016.06.08 Ark. Code R. 008 - 2008 HCPCS & CPT Procedure Code Conversion

I. General Information

A review of the 2008 CPT procedure codes has been completed, and the Arkansas Medicaid Program will begin accepting CPT 2008 procedure codes for dates of service on and after March 1, 2008. Please add this information to your Medicaid provider manual until revised manual sections have been included in future updates.

Procedure codes that are identified as deletions in CPT 2008 (Appendix B) are non-payable for dates of service on and after March 1, 2008.

For the benefit of those programs impacted by the conversions, the Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2008 CPT and HCPCS conversions.

II. Non-Covered CPT 2008 Procedure Codes
A. Effective for dates of service on and after March 1, 2008, the following CPT procedure codes are non-payable. Arkansas Medicaid does not cover the services they represent.

21073

34806

90661

90662

90663

93982

96125

98966

98967

98968

98969

99174

99366

99367

99368

99408

99409

99441

99442

99443

99444

99605

99606

99607
B. All CPT 2008 procedure codes listed in Category II and Category III are non-covered.
C. Effective for dates of service on and after March 1, 2008, the following new 2008 CPT procedure codes are not payable to Outpatient Hospitals and Ambulatory Surgical Centers because these services are covered by another CPT procedure code, another HCPCS code or a revenue code.

20985

20986

20987

22208

33257

33258

33259

36591

36592

90770

90771

90776
D. Effective for dates of service on and after March 1, 2008, the following new 2008 CPT procedure codes are not payable to physicians and certified nurse midwives because these services are covered by another CPT procedure code, another HCPCS code or a revenue code.

99406

99407
E. Effective for dates of service on and after March 1, 2008, the following currently payable 2008 CPT procedure codes have revised descriptions and are no longer payable to outpatient hospitals and ambulatory surgical centers because these services are covered by another CPT procedure code, another HCPCS code, or another revenue code.

20930

20931

20936

20937

20938

22840

22841

22842

22843

22844

22845

22846

22847

22848

22851

33517

33518

33519

33521

33522

33523

35600

49568

51797
F. Revised CPT Descriptions Affecting Multiple Provider Types

Effective for dates of service on and after March 1, 2008, procedure code 90698 will become non-payable for all provider types.

III. Prior Authorization
A. The following 2008 CPT procedure codes require prior authorization from AFMC.

27416

28446

58570

58571

58572

58573
B. The following existing CPT procedure codes will become payable effective for dates of service on or after March 1, 2008. The procedure codes require prior authorization from AFMC.

58541

58542

58543

58544
IV. CPT 2008 Procedure Codes Manually Reviewed

Effective for dates of service on and after March 1, 2008, the new CPT procedure codes listed below are manually reviewed before payment. Providers must submit claims as indicated below:

A. CPT Procedure Code 90284 will be approved for payment based on a diagnosis code that proves medical necessity.
B. Effective for dates of service on and after March 1, 2008, the following CPT procedure codes require a paper claim with form DMS-2606 attached.

58570

58571

58572

58573
V. Current Procedure Codes to Become Payable

The following existing CPT procedure codes will become payable effective for dates of service on or after March 1, 2008 for physicians, hospitals and ambulatory surgical centers. These procedure codes will be manually reviewed prior to payment and require prior authorization from AFMC and a paper claim with form DMS-2606 attached.

58541

58542

58543

58544
VI. New Local HCPCS Procedure Code

Effective for dates of service on and after March 1, 2008, the following locally assigned HCPCS procedure code is payable to Arkansas Medicaid physician providers. This procedure code requires manual review prior to payment and must be billed on a paper claim form with form DMS-2606 attached. See sections 272.100, 292.440, 292.444 and 292.447 of the Physician Provider Manual.

Procedure Code

Description

Z9950

Anesthesia for laparoscopic supracervical hysterectomy
VII. The following codes are payable to podiatrists:

29904

29905

29906

29907

36591

36592
VIII. The following codes are payable to oral surgeons:

36591

36592
IX. Effective for dates of service on or after March 1, 2008 the following CPT procedure codes are payable to Certified Nurse Midwives:

36591

36592

90769

90770

90771
X. CPT Procedure Codes Payable to Ambulatory Surgical Centers
A. The following CPT 2008 procedure codes are payable to ambulatory surgical centers.

