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INDIANA HEALTH COVERAGE PROGRAMS

PROVIDER CODE TABLES

Published: April 10, 2018 1

Revenue Codes

Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables does not necessarily indicate current coverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedule for updates to coding, coverage, and benefit information. Previous versions of code tables are archived for purposes of historical reference.

For information about using revenue codes, see the Claim Submission and Processing provider reference module.

Revenue Codes and Outpatient Payment Methodologies Reviewed/Updated: March 15, 2018

Note: While this table includes all active revenue codes, the final three columns (Outpatient Payment Disposition, Outpatient Unit Restrictions, and Other Outpatient Billing Limitations) apply only to outpatient claims.

Providers are reminded to bill the appropriate revenue code descriptive of the service or of the setting where the service was delivered.

Revenue Code Description Outpatient Payment

Disposition Outpatient Unit

Restrictions Other Outpatient

Billing Limitations

100 All-Inclusive Room and Board Plus Ancillary

N/A N/A N/A

101 All-Inclusive Room and Board N/A N/A N/A 110 Room and Board Private – General N/A N/A N/A 111 Room and Board Private –

Medical/Surgical/Gynecological N/A N/A N/A

112 Room and Board Private – Obstetrics N/A N/A N/A 113 Room and Board Private – Pediatric N/A N/A N/A 114 Room and Board Private – Psychiatric N/A N/A N/A 115 Room and Board Private – Hospice N/A N/A N/A 116 Room and Board Private – Detoxification N/A N/A N/A 117 Room and Board Private – Oncology N/A N/A N/A 118 Room and Board Private – Rehabilitation N/A N/A N/A 119 Room and Board Private – Other N/A N/A N/A 120 Room and Board Semiprivate (2 Beds) –

General N/A N/A N/A

121 Room and Board Semiprivate (2 Beds) – Medical/Surgical/Gynecological

N/A N/A N/A

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Indiana Health Coverage Programs Revenue Codes








Billing Limitations

122 Room and Board Semiprivate (2 Beds) – Obstetrics

N/A N/A N/A

123 Room and Board Semiprivate (2 Beds) – Pediatric

N/A N/A N/A

124 Room and Board Semiprivate (2 Beds) – Psychiatric

N/A N/A N/A

125 Room and Board Semiprivate (2 Beds) – Hospice

N/A N/A N/A

126 Room and Board Semiprivate (2 Beds) – Detoxification

N/A N/A N/A

127 Room and Board Semiprivate (2 Beds) – Oncology

N/A N/A N/A

128 Room and Board Semiprivate (2 Beds) – Rehabilitation

N/A N/A N/A

129 Room and Board Semiprivate (2 Beds) – Other

N/A N/A N/A

130 Room and Board Semiprivate (3–4 Beds) – General

N/A N/A N/A

131 Room and Board Semiprivate (3–4 Beds) – Medical/Surgical/Gynecological

N/A N/A N/A

132 Room and Board Semiprivate (3–4 Beds) – Obstetrics

N/A N/A N/A

133 Room and Board Semiprivate (3–4 Beds) – Pediatric

N/A N/A N/A

134 Room and Board Semiprivate (3–4 Beds) – Psychiatric

N/A N/A N/A

135 Room and Board Semiprivate (3–4 Beds) – Hospice

N/A N/A N/A

136 Room and Board Semiprivate (3–4 Beds) – Detoxification

N/A N/A N/A

137 Room and Board Semiprivate (3–4 Beds) – Oncology

N/A N/A N/A

138 Room and Board Semiprivate (3–4 Beds) – Rehabilitation

N/A N/A N/A

139 Room and Board Semiprivate (3–4 Beds) – Other

N/A N/A N/A

140 Room and Board Private (Deluxe) – General

N/A N/A N/A









Billing Limitations

141 Room and Board Private (Deluxe) – Medical/Surgical/Gynecological

N/A N/A N/A

142 Room and Board Private (Deluxe) – Obstetrics

N/A N/A N/A

143 Room and Board Private (Deluxe) – Pediatric

N/A N/A N/A

144 Room and Board Private (Deluxe) – Psychiatric

N/A N/A N/A

145 Room and Board Private (Deluxe) – Hospice

N/A N/A N/A

146 Room and Board Private (Deluxe) – Detoxification

N/A N/A N/A

147 Room and Board Private (Deluxe) – Oncology

N/A N/A N/A

148 Room and Board Private (Deluxe) – Rehabilitation

N/A N/A N/A

149 Room and Board Private (Deluxe) – Other N/A N/A N/A 150 Room and Board Ward – General N/A N/A N/A 151 Room and Board Ward –

Medical/Surgical/Gynecological N/A N/A N/A

152 Room and Board Ward – Obstetrics N/A N/A N/A 153 Room and Board Ward – Pediatric N/A N/A N/A 154 Room and Board Ward – Psychiatric N/A N/A N/A 155 Room and Board Ward – Hospice N/A N/A N/A 156 Room and Board Ward – Detoxification N/A N/A N/A 157 Room and Board Ward – Oncology N/A N/A N/A 158 Room and Board Ward – Rehabilitation N/A N/A N/A 159 Room and Board Ward – Other N/A N/A N/A 160 Room and Board Other – General N/A N/A N/A 164 Room and Board Other – Sterile

Environment N/A N/A N/A

167 Room and Board Other – Self Care N/A N/A N/A 169 Room and Board Other – Other N/A N/A N/A 170 Nursery – General N/A N/A N/A 171 Nursery – Newborn Level I N/A N/A N/A 172 Nursery – Newborn Level II N/A N/A N/A









Billing Limitations

173 Nursery – Newborn Level III N/A N/A N/A 174 Nursery – Newborn Level IV N/A N/A N/A 179 Nursery – Other N/A N/A N/A 180 Leave of Absence – General N/A N/A N/A 182 Leave of Absence – Patient Convenience

