. Medicaid maximum allowable is 50% of the rate forS9124.
242.130
Medical Supplies Procedure
			 Codes
The following HCPCS procedure codes must be used when billing
				the Arkansas Medicaid Program for medical supplies.
A4206
A4216
A4217
A4221
A4222
A4253
A4256
A4259
A4265
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4322
A4326
A4327
A4328
A4330
A4338
A4340
A4344
A4346
A4347
A4348
A4351
A4352
A4354
A4355
A4356
A4357
A4358
A4359
A4361
A4362
A4364
A4367
A4369
A4371
A4397
A4398
A4399
A4400
A4402
A4404
A4405
A4406
A4414
A4452
A4454
A4455
A4558
A4560
A4561
A4562
A4623
A4624
A4625
A4626
A4628
A4629
A4772
A4927
A5051
A5052
A5053
A5054
A5055
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5093
A5102
A5105
A5112
A5113
A5114
A5119
A5121
A5122
A5126
A5131
A6154
A6234
A6241
A6242
A6248
A6441
A6442
A6443
A6444
A6445
A6446
A6447
A6448
A6449
A6450
A6451
A6452
A6453
A6454
A6455
A7520
A7521
A7522
A7524
A7525
B4086
E0776
National HCPCS Codes
Procedure Code
Required Modifier
Description
A6257
Transparent Film, each (16 square inches or
						  less)
A6258
Transparent Film, each (more than 16, but less than 48
						  square inches)
A6259
Transparent Film, each (more than 48 square
						  inches)
A6216 A6219 A6228
Gauze Pad, Medicated or Non-Medicated, each (16 square
						  inches or less)
A6220 A6229 A6217
Gauze Pads, Medicated or Non-Medicated, each (more than
						  16, but less than 48 square inches)
A6221 A6230 A6218
Gauze Pads, Medicated or Non-Medicated, each (more than
						  48 square inches)
A4450
Gauze, Non-Elastic, Per Roll (1 linear
						  yard)
A6245 A6242
Hydro gel Dressing, each (16 square inches or
						  less)
A6246
Hydro gel Dressing, each (more than 16, but less than
						  48 square inches)
A6247 A6244
Hydro gel Dressing, each (more than 48 square
						  inches)
A6248
Hydro gel Dressing, each (1 ounce)
A6237 A6234
Hydrocolloid Dressing, each (16 square inches or
						  less)
A6238 A6235
Hydrocolloid Dressing, each (more than 16, but less
						  than 48 square inches)
A6236 A6239
Hydrocolloid Dressing, each (more than 48 square
						  inches)
A6196
Alginate Dressing, each (16 square inches or
						  less)
A6197
Alginate Dressing, each (more than 16, but less than 48
						  square inches)
A6198
Alginate Dressing, each (more than 48 square
						  inches)
A6197
UB
Alginate Dressing, each (1 linear yard)
A6209
Foam Dressing, each (16 square inches or
						  less)
A6210
Foam Dressing, each (more than 16, but less than 48
						  square inches)
A6211
Foam Dressing, each (more than 48 square
						  inches)
A6200
Composite Dressing, each (16 square inches or
						  less)
A6201
Composite Dressing, each (more than 16, but less than
						  48 square inches)
A6202
Composite Dressing, each (more than 48 square
						  inches)
A4253
UB
Blood Glucose test or reagent strip for home blood
						  glucose monitor, per 25 strips
A4353
Urinary intermittent catheter with insertion
						  tray
A4394
Ostomy deodorant, all types, per ounce
A4365
Adhesive remover wipes, 50 per box
A4368
Ostomy filters, any type, each
A4483
Tracheostomy vent-heat moisture device
L8239*
Stocking (Jobst)
* Refer to section
				242.430.