CPT 2008 Procedure Codes Payable to Ambulatory Surgical Centers

20555

22206

22207

24357

24358

24359

27267

27268

27269

27416

27726

27767

27768

27769

28446

29828

29904

29905

29906

29907

32421

32422

32550

32551

32560

33864

35523

36593

41019

49203

49204

49205

49440

49441

49442

49446

49450

49451

49452

49460

49465

50385

50386

50593

51100

51101

51102

52649

55920

57285

57423

58570

58571

58572

58573

60300

67041

67042

67043

67113

67229

68816

75557

75558

75559

75560

75561

75562

75563

75564

80047

82610

83993

84704

86356

86486

87500

87809

88381

89322

89331

95980

95981

95982
B. The following current CPT procedure codes are payable to Ambulatory Surgical Centers:

58541

58542

58543

58544
XI. Additional Information

Procedure code 84704 is exempt from ARKids First-B copayment.

Thank you for your participation in the Arkansas Medicaid Program.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-8323 or (501) 682-6789 (TDD); In-State Toll Free at 800-482-1141 or Out-of-State Toll Free at 800-482-5850. The Toll-Free lines are voice only.

Please direct inquiries regarding this Official Notice to the EDS Provider Assistance Center at 501-376-2211 or (In-State Toll Free) 800-457-4454.

Arkansas Medicaid provider manuals, update transmittals, proposed rules for public comment, official notices and remittance advice (RA) messages can be downloaded without charge from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Roy Jeffus, Director

I. General Information

A review of the 2008 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 March 1, 2008.

II. 2008 HCPCS Payable Procedure Codes Tables Information

Procedure codes have been broken into separate tables. Tables have been created for each affected provider type (e.g.: prosthetics, home health etc.).

The tables of payable procedure codes for all affected programs 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 of the list contains the HCPCS procedure codes. The procedure code may be shown on multiple lines on the table, depending on the applicable modifier based on the service performed.

II. 2008 HCPCS Payable Procedure Code Tables Information

The second column shows procedure codes that require manual pricing and is titled Manually Priced 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.

Certain procedure codes are covered only when the primary diagnosis is covered within a specific diagnosis range. This information is used, for example, by physicians, hospitals and others. The third and fourth columns, for all affected programs, indicate the beginning and ending range of diagnoses for which a procedure code may be used. (e.g.: 0530 through 0549).

The fifth column contains information about the diagnosis list for which a procedure code may be used. (See Section III below for more information about diagnosis range and lists.)

The sixth column indicates whether a procedure is subject to medical review before payment. The column is titled "Review Y/N". The letter "Y" in the column indicates 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 seventh 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" indicates 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 eighth column indicates any modifiers that must be used in conjunction with the procedure code, when billed, either electronically or on paper.

The ninth column indicates a procedure code requiring a prior approval letter from the Arkansas Medicaid Medical Director. The letter "Y" in the column indicates that a procedure code requires a prior approval letter and an "N" indicates that a prior approval letter is not required. A prior approval letter, when required, must be attached to the paper claim when it is filed.

Please Note: The Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2008 CPT and HCPCS conversions.

III. Diagnosis Range and Diagnosis Lists

Certain procedure codes are covered only when the primary diagnosis is covered within a diagnosis range or on a diagnosis list.

Diagnosis List 003

042, 140.0 through 208.91

230.0 through 238.9

IV. HCPCS Procedure Codes Payable to Ambulatory Surgical Centers (ASC) The following information is related to procedure codes found in the ASC table.

J7321, J7322, J7323 J7324K

Prior authorization must be obtained through the Utilization Review Section of the Division of Medical Services (DMS). A written request must be submitted to the Division of Medical Services Utilization Review Section.

The request must include the patient's name, Medicaid ID number, physician's name, physician's Arkansas Medicaid provider number and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one series of injections per knee, per beneficiary, per lifetime.

The contact information for Utilization Review is:

In-State WATS:

Direct: (501) 682-8340

Toll Free: 1-800-482 -5850, Extension 28340

FAX: (501) 682-8013

Mailing Arkansas Division of Medical Services Utilization

Review Section Address: P. O. Box 1437, Slot S413

Little Rock, AR 72203-1437

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

(1) an ICD-9-CM diagnosis code of 335.20 and symptoms of muscle weakness.
(2) documentation of muscle testing must be provided.
(3) a completed evaluation by a neurologist to rule out other causes of muscle weakness.