Charges Billable N/A N/A N/A

183 Leave of Absence – Therapeutic Leave N/A N/A N/A 185 Leave of Absence – From Nursing Home

for Hospitalization N/A N/A N/A

189 Leave of Absence – Other N/A N/A N/A 190 Subacute Care – General N/A N/A N/A 191 Subacute Care – Level I N/A N/A N/A 192 Subacute Care – Level II N/A N/A N/A 193 Subacute Care – Level III N/A N/A N/A 194 Subacute Care – Level IV N/A N/A N/A 199 Subacute Care – Other N/A N/A N/A 200 Intensive Care – General N/A N/A N/A 201 Intensive Care – Surgical N/A N/A N/A 202 Intensive Care – Medical N/A N/A N/A 203 Intensive Care – Pediatric N/A N/A N/A 204 Intensive Care – Psychiatric N/A N/A N/A 206 Intensive Care – Intermediate Intensive

Care Unit (ICU) N/A N/A N/A

207 Intensive Care – Burn Care N/A N/A N/A 208 Intensive Care – Trauma N/A N/A N/A 209 Intensive Care – Other N/A N/A N/A 210 Coronary Care – General N/A N/A N/A 211 Coronary Care – Myocardial Infarction N/A N/A N/A 212 Coronary Care – Pulmonary Care N/A N/A N/A 213 Coronary Care – Heart Transplant N/A N/A N/A 214 Coronary Care – Intermediate Coronary

Care Unit (CCU) N/A N/A N/A

219 Coronary Care – Other N/A N/A N/A 220 Special Charges – General N/A N/A N/A









Billing Limitations

221 Special Charges – Admission Charge N/A N/A N/A 222 Special Charges – Technical Support

Charge N/A N/A N/A

223 Special Charges – Utilization Review (UR) Service Charge

N/A N/A N/A

224 Special Charges – Late Discharge, Medically Necessary

N/A N/A N/A

229 Special Charges – Other N/A N/A N/A 230 Incremental Nursing Charge – General N/A N/A N/A 231 Incremental Nursing Charge – Nursery N/A N/A N/A 232 Incremental Nursing Charge – Obstetrics N/A N/A N/A 233 Incremental Nursing Charge – ICU N/A N/A N/A 234 Incremental Nursing Charge – CCU N/A N/A N/A 235 Incremental Nursing Charge – Hospice N/A N/A N/A 239 Incremental Nursing Charge – Other N/A N/A N/A 240 All Inclusive Ancillary – General N/A N/A N/A 241 All Inclusive Ancillary – Basic N/A N/A N/A 242 All Inclusive Ancillary – Comprehensive N/A N/A N/A 243 All Inclusive Ancillary – Specialty N/A N/A N/A 249 All Inclusive Ancillary – Other N/A N/A N/A 250 Pharmacy – General Flat Rate – 9.56 1/day/provider Add-on – Must

be billed with stand-alone only.

251 Pharmacy – Generic Drugs Flat Rate – 9.56 1/day/provider Add-on – Must be billed with stand-alone only.

252 Pharmacy – Nongeneric Drugs Flat Rate – 9.56 1/day/provider Add-on – Must be billed with stand-alone only.

253 Pharmacy – Take-Home Drugs Noncovered N/A N/A 254 Pharmacy – Drugs Incident to Other

Diagnostic Services Noncovered N/A N/A

255 Pharmacy – Drugs Incident to Radiology Flat Rate – 111.55 1/day/provider Add-on – May be billed with treatment room or stand-alone.

256 Pharmacy – Experimental Drugs Noncovered N/A N/A









Billing Limitations

257 Pharmacy – Nonprescription Flat Rate – 3.18 1/day/provider Add-on – Must be billed with stand-alone only.

258 Pharmacy – Intravenous (IV) Solutions Flat Rate – 19.12 1/day/provider Add-on – May be billed with treatment room or stand-alone.

259 Pharmacy – Other Pharmacy Flat Rate – 9.56 1/day/provider Add-on – Must be billed with stand-alone only.

260 IV Therapy – General Flat Rate – 18.90 1/day/provider Stand-alone – May be billed alone or with treatment room. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

261 IV Therapy – Infusion Pump Flat Rate – 42.53 1/day/provider Stand-alone – May be billed alone or with treatment room.

262 IV Therapy – IV Therapy/Pharmacy Services

Flat Rate – 18.90 1/day/provider Stand-alone – May be billed alone or with treatment room.

263 IV Therapy – IV Therapy/Drug/Supply Delivery


264 IV Therapy – IV Therapy/Supplies Flat Rate – 18.90 1/day/provider Stand-alone – May be billed alone or with treatment room.

269 IV Therapy – Other IV Therapy Noncovered N/A N/A 270 Medical/Surgical Supplies and Devices –

General Flat Rate – 24.83 1/day/provider Add-on – Must

be billed with stand-alone only.

271 Medical/Surgical Supplies and Devices – Nonsterile Supply

Flat Rate – 21.01 1/day/provider Add-on – Must be billed with stand-alone only.

272 Medical/Surgical Supplies and Devices – Sterile Supply


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Billing Limitations

273 Medical/Surgical Supplies and Devices – Take-Home Supplies


274 Medical/Surgical Supplies and Devices – Prosthetic/Orthotic Devices

Procedure Code None Stand-alone – May be billed alone or with treatment room. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

275 Medical/Surgical Supplies and Devices – Pacemaker


276 Medical/Surgical Supplies and Devices – Intraocular Lens (IOL)


277 Medical/Surgical Supplies and Devices – Oxygen – Take-Home


278 Medical/Surgical Supplies and Devices – Other Implants


279 Medical/Surgical Supplies and Devices – Other Supplies/Devices


280 Oncology – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

289 Oncology – Other Procedure Code None Stand-alone – May be billed alone or with treatment room.

290 Durable Medical Equipment (Other than Renal) – General

Flat Rate – 32.93 1/day/provider Add-on – May be billed with treatment room or stand-alone.

291 Durable Medical Equipment (Other than Renal) – Rental


292 Durable Medical Equipment (Other than Renal) – Purchase of New DME











Billing Limitations

293 Durable Medical Equipment (Other than Renal) – Purchase of Used DME

Noncovered N/A N/A

294 Durable Medical Equipment (Other than Renal) – Supplies/Drugs for DME


299 Durable Medical Equipment (Other than Renal) – Other Equipment

Noncovered N/A N/A

300 Laboratory – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

301 Laboratory – Chemistry Procedure Code None Stand-alone – May be billed alone or with treatment room.

302 Laboratory – Immunology Procedure Code None Stand-alone – May be billed alone or with treatment room.

303 Laboratory – Renal Patient (Home) Procedure Code None Stand-alone – May be billed alone or with treatment room.

304 Laboratory – Nonroutine Dialysis Procedure Code None Stand-alone – May be billed alone or with treatment room.

305 Laboratory – Hematology Procedure Code None Stand-alone – May be billed alone or with treatment room.

306 Laboratory – Bacteriology and Microbiology

Procedure Code None Stand-alone – May be billed alone or with treatment room.

