Oregon Health Authority Division of Medical Assistance Programs Revenue Center Code Table

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1 11X ROOM AND BOARD PRIVATE (MEDICAL OR GENERAL) 110# 111# 112# 113# 114# # 117# 118# 119# Medical/Surgical/Gyn OB Pediatric Psychiatric Hospice (Not Covered) Detoxification Oncology Rehab/Private 12X ROOM AND BOARD SEMI-PRIVATE (MEDICAL OR GENERAL) 120# 121# 122# 123# 124# # 127# 128# 129# Medical/Surgical/Gyn OB Pediatric Psychiatric Hospice (Not Covered) Detoxification Oncology Rehabilitation 13X SEMI-PRIVATE THREE AND FOUR BEDS 130# 131# 132# 133# 134# # 137# 138# 139# 14X 140# 141# 142# 143# 144# # 147# 148# 149# Medical/Surgical/Gyn OB Pediatric Psychiatric Hospice (Not Covered) Detoxification Oncology Rehabilitation PRIVATE (DELUXE) Medical/Surgical/Gyn OB Pediatric Psychiatric Hospice (Not Covered) Detoxification Oncology Rehab/Deluxe Page 1 of 14 Last updated 10/24/2012

2 15X 150# 151# 152# 153# 154# # 157# 158# 159# 16X 160# 164# 167# 169# 17X 170# 171# 172# 173# 174# 179# 18X 180# # X X 200# 201# 202# 203# 204# 206# 207# ROOM AND BOARD WARD (MEDICAL OR GENERAL) Medical/Surgical/Gyn OB Pediatric Psychiatric Hospice (Not Covered) Detoxification Oncology Rehabilitation OTHER ROOM AND BOARD Sterile Environment Self Care NURSERY (Nursery) Newborn Level I Newborn Level II Newborn Level III Newborn Level IV LEAVE OF ABSENCE - Bill hard-copy. RESERVED (Not Covered) Patient Convenience (Not Covered) Therapeutic Leave RESERVED (Not Covered) Nursing Home (for hospitalization) (Not Covered) Leave of Absence (Not Covered) SUBACUTE CARE (NOT COVERED) (Not Covered) Subacute Care Level I (Not Covered) Subacute Care Level II (Not Covered) Subacute Care Level III (Not Covered) Subacute Care Level IV (Not Covered) Subacute Care (Not Covered) INTENSIVE CARE Surgical Medical Pediatric Psychiatric Intermediate ICU Burn Care Page 2 of 14 Last updated 10/24/2012

3 # = Accommodation days 208# 209# 21X 210# 211# 212# 213# 214# 219# 22X X X X Trauma Intensive Care CORONARY CARE Myocardial Infarction Pulmonary Care Heart Transplant Intermediate CCU Coronary Care SPECIAL CHARGES Oregon Health Authority INCREMENTAL NURSING CHARGE RATE Nursery OB ICU CCU Hospice (Not Covered) ALL INCLUSIVE ANCILLARY (NOT COVERED) (Not Covered) Basic (Not Covered) Comprehensive (Not Covered) Specialty (Not Covered) Inclusive Ancillary (Not Covered) PHARMACY * = CPT/HCPCS code required = NDC reporting required (Not Covered) Admission Charge (Not Covered) Technical Support Charge (Not Covered) U.R. Service Charge (Not Covered) Late Discharge, Medically appropriate (Not Covered) Special Charges - This Revenue Center Code is authorized only for Administrative Reports requested by branch office staff. National Drug Code reporting is required for all services in this category (25X) * Generic Drugs 252* Non-Generic Drugs 253* Take Home Drugs 254* Drugs Incident to Diagnostic Services 255* Drugs Incident to Radiology 256* Experimental Drugs (Not Covered) 257* Non-prescription 258* IV Solutions 259* Pharmacy Page 3 of 14 Last updated 10/24/2012

4 26X X * * X X IV THERAPY * Infusion Pump* IV Therapy/Pharmacy Services IV Therapy/Drug/Supply Delivery IV Therapy/Supplies IV Therapy* MEDICAL/SURGICAL SUPPLIES AND DEVICES Nonsterile Supplies Sterile Supply Take Home Supplies Prosthetic/Orthotic Devices* Pacemaker Intraocular Lens* Oxygen Take Home Implants Supplies/Devices* ONCOLOGY* Oncology DURABLE MEDICAL EQUIPMENT (OTHER THAN RENAL)* Prior authorization of services is required for all outpatient services in this category (29X) X * X 310* 311* 312* 314* 319 Rental Purchase of new durable medical equipment Purchase of used durable medical equipment Supplies/Drugs for DME effectiveness (Not Covered) Equipment LABORATORY Chemistry Immunology Renal Patient (Home) Non-Routine Dialysis Hematology Bacteriology & Microbiology Urology Laboratory LABORATORY PATHOLOGICAL Cytology Histology Biopsy Page 4 of 14 Last updated 10/24/2012