2008 Codes

Manually Priced Y/N

Beginning Diagnosis Range

Ending Diagnosis Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior Approval Letter (Y/N)

J7321K

N

N

Y

N

J7322K

N

N

Y

N

J7323K

N

N

Y

N

J7324K

N

N

Y

N

S2066

Y

N

Y

N

S2067

Y

N

Y

N

S3800H

Y

33520

33520

N

Y

*

N

* Bill any applicable modifiers with the procedure code.

V. HCPCS Procedure Codes Payable to ARKids First-B

B4087This procedure code is included in the $125 per month ARKidsFirst-B medical supply benefit limit.

2008 Codes

Manually Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review

Y/N

PA

Y/N

Modifier

Prior

Approval

Letter (Y/N)

B4087

N

N

N

NU

N
VI. HCPCS Procedure Codes Payable to Certified Nurse Midwife

Family planning services require a primary family planning detail diagnosis code.

The following information is related to procedure codes found in the family planning clinic table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol listed below applies to that procedure code in the grid.

J7307FThis procedure code requires a primary family planning detail diagnosis code. It is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

* Procedure codes J2791 and J7307 are exempt from ARKids First-B co-pay.

2008 Codes

Manually Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review

Y/N

PA

Y/N

Modifier

Prior

Approval

Letter (Y/N)

*J2791

N

N

N

N

*J7307F

N

N

N

FP

N
VII. HCPCS Procedure Codes Payable to Family Planning Clinic

Family planning services require a primary family planning detail diagnosis code.

The following information is related to procedure codes found in the family planning clinic table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol listed below applies to that procedure code in the grid.

J7307FThis procedure code requires a primary family planning detail diagnosis code. It is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

* Procedure code J7307 is exempt from ARKids First-B co-pay.

2008 Codes

Manually Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review

Y/N

PA

Y/N

Modifier

Prior

Approval

Letter (Y/N)

*J7307F

N

N

N

FP

N
VIII. HCPCS Procedure Codes Payable to Federally Qualified Health Centers (FQHC)

Family planning services require a primary family planning diagnosis code.

The following information is related to procedure codes found in the FQHC table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol listed below applies to that procedure code in the grid.

7307FThis procedure code is covered as a family planning benefit for

"regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit limited to two per seven years per beneficiary.

* Procedure code J7307 is exempt from ARKids First-B co-pay.

2008 Codes

Manually Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review

Y/N

PA

Y/N

Modifier

Prior

Approval

Letter (Y/N)

*J7307F

N

N

N

FP

N
IX. HCPCS Procedure Codes Payable to Arkansas Department of Health * Procedure code J2791 is exempt from ARKids First-B co-pay.

2008 Codes

Manually Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review

Y/N

PA

Y/N

Modifier

Prior

Approval

Letter (Y/N)

*J2791

N

N

N

N
X. HCPCS Procedure Codes Payable to Home Health

B4087This procedure code is included in the $250.00 per month medical supply benefit limit.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter (Y/N)

B4087

N

N

N

N
XI. HCPCS Procedure Codes Payable to Hospitals

The following information is related to procedure codes found in the hospital table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol listed below applies to that procedure code in the grid.

C9240A.Coverage of this procedure code requires an ICD-9-CM diagnosis code of 174.0-175.9. Any one of the diagnosis codes from the above listed ranges is acceptable. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J0220BThis procedure code requires an ICD-9-CM diagnosis code of 271.0. An evaluation by a physician with a specialty in clinical genetics documenting progress is required annually. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

XI. HCPCS Procedure Codes Payable to Hospitals

J1743CThis procedure code requires an ICD-9-CM diagnosis code of 277.5 (MPSII) . An evaluation by a physician with a specialty in clinical genetics documenting progress and response to the medication is required annually. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J2323DA prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. A history and physical showing a relapse of multiple sclerosis must be submitted. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J2778EThis procedure code requires an ICD-9-CM diagnosis code of362.50 or 362.52 as the principle diagnosis. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J7307FFamily planning services require a family planning diagnosis code.