307 Laboratory – Urology Procedure Code None Stand-alone – May be billed alone or with treatment room.

309 Laboratory – Other Laboratory Procedure Code None Stand-alone – May be billed alone or with treatment room.

310 Laboratory Pathology – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

311 Laboratory Pathology – Cytology Procedure Code None Stand-alone – May be billed alone or with treatment room.









Billing Limitations

312 Laboratory Pathology – Histology Procedure Code None Stand-alone – May be billed alone or with treatment room.

314 Laboratory Pathology – Biopsy Procedure Code None Stand-alone – May be billed alone or with treatment room.

319 Laboratory Pathology – Other Procedure Code None Stand-alone – May be billed alone or with treatment room.

320 Radiology – Diagnostic – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

321 Radiology – Diagnostic – Angiocardiography


322 Radiology – Diagnostic – Arthrography Procedure Code None Stand-alone – May be billed alone or with treatment room.

323 Radiology – Diagnostic – Arteriography Procedure Code None Stand-alone – May be billed alone or with treatment room.

324 Radiology – Diagnostic – Chest X-Ray Procedure Code None Stand-alone – May be billed alone or with treatment room.

329 Radiology – Diagnostic – Other Procedure Code None Stand-alone – May be billed alone or with treatment room.

330 Radiology – Therapeutic and/or Chemotherapy Administration – General


331 Radiology – Therapeutic and/or Chemotherapy Administration – Chemotherapy Administration – Injected


332 Radiology – Therapeutic and/or Chemotherapy Administration – Chemotherapy – Oral


333 Radiology – Therapeutic and/or Chemotherapy Administration – Radiation Therapy










Billing Limitations

335 Radiology – Therapeutic and/or Chemotherapy Administration – Chemotherapy Administration – IV


339 Radiology – Therapeutic and/or Chemotherapy Administration – Other


340 Nuclear Medicine – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

341 Nuclear Medicine – Diagnostic Procedure Code None Stand-alone – May be billed alone or with treatment room.

342 Nuclear Medicine – Therapeutic Procedure Code None Stand-alone – May be billed alone or with treatment room.

343 Nuclear Medicine – Diagnostic Radiopharmaceuticals


344 Nuclear Medicine – Therapeutic Radiopharmaceuticals


349 Nuclear Medicine – Other Procedure Code None Stand-alone – May be billed alone or with treatment room.

350 Computed Tomographic (CT) Scan – General


351 CT Scan – Head Scan Procedure Code None Stand-alone – May be billed alone or with treatment room.

352 CT Scan – Body Scan Procedure Code None Stand-alone – May be billed alone or with treatment room.

359 CT Scan – Other CT Scans Procedure Code None Stand-alone – May be billed alone or with treatment room.









Billing Limitations

360 Operating Room Services – General ASC – Procedure Surgical Two surgery procedures per provider per day (highest paying at 100%, second highest at 50%). All other claim lines for that date of service deny.

361 Operating Room Services – Minor Surgery ASC – Procedure Surgical Two surgery procedures per provider per day (highest paying at 100%, second highest at 50%). All other claim lines for that date of service deny.

362 Operating Room Services – Organ Transplant – Other than Kidney

ASC – Procedure Surgical Two surgery procedures per provider per day (highest paying at 100%, second highest at 50%). All other claim lines for that date of service deny.

367 Operating Room Services – Kidney Transplant










Billing Limitations

369 Operating Room Services – Other Operating Room Services


370 Anesthesia – General Flat Rate – 60.48 1/day/provider Add-on – May be billed with treatment room or stand-alone.

371 Anesthesia – Anesthesia Incident to Radiology

Noncovered N/A N/A

372 Anesthesia – Anesthesia Incident to Other Diagnostic Services

Noncovered N/A N/A

374 Anesthesia – Acupuncture Noncovered N/A N/A 379 Anesthesia – Other Anesthesia Noncovered N/A N/A 380 Blood and Blood Components – General Noncovered N/A N/A 381 Blood and Blood Components – Packed

Red Cells Noncovered N/A N/A

382 Blood and Blood Components – Whole Blood

Noncovered N/A N/A

383 Blood and Blood Components – Plasma Flat Rate – 51.98 1/day/provider Add-on – May be billed with treatment room or stand-alone.

384 Blood and Blood Components – Platelets Flat Rate – 447.33 1/day/provider Add-on – May be billed with treatment room or stand-alone.

385 Blood and Blood Components – Leukocytes

Noncovered N/A N/A

386 Blood and Blood Components – Other Components


387 Blood and Blood Components – Other Derivatives (Cryoprecipitates)


389 Blood and Blood Components – Other Blood and Blood Components

Noncovered N/A N/A









Billing Limitations

390 Administration, Processing and Storage for Blood and Blood Components – General


391 Administration, Processing and Storage for Blood and Blood Components – Administration (e.g., Transfusions)


392 Administration, Processing and Storage for Blood and Blood Components – Processing and Storage

Noncovered N/A N/A

399 Administration, Processing and Storage for Blood and Blood Components – Other Processing and Storage

Noncovered N/A N/A

400 Other Imaging Services – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

401 Other Imaging Services – Diagnostic Mammography


402 Other Imaging Services – Ultrasound Procedure Code None Stand-alone – May be billed alone or with treatment room.

403 Other Imaging Services – Screening Mammography


404 Other Imaging Services – Positron Emission Tomography (PET)


409 Other Imaging Services – Other Imaging Services


410 Respiratory Services – General Flat Rate – 6.37 1/day/provider Stand-alone – May be billed alone or with treatment room.

412 Respiratory Services – Inhalation Services Flat Rate – 10.62 1/day/provider Stand-alone – May be billed alone or with treatment room.