5 32X * X X X X * X RADIOLOGY DIAGNOSTIC * Angiocardiography* Arthrography Arteriography* Chest X-Ray* * RADIOLOGY THERAPEUTIC* General Chemotherapy Injected Chemotherapy Oral Radiation Therapy Chemotherapy IV NUCLEAR MEDICINE (RADIOISOTOPES)* General classification Diagnostic Procedures Therapeutic procedures Diagnostic Radiopharmaceuticals Therapeutic Radiopharmaceuticals CT SCAN* General classification Head Scan Body Scan CT Scans OPERATING ROOM SERVICES Minor Surgery Organ Transplant other than kidney Kidney Transplant Operating Room Services ANESTHESIA Anesthesia Incident to Radiology Incident to Diagnostic Services Acupuncture Covered only when procedure performed by a physician or physician s employee acupuncturist under a physician s supervision X 380* 381* 382* 383* 384* 385* Anesthesia BLOOD Packed Red Cells Whole Blood (Not Covered) Plasma Platelets Leukocytes Page 5 of 14 Last updated 10/24/2012

6 386* 387* 389* 39X X X * 413* X Components Derivatives (Cyroprecipitates) Blood BLOOD STORAGE AND PROCESSING Blood Administration (e.g., Transfusions) Blood Storage & Processing OTHER IMAGING SERVICES* Diagnostic Mammography Ultrasound Screening Mammography Positron Emission Tomography Imaging Services RESPIRATORY SERVICES * Inhalation Services Hyperbaric Oxygen Therapy Respiratory Services PHYSICAL THERAPY* Prior authorization of services is required for outpatient physical therapy services, unless Medicare Part B is the primary payer. Evaluations do not require prior authorization X Visit Charge Hourly Charge Group Rate Evaluation or Reevaluation Physical Therapy OCCUPATIONAL THERAPY* Prior authorization of services is required for outpatient occupational therapy services, unless Medicare Part B is the primary payer. Evaluations do not require prior Visit Charge 432 Hourly Charge 432 Group Rate 434 Evaluation or Reevaluation 439 Occupational Therapy 44X SPEECH-LANGUAGE PATHOLOGY* Prior authorization of services is required for outpatient speech-language services, unless Medicare Part B is the primary payer. Evaluations do not require prior authorization Visit Charge Hourly Charge Group Rate Evaluation or Reevaluation Speech-Language Pathology Page 6 of 14 Last updated 10/24/2012

7 45X * X X EMERGENCY ROOM * EMTALA Emergency Medical Screening Services ER Beyond EMTALA Screening Urgent Care Emergency Room* PULMONARY FUNCTION* Pulmonary Function AUDIOLOGY* Prior authorization of services is required for outpatient audiology services, unless Medicare Part B is the primary payer. Evaluations (471) do not require prior authorization X * X X X * 52X Diagnostic Treatment Audiology CARDIOLOGY * Cardiac Cath Lab* Stress Test* Echocardiology Cardiology* AMBULATORY SURGICAL CARE* Ambulatory Surgical Care OUTPATIENT SERVICES Outpatient Services CLINIC * Chronic Pain Center (Not Covered) Dental Clinic - Prior authorization required for hospital non-emergency services. Psychiatric Clinic (Not Covered) OB/GYN Clinic Pediatric Clinic Urgent Care Clinic Family Practice Clinic Clinic FREE-STANDING CLINIC (Not Covered) Rural Health Clinic Rural Health Home (Not Covered) Family Practice Urgent Care Clinic Freestanding Clinic (Not Covered) Page 7 of 14 Last updated 10/24/2012