This procedure code is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

J9303GThis procedure code requires an ICD-9-CM diagnosis code of 153.0-154.8. A prior approval letter from the DMS Medical Director is required for billing and must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

(1) an ICD-9-CM diagnosis code of 335.20 and symptoms of muscle weakness.
(2) documentation of muscle testing must be provided.
(3) a completed evaluation by a neurologist to rule out other causes of muscle weakness.
XI. HCPCS Procedure Codes Payable to Hospitals

J7321, J7322, J7323 J7324K

Prior authorization must be obtained through the Utilization Review Section of the Division of Medical Services (DMS). A written request must be submitted to the Division of Medical Services Utilization Review Section.

The request must include the patient's name, Medicaid ID number, physician's name, physician's Arkansas Medicaid provider number and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one series of injections per knee, per beneficiary, per lifetime.

The contact information for Utilization Review is:

In-State WATS:

Direct: (501) 682-8340

Toll Free: 1-800-482 -5850 Extension 28340

FAX: (501) 682-8013

Mailing Arkansas Division of Medical Services Utilization

Review Section Address: P. O. Box 1437, Slot S413

Little Rock, AR 72203-1437

* Procedure codes J2791 and J7307 are exempt from ARKids First-B co-pay.

* Procedure codes J1561,J1568and J1569will be reviewed for medical necessity based on diagnosis code.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

A9572

N

N

N

N

A9576

N

N

N

N

A9577

N

N

N

N

A9578

N

N

N

N

A9579

N

N

N

N

C2698

Y

N

N

N

C2699

Y

N

N

N

C9237

Y

N

N

N

C9238

Y

N

N

N

C9239

Y

003

N

N

N

C9240A

Y

1740

1759

Y

N

Y

J0220B

N

2710

2710

Y

N

Y

J0400

N

N

N

N

J1561.

N

Y

N

N

J1568.

N

Y

N

N

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

J1569.

N

Y

N

N

J1571

N

N

N

N

J1572

N

N

N

N

J1573

N

N

N

N

J1743C

N

2775

2775

Y

N

Y

J2323D

N

Y

N

Y

J2724

N

N

N

N

J2778E

N

Y

N

Y

*J2791

N

N

N

N

J3488

N

N

N

N

*J7307F

N

N

N

N

J7321K

N

N

Y

N

J7322K

N

N

Y

N

J7323K

N

N

Y

N

J7324K

N

N

Y

N

J7347

N

N

N

N

J7349

N

N

N

N

J9226

N

003

N

N

N

J9303G

N

1530

1548

Y

N

Y

S2066

Y

N

Y

*

N

S2067

Y

N

Y

*

N

S3800H

Y

33520

33520

N

Y

*

N

* Bill any applicable modifiers with the procedure code.

XII. HCPCS Procedures Codes Payable to Independent Lab

S3800 H This procedure code requires prior authorization by AFMC based on the following criteria:

(1) an ICD-9-CM diagnosis code of 335.20 and symptoms of muscle weakness.
(2) documentation of muscle testing must be provided.
(3) a completed evaluation by a neurologist to rule out other causes of muscle weakness.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

S3800H

Y

33520

33520

N

Y

*

N

* Bill any applicable modifiers with the procedure code.

XIII. HCPCS Procedures Codes Payable to Independent Radiology

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

A9572

N

N

N

N

A9576

N

N

N

N

A9577

N

N

N

N

A9578

N

N

N

N

A9579

N

N

N

N

C2698

Y

N

N

*

N

C2699

Y

N

N

*

N

*Bill any applicable modifiers with the procedure code.

XIV. HCPCS Procedure Codes Payable to Nurse Practitioners

*Procedure codes J1561will be reviewed for medical necessity base on diagnosis code.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

J1561.

N

Y

N

N
XV. HCPCS Procedure Codes Payable to Physicians and Area Health Care Education Centers (AHECs)

The following information is related to procedure codes found in the physicians and AHECs section table. Reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the grid.

C9240A.Coverage of this procedure code requires an ICD-9-CM diagnosis code of 174.0-175.9. Any one of the diagnosis codes from the above listed ranges is acceptable. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

XV. HCPCS Procedure Codes Payable to Physicians and Area Health Care Education Centers (AHECs)

J0220BThis procedure code requires an ICD-9-CM diagnosis code of 271.0. An evaluation by a physician with a specialty in clinical genetics documenting progress is required annually. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J1743CThis procedure code requires an ICD-9-CM diagnosis code of 277.5 (MPSII) . An evaluation by a physician with a specialty in clinical genetics documenting progress and response to the medication is required annually. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J2323DA prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each paper claim. A history and physical showing a relapse of multiple sclerosis must be submitted. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J2778EThis procedure code requires an ICD-9-CM diagnosis code of 362.50 or 362.52 as the principle diagnosis. A prior approval letter from the DMS Medical Director is required for billing and a copy must be attached to each claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

J7307FFamily planning services require a family planning diagnosis code.