413 Respiratory Services – Hyperbaric Oxygen Therapy










Billing Limitations

419 Respiratory Services – Other Respiratory Services


420 Physical Therapy – General Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

421 Physical Therapy – Visit Charge Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

422 Physical Therapy – Hourly Charge Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

423 Physical Therapy – Group Rate Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

424 Physical Therapy – Evaluation or Reevaluation


429 Physical Therapy – Other Physical Therapy


430 Occupational Therapy – General Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

431 Occupational Therapy – Visit Charge Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

432 Occupational Therapy – Hourly Charge Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

433 Occupational Therapy – Group Rate Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room

434 Occupational Therapy – Evaluation or Reevaluation


439 Occupational Therapy – Other Occupational Therapy










Billing Limitations

440 Speech Therapy – Language Pathology – General


441 Speech Therapy – Language Pathology – Visit Charge


442 Speech Therapy – Language Pathology – Hourly Charge


443 Speech Therapy – Language Pathology – Group Rate


444 Speech Therapy – Language Pathology – Evaluation or Reevaluation


449 Speech Therapy – Language Pathology – Other Speech-Language Pathology


450 Emergency Room (ER) – General Flat Rate – 75.80 / ASC – Procedure

1/day/provider OR surgery

Treatment room – Either two surgeries per day per provider (highest paying at 100%, second highest at 50%), OR one flat rate per day and add-on revenue codes (RCs) and stand-alone RCs should pay for that date of service.

451 Emergency Room – Emergency Medical Treatment and Labor Act (EMTALA) Emergency Medical Screening Services

Flat Rate – 25.00 None All other lines on the claim for that date of service should deny. Used for screening costs when patient presents in ER without emergency.

452 Emergency Room – ER Beyond EMTALA Noncovered N/A N/A









Billing Limitations

456 Emergency Room – Urgent Care Flat Rate – 75.80 / ASC – Procedure


Treatment room – Either two surgeries per day per provider (highest paying at 100%, second highest at 50%), OR one flat rate per day and add-on RCs and stand-alone RCs should pay for that date of service.

459 Emergency Room – Other Emergency Room

Flat Rate – 75.80 / ASC – Procedure



460 Pulmonary Function – General Flat Rate – 36.37 1/day/provider Stand-alone – May be billed alone or with treatment room.

469 Pulmonary Function – Other Pulmonary Function


470 Audiology – General Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

471 Audiology – Diagnostic Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

472 Audiology – Treatment Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.

479 Audiology – Other Audiology Flat Rate – 47.81 1/day/provider Stand-alone – May be billed alone or with treatment room.









Billing Limitations

480 Cardiology – General Flat Rate – 166.32 / ASC – Procedure

1/day/provider Treatment room – Either two surgeries per day per provider (highest paying at 100%, second highest at 50%), OR one flat rate per day and add-on RCs and stand-alone RCs should pay for that date of service.

481 Cardiology – Cardiac Catheter Lab Flat Rate – 475.51 / ASC – Procedure


482 Cardiology – Stress Test Flat Rate – 121.91 / ASC – Procedure


483 Cardiology – Echocardiology Flat Rate – 202.23 1/day/provider Treatment room – Either two surgeries per day per provider (highest paying at 100%, second highest at 50%), OR one flat rate per day and add-on RCs and stand-alone RCs should pay for that date of service.









Billing Limitations

489 Cardiology – Other Cardiology Flat Rate – 202.23 / ASC – Procedure


490 Ambulatory Surgical Care – General ASC – Procedure Surgical Two surgery procedures per provider per day (highest paying at 100%, second highest at 50%). All other claim lines for that date of service deny.

499 Ambulatory Surgical Care – Other ASC – Procedure Surgical Two surgery procedures per provider per day (highest paying at 100%, second highest at 50%). All other claim lines for that date of service deny.

500 Outpatient Services – General Noncovered N/A N/A 509 Outpatient Services – Other Outpatient

Services Noncovered N/A N/A

510 Clinic – General Flat Rate – 40.80 / ASC – Procedure











Billing Limitations

511 Clinic – Chronic Pain Center Flat Rate – 40.80 / ASC – Procedure



512 Clinic – Dental Clinic Flat Rate – 40.80 / ASC – Procedure



513 Clinic – Psychiatric Clinic Flat Rate – Family and group therapy codes = 20.40; Individual therapy = 40.80

1/day/Provider Treatment room – One flat rate per day and add-on RCs and stand-alone RCs should pay for that date of service. SPECIAL NOTE: No surgical methodology allowed. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for guidance regarding procedure code linkages.










Billing Limitations

514 Clinic – OB/GYN Clinic Flat Rate – 40.80 / ASC – Procedure



515 Clinic – Pediatric Clinic Flat Rate – 40.80 / ASC – Procedure



516 Clinic – Urgent Care Clinic Flat Rate – 40.80 / ASC – Procedure



517 Clinic – Family Practice Clinic Flat Rate – 40.80 / ASC – Procedure











Billing Limitations

519 Clinic – Other Clinic Flat Rate – 40.80 / ASC – Procedure



520 Freestanding Clinic – General Flat Rate – 40.80 / ASC – Procedure



521 Freestanding Clinic – Clinic Visit by Member to Rural Health Clinic (RHC)/Federally Qualified Health Center (FQHC)




522 Freestanding Clinic – Home Visit by RHC/FQHC Practitioner

Noncovered N/A N/A









Billing Limitations

523 Freestanding Clinic – Family Practice Clinic




524 Freestanding Clinic – Visit by RHC/FQHC Practitioner to a Member in a Skilled Nursing Facility (SNF) or Skilled Swing Bed in a Covered Part A Stay

Noncovered N/A N/A

525 Freestanding Clinic – Visit by RHC/FQHC Practitioner to a Member in a SNF (Not in a Covered Part A Stay) or NF or ICF MR [Intermediate Care Facility for Individuals with Intellectual Disabilities] or Other Residential Facility