8 53X X X X X X X X OSTEOPATHIC SERVICES Osteopathic Therapy Osteopathic Services AMBULANCE (Not Covered) Supplies (Not Covered) Medical TransportThis Revenue Center Code must be used to bill for medical transportation Heart Mobile (Not Covered) Oxygen (Not Covered) Air Ambulance (Not Covered) Neonatal Ambulance Service (Not Covered) Ambulance Pharmacy (Not Covered) Telephonic EKG (Not Covered) Ambulance (Not Covered) SKILLED NURSING (NOT COVERED) (Not Covered) Visit Charge (Not Covered) Hourly Charge (Not Covered) Skilled Nursing (Not Covered) MEDICAL SOCIAL SERVICES (Not covered in outpatient setting) Visit Charge (Not covered in outpatient setting) Hourly Charge (Not covered in outpatient setting) Medical Social Services* - Covered in outpatient setting for Maternity Case HOME HEALTH AIDE (HOME HEALTH) (NOT COVERED) (Not Covered) Visit Charge (Not Covered) Hourly Charge (Not Covered) Home Health Aide (Not Covered) OTHER VISITS (HOME HEALTH) (NOT COVERED) (Not Covered) Visit Charge (Not Covered) Hourly Charge (Not Covered) Assessment (Not Covered) Home Health Visits (Not Covered) UNITS OF SERVICE (HOME HEALTH) (NOT COVERED) (Not Covered) Home Health Units (Not Covered) OXYGEN HOME HEALTH (NOT COVERED) (Not Covered) Oxygen-State/Equip/Supply or contents (Not Covered) Oxygen-State/Equip/Supply Under 1 LPM (Not Covered) Oxygen-State/Equip/Supply Over 4 LPM (Not Covered) Oxygen Portable Add-On (Not Covered) Page 8 of 14 Last updated 10/24/2012

9 61X X X * 635* 636* X X MAGNETIC RESONANCE IMAGING (MRI)* Brain (including brain stem) Spinal Cord (including spine) MRI - MRA - Head and Neck MRA - Lower Extremities RESERVED (Not Covered) MRA - MRI - MEDICAL/SURGICAL SUPPLIES EXTENSION OF 27X Supplies Incident to Radiology Supplies Incident to Diagnostic Services Surgical Dressing Investigational Device (Not Covered) DRUGS REQUIRING SPECIFIC IDENTIFICATION (Not Covered) Single source drug Multiple source drug Restrictive prescription Epoetin, under 10,000 units per administration Epoetin, 10,000 units or more per administration Drugs requiring detail coding* Self-administrable Drugs HOME IV THERAPY SERVICES (NOT COVERED) (Not Covered) Nonroutine Nursing (Not Covered) IV Site Care, Central Line (Not Covered) IV StartChange Peripheral Line (Not Covered) Nonroutine Nursing, Peripheral Line (Not Covered) Training Patient/Caregiver, Central Line (Not Covered) Training Disabled Patient, Central Line (Not Covered) Training Patient/Caregiver, Peripheral Line (Not Covered) Training Disabled Patient, Peripheral Line (Not Covered) IV Therapy Services (Not Covered) HOSPICE SERVICES (NOT COVERED) (Not Covered) Routine Home Care (Not Covered) Continuous Home Care (Not Covered) Reserved (Not Covered) Reserved (Not Covered) Inpatient Respite Care (Not Covered) General Inpatient Care (Non-Respite) (Not Covered) Physician Services (Not Covered) Hospice Room and Board - Nursing Facility (Not Covered) Hospice (Not Covered) Page 9 of 14 Last updated 10/24/2012

10 66X X X X 70X X X # X X X RESPITE CARE (HOME HEALTH) (NOT COVERED) General (Not Covered) Hourly Charge/Skilled Nursing (Not Covered) Hourly Charge/Home Health (Not Covered) Daily Respite Charge (Not Covered) Respite Care (Not Covered) OUTPATIENT SPECIAL RESIDENCE CHARGES (NOT COVERED) General (Not Covered) Hospital-Based (Not Covered) Contracted (Not Covered) (Not Covered) TRAUMA RESPONSE (NOT COVERED) Not Used Trauma Level I (Not Covered) Trauma Level II (Not Covered) Trauma Level III (Not Covered) Trauma Level IV (Not Covered) Trauma Response (Not Covered) NOT ASSIGNED (NOT COVERED) CAST ROOM* Cast Room RECOVERY ROOM Recovery Room LABOR ROOM/DELIVERY Labor Delivery Circumcision Birthing Center Labor Room/Delivery EKG/ECG (ELECTROCARDIOGRAM)* Holter Monitor Telemetry EKG/ECG EEG (ELECTROENCEPHALOGRAM)* EEG GASTROINTESTINAL SERVICES* 0 9 Gastrointestinal Page 10 of 14 Last updated 10/24/2012