This procedure code is covered as a family planning benefit for "regular Medicaid" beneficiaries. It is not covered for aid category 69 beneficiaries. It is benefit-limited to two per seven years per beneficiary.

J9303GThis procedure code requires an ICD-9-CM diagnosis code of 153.0-154.8. A prior approval letter from the DMS Medical Director is required for billing and must be attached to each paper claim. Review the appropriate provider manual for additional coverage information and instructions for requesting prior approval or contact the DMS Medical Director at (501)-682-9868.

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

(1) an ICD-9-CM diagnosis code of 335.20 and symptoms of muscle weakness.
(2) documentation of muscle testing must be provided.
(3) a completed evaluation by a neurologist to rule out other causes of muscle weakness.

J7321, J7322, J7323 J7324K

Prior authorization must be obtained through the Utilization Review Section of the Division of Medical Services (DMS). Providers must specify the brand name of Hyaluronon or derivative when requesting prior authorization for this procedure code. A written request must be submitted to the Division of Medical Services Utilization Review Section.

The request must include the patient's name, Medicaid ID number, physician's name, physician's Medicaid provider number and medical records that document the severity of osteoarthritis, previous treatments and site of injection. Hyaluronon is limited to one series of injections per knee, per beneficiary, per lifetime.

The contact information for Utilization Review is:

In-State WATS:

Direct: (501) 682-8340

Toll Free: 1-800-482 -5850 Extension 28340

FAX: (501) 682-8013

Mailing Arkansas Division of Medical Services Utilization

Review Section Address: P. O. Box 1437, Slot S413

Little Rock, AR 72203-1437

* Procedure codes J2791 and J7307 are exempt from PCP referral and exempt from ARKids First-B co-pay.

* Procedure codes J1561,J1568and J1569will be reviewed for medical necessity base on diagnosis code.

Effective for dates of service on and after March 1, 2008, locally assigned HCPCS procedure code Z9950, "Anesthesia for laparoscopic supracervical hysterectomy," is payable to physicians and CRNAs. The procedure requires manual review before payment and it must be billed on a redlined paper claim form with form DMS-2606 attached.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

A9572

N

N

N

N

A9576

N

N

N

N

A9577

N

N

N

N

A9578

N

N

N

N

A9579

N

N

N

N

C9237

Y

N

N

N

C9238

Y

N

N

N

C9239

Y

003

N

N

N

C9240A

Y

1740

1759

Y

N

Y

J0220B

N

2710

2710

Y

N

Y

J0400

N

N

N

N

J1561.

N

Y

N

N

J1568.

N

Y

N

N

J1569.

N

Y

N

N

J1571

N

N

N

N

J1572

N

N

N

N

J1573

N

N

N

N

J1743C

N

2775

2775

Y

N

Y

J2323D

N

Y

N

Y

J2724

N

N

N

N

J2778E

N

Y

N

Y

*J2791

N

N

N

N

J3488

N

N

N

N

*J7307F

N

N

N

FP

N

J7321

N

N

Y

N

J7322

N

N

Y

N

J7323

N

N

Y

N

J7324

N

N

Y

N

J9226

N

003

N

N

N

J9303G

N

1530

1548

Y

N

Y

S2066

Y

N

Y

*

N

S2067

Y

N

Y

*

N

S3800H

Y

33520

33520

N

Y

*

N

Z9950

N

Y

N

N

*Bill any applicable modifiers with the procedure code.