Noncovered N/A N/A

526 Freestanding Clinic – Urgent Care Clinic Noncovered N/A N/A 527 Freestanding Clinic – Visiting Nurse

Service(s) to a Member’s Home When in a Home Health Shortage Area

Noncovered N/A N/A

528 Freestanding Clinic – Visit by RHC/FQHC Practitioner to Other Non-RHC/FQHC Site (e.g. Scene of Accident)

Noncovered N/A N/A

529 Freestanding Clinic – Other Freestanding Clinic




530 Osteopathic Services – General Procedure Code None Stand-alone – May be billed alone or with treatment room.









Billing Limitations

531 Osteopathic Services – Osteopathic Therapy

Noncovered N/A N/A

539 Osteopathic Services – Other Osteopathic Services

Noncovered N/A N/A

540 Ambulance – General N/A N/A N/A 541 Ambulance – Supplies N/A N/A N/A 542 Ambulance – Medical Transport N/A N/A N/A 543 Ambulance – Heart Mobile N/A N/A N/A 544 Ambulance – Oxygen N/A N/A N/A 545 Ambulance – Air Ambulance N/A N/A N/A 546 Ambulance – Neonatal Ambulance

Services N/A N/A N/A

547 Ambulance – Pharmacy N/A N/A N/A 548 Ambulance – Electrocardiogram (EKG)

Transmission N/A N/A N/A

549 Ambulance – Other Ambulance N/A N/A N/A 550 Skilled Nursing – General N/A N/A N/A 551 Skilled Nursing – Visit Charge N/A N/A N/A 552 Skilled Nursing – Hourly Charge N/A N/A N/A 559 Skilled Nursing – Other Skilled Nursing N/A N/A N/A 560 Home Health – Medical Social Services –

General N/A N/A N/A

561 Home Health – Medical Social Services – Visit Charge

N/A N/A N/A

562 Home Health – Medical Social Services – Hourly Charge

N/A N/A N/A

569 Home Health – Medical Social Services – Other Medical Social Services

N/A N/A N/A

570 Home Health Aide – General N/A N/A N/A 571 Home Health Aide – Visit Charge N/A N/A N/A 572 Home Health Aide – Hourly Charge N/A N/A N/A 579 Home Health Aide – Other Home Health

Aide N/A N/A N/A

580 Home Health – Other Visits – General N/A N/A N/A 581 Home Health – Other Visits – Visit Charge N/A N/A N/A









Billing Limitations

582 Home Health – Other Visits – Hourly Charge

N/A N/A N/A

583 Home Health – Other Visits – Assessment N/A N/A N/A 589 Home Health – Other Visits – Other Home

Health Visits N/A N/A N/A

590 Home Health Units of Service – General N/A N/A N/A 600 Home Health – Oxygen – General N/A N/A N/A 601 Home Health – Oxygen – Stationary

Equipment/Supplies/Contents N/A N/A N/A

602 Home Health – Oxygen – Stationary Equipment/Supplies Less than 1 Liter per Minute (LPM)

N/A N/A N/A

603 Home Health – Oxygen – Stationary Equipment/Supplies Greater than 4 LPM

N/A N/A N/A

604 Home Health – Oxygen – Oxygen Port Add-On

N/A N/A N/A

609 Home Health – Oxygen – Other Oxygen N/A N/A N/A 610 Magnetic Resonance Technology –

General Procedure Code None Stand-alone – May be

billed alone or with treatment room.

611 Magnetic Resonance Technology – Magnetic Resonance Imaging (MRI) – Brain/Brain Stem


612 Magnetic Resonance Technology – MRI – Spinal Cord/Spine


614 Magnetic Resonance Technology – MRI – Other


615 Magnetic Resonance Technology – Magnetic Resonance Angiography (MRA) – Head and Neck


616 Magnetic Resonance Technology – MRA – Lower Extremities


618 Magnetic Resonance Technology – MRA – Other










Billing Limitations

619 Magnetic Resonance Technology – Other Magnetic Resonance Technology


621 Medical/Surgical Supplies (extension of 027X) – Supplies Incident to Radiology


622 Medical/Surgical Supplies (extension of 027X) – Supplies Incident to Other Diagnostic Services

Flat Rate – 10.62 1/ day/provider Add-on – May be billed with treatment room or stand-alone.

623 Medical/Surgical Supplies (extension of 027X) – Surgical Dressings

Noncovered N/A N/A

624 Medical/Surgical Supplies (extension of 027X) – Food and Drug Administration (FDA) Investigational Devices

Noncovered N/A N/A

631 Pharmacy (extension of 025X) – Single-Source Drug

Noncovered N/A N/A

632 Pharmacy (extension of 025X) – Multiple-Source Drug

Noncovered N/A N/A

633 Pharmacy (extension of 025X) – Restrictive Prescription

Noncovered N/A N/A

634 Pharmacy (extension of 025X) – Erythropoietin (EPO) Less than 10,000 Units


635 Pharmacy (extension of 025X) – Erythropoietin (EPO) 10,000 or More Units


636 Pharmacy (extension of 025X) – Drugs Requiring Detailed Coding


637 Pharmacy (extension of 025X) – Self-Administrable Drugs

Noncovered N/A N/A

640 Home IV Therapy Services – General N/A N/A N/A










Billing Limitations

641 Home IV Therapy Services – Nonroutine Nursing, Central Line

N/A N/A N/A

642 Home IV Therapy Services – IV Site Care, Central Line

N/A N/A N/A

643 Home IV Therapy Services – IV Start/Change, Peripheral Line

N/A N/A N/A

644 Home IV Therapy Services – Nonroutine Nursing, Peripheral Line

N/A N/A N/A

645 Home IV Therapy Services – Training Patient/Caregiver, Central Line

N/A N/A N/A

646 Home IV Therapy Services – Training, Disabled Patient, Central Line

N/A N/A N/A

647 Home IV Therapy Services – Training, Patient/Caregiver, Peripheral Line

N/A N/A N/A

648 Home IV Therapy Services – Training, Disabled Patient, Peripheral Line

N/A N/A N/A

649 Home IV Therapy Services – Other IV Therapy Services

N/A N/A N/A

650 Hospice Service – General N/A N/A N/A 651 Hospice Service – Routine Home Care N/A N/A N/A 652 Hospice Service – Continuous Home Care N/A N/A N/A 653 Hospice Service – Routine Home Care

Delivered in a Nursing Facility N/A N/A N/A

654 Hospice Service – Continuous Home Care Delivered in a Nursing Facility

N/A N/A N/A

655 Hospice Service – Inpatient Respite Care N/A N/A N/A 656 Hospice Service – General Inpatient Care

(Nonrespite) N/A N/A N/A

657 Hospice Service – Physician Services N/A N/A N/A 658 Hospice Service – Hospice Room and

Board – Nursing Facility N/A N/A N/A

659 Hospice Service – Other Hospice Service N/A N/A N/A 660 Respite Care – General N/A N/A N/A 661 Respite Care – Hourly Charge – Nursing N/A N/A N/A









Billing Limitations

662 Respite Care – Hourly Charge – Aide/Homemaker/Companion

N/A N/A N/A

663 Respite Care – Daily Respite Charge N/A N/A N/A 669 Respite Care – Other Respite Care N/A N/A N/A 670 Outpatient Special Residence Charges –

General Noncovered N/A N/A

671 Outpatient Special Residence Charges – Hospital Owned

Noncovered N/A N/A

672 Outpatient Special Residence Charges – Contracted

Noncovered N/A N/A

679 Outpatient Special Residence Charges – Other Special Residence Charges

Noncovered N/A N/A

681 Trauma Response – Level I Noncovered N/A N/A 682 Trauma Response – Level II Noncovered N/A N/A 683 Trauma Response – Level III Noncovered N/A N/A 684 Trauma Response – Level IV Noncovered N/A N/A 689 Trauma Response – Other Trauma

Response Noncovered N/A N/A

700 Cast Room – General Flat Rate – 103.04 / ASC – Procedure



710 Recovery Room – General Flat Rate – 103.04 / ASC – Procedure











Billing Limitations

720 Labor Room/Delivery – General Flat Rate – 126.33 / ASC – Procedure



721 Labor Room/Delivery – Labor Flat Rate – 138.06 / ASC – Procedure



722 Labor Room/Delivery – Delivery Room Noncovered N/A N/A 723 Labor Room/Delivery – Circumcision Noncovered N/A N/A 724 Labor Room/Delivery – Birthing Center Flat Rate – 1652.98 /

ASC – Procedure 1/day/provider OR surgery

Treatment room – Either two surgeries per day per provider (highest paying at 100%, second highest at 50%), OR one flat rate per day and add-on RCs and stand-alone RCs should pay for that date of service. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

729 Labor Room/Delivery – Other Labor Room/Delivery

Noncovered N/A N/A










Billing Limitations

730 Electrocardiogram (EKG/ECG) – General Flat Rate – 34.97 1/day/provider Stand-alone – May be billed alone or with treatment room.

731 Electrocardiogram (EKG/ECG) – Holter Monitor


732 Electrocardiogram (EKG/ECG) – Telemetry


739 Electrocardiogram (EKG/ECG) – Other EKG/ECG


740 Electroencephalogram (EEG) – General Flat Rate – 200.10 1/day/provider Stand-alone – May be billed alone or with treatment room.

750 Gastrointestinal (GI) Services – General Flat Rate – 39.30 1/day/provider Stand-alone – May be billed alone or with treatment room.

760 Specialty Services – General Flat Rate – 194.29 / ASC – Procedure



761 Specialty Services – Treatment Room Flat Rate – 40.80 / ASC – Procedure











Billing Limitations

762 Specialty Services – Observation Hours Flat Rate – 194.29 1/day/provider Treatment room (WITH SPECIAL INSTRUCTIONS) – One flat rate per day; no surgical logic; add-on RCs and stand-alone RCs should pay for that date of service.

769 Specialty Services – Other Specialty Services

Noncovered N/A N/A

770 Preventive Care Services – General Noncovered N/A N/A 771 Preventive Care Services – Vaccine

Administration Noncovered N/A N/A

780 Telemedicine – General Procedure Code None Stand-alone – May be billed alone or with treatment room.

790 Extra-Corporeal Shock Wave Therapy (Formerly Lithotripsy) – General

Flat Rate – 2835 1/day/provider Stand-alone – May be billed alone or with treatment room.

800 Inpatient Renal Dialysis – General N/A N/A N/A 801 Inpatient Renal Dialysis – Inpatient

Hemodialysis N/A N/A N/A

802 Inpatient Renal Dialysis – Inpatient Peritoneal (Non-CAPD)

N/A N/A N/A

803 Inpatient Renal Dialysis – Continuous Ambulatory Peritoneal Dialysis (CAPD)

N/A N/A N/A

804 Inpatient Renal Dialysis – Inpatient Continuous Cycling Peritoneal Dialysis (CCPD)

N/A N/A N/A

809 Inpatient Renal Dialysis – Other Inpatient Dialysis

N/A N/A N/A

810 Acquisition of Body Components – General

Noncovered N/A N/A

811 Acquisition of Body Components – Living Donor

Noncovered N/A N/A

812 Acquisition of Body Components – Cadaver Donor

Noncovered N/A N/A









Billing Limitations

813 Acquisition of Body Components – Unknown Donor

Noncovered N/A N/A

814 Acquisition of Body Components – Unsuccessful Organ Search – Donor Bank Charges

Noncovered N/A N/A

819 Acquisition of Body Components – Other Donor

Noncovered N/A N/A

820 Hemodialysis – Outpatient or Home – General

Flat Rate – 6.37 1/day End-Stage Renal Disease (ESRD) – Use composite logic; only one ESRD revenue code allowable per day.

821 Hemodialysis – Outpatient or Home – Hemodialysis/Composite or Other Rate

Flat Rate – 104.11 1/day ESRD – Use composite logic; only one ESRD revenue code allowable per day.