XVI. HCPCS Procedure Codes Payable to Private Duty Nursing

B4087This procedure code is included in the medical supply benefit limit of $80.00 per month.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

B4087

N

N

N

N
XVII. HCPCS Procedure Codes Payable to Prosthetics

B4087This procedure code is included in the medical supply benefit limit of $250.00 per month. L3925This procedure code is included in the orthotic benefit limit of

$3000.00 per SFY for beneficiaries age 21 and over. L3929This procedure code is included in the orthotic benefit limit of

$3000.00 per SFY for beneficiaries age 21 and over L3931This procedure code is included in the orthotic benefit limit of

$3000.00 per SFY for beneficiaries age 21 and over.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

B4087

N

N

N

NU

N

L3925

N

N

N

NU

N

L3925

N

N

N

EP

N

L3929

N

N

N

NU

N

L3929

N

N

N

EP

N

L3931

N

N

N

NU

N

L3931

N

N

N

EP

N
XVIII. HCPCS Procedure Codes Payable to Rehabilitation Center

S3800HThis procedure code requires prior authorization by AFMC based on the following criteria:

(1) an ICD-9-CM diagnosis code of 335.20 and symptoms of muscle weakness.
(2) documentation of muscle testing must be provided.
(3) a completed evaluation by a neurologist to rule out other causes of muscle weakness.

2008 Codes

Manually

Priced

Y/N

Beginning

Diagnosis

Range

Ending

Diagnosis

Range

Diagnosis List

Review Y/N

PA Y/N

Modifier

Prior

Approval

Letter

(Y/N)

S3800H

Y

33520

33520

N

Y

*

N

*Bill any applicable modifiers with the procedure code.

XIX. Non-Covered 2008 HCPCS with Elements of CPT or Other Procedure Codes
A. The following 2008 HCPCS procedure codes are not payable because these services are covered by another CPT procedure code, another HCPCS procedure code or by a revenue code.

A7027

A7029

C9352

C9354

E0328

E2227

E2312

E2397

G8453

Q9965

Q9967

A7028

A9274

C9353

C9355

E0329

E2228

E2313

G8402

J7348

Q9966

S9152
B. Effective for dates of service on and after March 1, 2008, HCPCS

procedure code S2078 will not be payable because this service is now covered by a CPT procedure code.

XX. Non-Covered 2008 HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

A4252

B4088

C9728

G8373

G8388

G8407

G8426

G8441

G8458

G8473

J7603

S0272

A4648

C2638

D2970

G8374

G8389

G8408

G8427

G8442

G8459

G8474

J7604

S0273

A4650

C2639

E0856

G8375

G8390

G8409

G8428

G8443

G8460

G8475

J7605

S0274

A5083

C2640

G0396

G8376

G8391

G8410

G8429

G8445

G8461

G8476

J7632

S3905

A6413

C2641

G0397

G8377

G8395

G8415

G8430

G8446

G8462

G8477

J7676

T1503

A9155

C2642

G8351

G8378

G8396

G8416

G8431

G8447

G8463

G8478

L3925

V2787

A9276

C2643

G8354

G8379

G8397

G8417

G8432

G8448

G8464

G8479

L3927

A9277

C8921

G8357

G8380

G8398

G8418

G8433

G8449

G8465

G8480

L7611

A9278

C8922

G8360

G8381

G8399

G8419

G8434

G8450

G8466

G8481

L7612

A9283

C8923

G8362

G8382

G8400

G8420

G8435

G8451

G8467

G8482

L7613

A9501

C8924

G8365

G8383

G8401

G8421

G8436

G8452

G8468

G8483

L7614

A9509

C8925

G8367

G8384

G8403

G8422

G8437

G8454

G8469

G8484

L7621

A9569

C8926

G8370

G8385

G8404

G8423

G8438

G8455

G8470

G9140

L7622

A9570

C8927

G8371

G8386

G8405

G8424

G8439

G8456

G8471

J1300

S0270

A9571

C8928

G8372

G8387

G8406

G8425

G8440

G8457

G8472

J7602

S0271
XXI. Miscellaneous Changes
A. Several previously payable HCPCS codes have been deleted in the 2008 HCPCS conversion. Providers may use their current HCPCS book to find replacement codes.
B. Effective for dates of service on and after March 1, 2008, the procedure codes listed below have been added for beneficiaries age 21 and over. The procedure codes are included in the monthly incontinence supply benefit limit.

T4530 Pediatric sized disposable incontinence product,

brief/diaper, large size, each

T4532 Pediatric size disposable incontinence product, protective underwear/pull-on, large size, each

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 have already been incorporated.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-8323 or (501) 682-6789 (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

Notes

016.06.08 Ark. Code R. 008
5/1/2008

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

No prior version found.