822 Hemodialysis – Outpatient or Home – Home Supplies

Noncovered N/A N/A

823 Hemodialysis – Outpatient or Home – Home Equipment


824 Hemodialysis – Outpatient or Home – Maintenance – 100%

Noncovered N/A N/A

825 Hemodialysis – Outpatient or Home – Support Services


829 Hemodialysis – Outpatient or Home – Other Outpatient Hemodialysis










Billing Limitations

830 Peritoneal Dialysis – Outpatient or Home – General


831 Peritoneal Dialysis – Outpatient or Home – Peritoneal/Composite or Other Rate


832 Peritoneal Dialysis – Outpatient or Home – Home Supplies

Noncovered N/A N/A

833 Peritoneal Dialysis – Outpatient or Home – Home Equipment

Noncovered N/A N/A

834 Peritoneal Dialysis – Outpatient or Home – Maintenance – 100%

Noncovered N/A N/A

835 Peritoneal Dialysis – Outpatient or Home – Support Services

Noncovered N/A N/A

839 Peritoneal Dialysis – Outpatient or Home – Other Outpatient Peritoneal Dialysis

Noncovered N/A N/A

840 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – General

Noncovered N/A N/A

841 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – CAPD/Composite or Other Rate


842 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – Home Supplies

Noncovered N/A N/A

843 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – Home Equipment

Noncovered N/A N/A

844 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – Maintenance – 100%

Noncovered N/A N/A

845 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – Support Services

Noncovered N/A N/A









Billing Limitations

849 Continuous Ambulatory Peritoneal Dialysis (CAPD) – Outpatient or Home – Other Outpatient CAPD

Noncovered N/A N/A

850 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – General

Noncovered N/A N/A

851 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – CCPD/Composite or Other Rate


852 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – Home Supplies

Noncovered N/A N/A

853 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – Home Equipment

Noncovered N/A N/A

854 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – Maintenance – 100%

Noncovered N/A N/A

855 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – Support Services

Noncovered N/A N/A

859 Continuous Cycling Peritoneal Dialysis (CCPD) – Outpatient or Home – Other Outpatient CCPD

Noncovered N/A N/A

860 Magnetoencephalography (MEG) – General


861 Magnetoencephalography (MEG) – MEG Procedure Code None Stand-alone – May be billed alone or with treatment room.

880 Miscellaneous Dialysis – General Noncovered N/A N/A 881 Miscellaneous Dialysis – Ultrafiltration Flat Rate – 41.30 1/day ESRD – Use

composite logic; only one ESRD revenue code allowable per day.

882 Miscellaneous Dialysis – Home Dialysis Aid Visit

Noncovered N/A N/A









Billing Limitations

889 Miscellaneous Dialysis – Other Miscellaneous Dialysis

Noncovered N/A N/A

900 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – General

Flat Rate – 40.80 1/day/provider Treatment room (WITH SPECIAL INSTRUCTIONS) – One flat rate per day; no surgical logic; add-on RCs and stand-alone RCs should pay for that date of service.

901 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Electroshock Treatment

Noncovered N/A N/A

902 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Milieu Therapy

Noncovered N/A N/A

903 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Play Therapy

Noncovered N/A N/A

904 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Activity Therapy

Noncovered N/A N/A

905 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Intensive Outpatient Services – Psychiatric

MCE: Procedure Code FFS – Noncovered

MCE ONLY: 1/day/member

MCE ONLY SPECIAL NOTE: May not be billed on the same date of service as RCs 906 or 513. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.










Billing Limitations

906 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Intensive Outpatient Services – Chemical Dependency



MCE ONLY SPECIAL NOTE: May not be billed on the same date of service as RCs 905 or 513. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

907 Behavioral Health Treatments/Services (also see 091X, an extension of 090X) – Community Behavioral Health Program (Day Treatment)


911 Behavioral Health Treatments/Services (extension of 090X) – Rehabilitation

Noncovered N/A N/A

912 Behavioral Health Treatments/Services (extension of 090X) – Partial Hospitalization – Less Intensive



MCE ONLY SPECIAL NOTE: May not be billed on the same date of service as RC 913. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.











Billing Limitations

913 Behavioral Health Treatments/Services (extension of 090X) – Partial Hospitalization – Intensive



MCE ONLY SPECIAL NOTE: May not be billed on the same date of service as RC 912. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

914 Behavioral Health Treatments/Services (extension of 090X) – Individual Therapy


915 Behavioral Health Treatments/Services (extension of 090X) – Group Therapy

Flat Rate – 20.40

1/day/provider Treatment room (WITH SPECIAL INSTRUCTIONS) – One flat rate per day; no surgical logic; add-on RCs and stand-alone RCs should pay for that date of service.

916 Behavioral Health Treatments/Services (extension of 090X) – Family Therapy


917 Behavioral Health Treatments/Services (extension of 090X) – Bio Feedback

Noncovered N/A N/A










Billing Limitations

918 Behavioral Health Treatments/Services (extension of 090X) – Testing


919 Behavioral Health Treatments/Services (extension of 090X) – Other Behavioral Health Treatments/Services

Noncovered N/A N/A

920 Other Diagnostic Services – General Procedure Code None Stand-alone – May be billed alone or with treatment room. See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

921 Other Diagnostic Services – Peripheral Vascular Lab


922 Other Diagnostic Services – Electromyogram


923 Other Diagnostic Services – Pap Smear Procedure Code None Stand-alone – May be billed alone or with treatment room.

924 Other Diagnostic Services – Allergy Test Flat Rate – 13.81 None Stand-alone – May be billed alone or with treatment room. SPECIAL NOTE: No unit restriction.

925 Other Diagnostic Services – Pregnancy Test

Procedure Code None Stand-alone – May be billed alone or with treatment room










Billing Limitations

929 Other Diagnostic Services – Other Diagnostic Service


931 Medical Rehabilitation Day Program – Half Day

N/A N/A N/A

932 Medical Rehabilitation Day Program – Full Day

N/A N/A N/A

940 Other Therapeutic Services (see also 095X, an extension of 094X) – General


941 Other Therapeutic Services (see also 095X, an extension of 094X) – Recreational Therapy

Noncovered N/A N/A

942 Other Therapeutic Services (see also 095X, an extension of 094X) – Education/Training

Noncovered N/A N/A

943 Other Therapeutic Services (see also 095X, an extension of 094X) – Cardiac Rehabilitation


944 Other Therapeutic Services (see also 095X, an extension of 094X) – Drug Rehabilitation

Noncovered N/A N/A

945 Other Therapeutic Services (see also 095X, an extension of 094X) – Alcohol Rehabilitation

Noncovered N/A N/A

946 Other Therapeutic Services (see also 095X, an extension of 094X) – Complex Medical Equipment – Routine

Noncovered N/A N/A











Billing Limitations

947 Other Therapeutic Services (see also 095X, an extension of 094X) – Complex Medical Equipment – Ancillary

Noncovered N/A N/A

948 Other Therapeutic Services (see also 095X, an extension of 094X) – Pulmonary Rehabilitation

Noncovered N/A N/A

949 Other Therapeutic Services (see also 095X, an extension of 094X) – Other Therapeutic Services

Noncovered N/A N/A

951 Other Therapeutic Services (extension of 094X) – Athletic Training

Noncovered N/A N/A

952 Other Therapeutic Services (extension of 094X) – Kinesiotherapy

Noncovered N/A N/A

960 Professional Fees (see also 097X and 098X) – General


N/A MCE ONLY SPECIAL NOTE: See Revenue Codes Linked to Specific Procedure Codes on the Code Sets page for applicable procedure codes.

961 Professional Fees (see also 097X and 098X) – Psychiatric

Noncovered N/A N/A

962 Professional Fees (see also 097X and 098X) – Ophthalmology

Noncovered N/A N/A

963 Professional Fees (see also 097X and 098X) – Anesthesiologist (MD)

Noncovered N/A N/A

964 Professional Fees (see also 097X and 098X) – Anesthetist (CRNA)

Noncovered N/A N/A

969 Professional Fees (see also 097X and 098X) – Other Professional Fees

Noncovered N/A N/A

971 Professional Fees (extension of 096X) – Laboratory

Noncovered N/A N/A

972 Professional Fees (extension of 096X) – Radiology – Diagnostic

Noncovered N/A N/A

973 Professional Fees (extension of 096X) – Radiology – Therapeutic

Noncovered N/A N/A










Billing Limitations

974 Professional Fees (extension of 096X) – Radiology – Nuclear

Noncovered N/A N/A

975 Professional Fees (extension of 096X) – Operating Room

Noncovered N/A N/A

976 Professional Fees (extension of 096X) – Respiratory Therapy

Noncovered N/A N/A

977 Professional Fees (extension of 096X) – Physical Therapy

Noncovered N/A N/A

978 Professional Fees (extension of 096X) – Occupational Therapy

Noncovered N/A N/A

979 Professional Fees (extension of 096X) – Speech Language Pathology

Noncovered N/A N/A

981 Professional Fees (extension of 096X and 097X) – Emergency Room

Noncovered N/A N/A

982 Professional Fees (extension of 096X and 097X) – Outpatient Services

Noncovered N/A N/A

983 Professional Fees (extension of 096X and 097X) – Clinic

Noncovered N/A N/A

984 Professional Fees (extension of 096X and 097X) – Medical Social Services

Noncovered N/A N/A

985 Professional Fees (extension of 096X and 097X) – EKG

Noncovered N/A N/A

986 Professional Fees (extension of 096X and 097X) – EEG

Noncovered N/A N/A

987 Professional Fees (extension of 096X and 097X) – Hospital Visit

Noncovered N/A N/A

988 Professional Fees (extension of 096X and 097X) – Consultation

Noncovered N/A N/A

989 Professional Fees (extension of 096X and 097X) – Private-Duty Nurse

Noncovered N/A N/A

990 Patient Convenience Items – General Noncovered N/A N/A 991 Patient Convenience Items –

Cafeteria/Guest Tray Noncovered N/A N/A

992 Patient Convenience Items – Private Linen Service

Noncovered N/A N/A









Billing Limitations

993 Patient Convenience Items – Telephone/Telecom

Noncovered N/A N/A

994 Patient Convenience Items – TV/Radio Noncovered N/A N/A 995 Patient Convenience Items – Nonpatient

Room Rentals Noncovered N/A N/A

996 Patient Convenience Items – Late Discharge Charge

Noncovered N/A N/A

997 Patient Convenience Items – Admission Kits

Noncovered N/A N/A

998 Patient Convenience Items – Beauty Shop/Barber

Noncovered N/A N/A

999 Patient Convenience Items – Other Convenience Items

Noncovered N/A N/A

1000 Behavioral Health Accommodations – General

N/A N/A N/A

1001 Behavioral Health Accommodations – Residential – Psychiatric

N/A N/A N/A

1002 Behavioral Health Accommodations – Residential – Chemical Dependency

N/A N/A N/A

1003 Behavioral Health Accommodations – Supervised Living

N/A N/A N/A

1004 Behavioral Health Accommodations – Halfway House

N/A N/A N/A

1005 Behavioral Health Accommodations – Group Home

N/A N/A N/A

2100 Alternative Therapy Services – General Noncovered N/A N/A 2101 Alternative Therapy Services –

Acupuncture Noncovered N/A N/A

2102 Alternative Therapy Services – Accupressure

Noncovered N/A N/A

2103 Alternative Therapy Services – Massage Noncovered N/A N/A 2104 Alternative Therapy Services –

Reflexology Noncovered N/A N/A

2105 Alternative Therapy Services – Biofeedback

Noncovered N/A N/A

2106 Alternative Therapy Services – Hypnosis Noncovered N/A N/A









Billing Limitations

2109 Alternative Therapy Services – Other Alternative Therapy Services

Noncovered N/A N/A

3101 Adult Care – Adult Day Care, Medical and Social – Hourly

Noncovered N/A N/A

3102 Adult Care – Adult Day Care, Social – Hourly

Noncovered N/A N/A

3103 Adult Care – Adult Day Care, Medical and Social – Daily

Noncovered N/A N/A

3104 Adult Care – Adult Day Care, Social – Daily

Noncovered N/A N/A

3105 Adult Care – Adult Foster Care – Daily Noncovered N/A N/A 3109 Adult Care – Other Adult Care Noncovered N/A N/A

Table Revision History

March 15, 2018, update: Updated outpatient payment information (effective March 15, 2018): 900, 907, 914–916, 918

December 1, 2017, update: Updated outpatient payment information (effective December 1, 2017): 480–482, 489 Updated outpatient payment information (effective February 12, 2017): 840, 842, 844, 845, 849, 850, 855

June 13, 2017, update: Updated outpatient payment information (effective July 1, 2016): 912, 913 Updated outpatient payment information (correction): 960

April 1, 2017, update: Added outpatient payment information (columns 3–5) Removed (correction): 630, 890

July 1, 2016, update: Added (effective January 1, 1990): 653, 654

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