11 76X X X X X X X X TREATMENT OR OBSERVATION ROOM* Treatment Room Observation Room Treatment Room PREVENTIVE CARE SERVICES General Vaccine Care Services* TELEMEDICINE* Telemedicine LITHOTRIPSY* INPATIENT RENAL DIALYSIS Inpatient Hemodialysis Inpatient Peritoneal (non-capd) Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) Inpatient Continuous Cycling Peritoneal Dialysis (CCPD) Inpatient Dialysis ORGAN ACQUISITION* Living Donor Cadaver Donor Unknown Donor Unsuccessful Organ Bank Donor Search Charge Organ Acquisition HEMODIALYSIS OUTPATIENT OR HOME Hemodialysis/Composite or Rate Home Supplies Home Equipment Maintenance/100% Support Services Outpatient Hemodialysis PERITONEAL DIALYSIS OUTPATIENT OR HOME Peritoneal/Composite or Rate Home Supplies Home Equipment Maintenance/100% Support Services Outpatient Peritoneal Dialysis Page 11 of 14 Last updated 10/24/2012

12 84X X X 87X 88X X 90X CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) - OUTPATIENT OR CAPD/Composite or Rate Home Supplies Home Equipment Maintenance/100% Support Services Outpatient CAPD CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) OUTPATIENT OR HOME CCPD/Composite or Rate Home Supplies Home Equipment Maintenance/100% Support Services Outpatient CCPD RESERVED FOR DIALYSIS (NATIONAL ASSIGNMENT) RESERVED FOR DIALYSIS (NATIONAL ASSIGNMENT) MISCELLANEOUS DIALYSIS Ultrafiltration Home Dialysis Aid Visit (Not Covered) Misc. Dialysis OTHER DONOR BANK (RESERVED FOR NATIONAL ASSIGNMENT)* PSYCHIATRIC/PSYCHOLOGICAL TREATMENTS (Not Covered) Electroconvulsive Therapy Milieu Therapy (Not Covered) Play Therapy (Not Covered) Activity Therapy (Not Covered) Intensive Outpatient Services - Psychiatric (Not Covered) Intensive Outpatient Services - Chemical Dependency (Not Covered) Community Behavioral Health Program - Day Treatment (Not Covered) Reserved For National Assignment * - Somatotherapy services and psychiatric or psychological evaluations are the only services billable under this Revenue Center Code. Page 12 of 14 Last updated 10/24/2012

13 91X PSYCHIATRIC/PSYCHOLOGICAL SERVICES Somatotherapy services and psychiatric or psychological evaluations are the only services billable under Revenue Center Codes 919 and X X X X X Reserved For National Assignment Rehabilitation (Not Covered) Partial Hospitalization Less Intensive (Not Covered) Partial Hospitalization Intensive (Not Covered) Individual Therapy (Not Covered) Group Therapy (Not Covered) Family Therapy (Not Covered) Biofeedback (Not Covered) Testing* * Behavior Health Treatments/Services OTHER DIAGNOSTIC SERVICES* Peripheral Vascular Lab Electromyelogram Pap Smear Allergy Test Pregnancy Test Diagnostic Services MEDICAL REHABILITATION DAY PROGRAM (NOT COVERED) Half Day (Not Covered) Full Day (Not Covered) OTHER THERAPEUTIC SERVICES * Recreational Therapy (Not Covered) Education/Training* Cardiac Rehabilitation* Drug Rehabilitation (Not Covered) Alcohol Rehabilitation (Not Covered) Routine Complex Equipment Ancillary Complex Equipment* Therapeutic Services* OTHER THERAPEUTIC SERVICES - Extension of 94X (NOT COVERED) Reserved For National Assignment Athletic Training (Not Covered) Kinesiotherapy (Not Covered) PROFESSIONAL FEES* Psychiatric Ophthalmology Anesthesiologist (MD) Anesthetist (CRNA) Professional Fees Page 13 of 14 Last updated 10/24/2012

14 97X X X PROFESSIONAL FEES* - Continued Laboratory* Radiology Diagnostic* Radiology Therapeutic* Radiology Nuclear Medicine* Operating Room Respiratory Therapy Physical Therapy (Outpatient services require prior authorization) Occupational therapy (Outpatient services require prior authorization) Speech Pathology (Outpatient services require prior authorization) PROFESSIONAL FEES*- Extension of 96X & 97X Emergency Room Outpatient Services Clinic Medical Social Services (Covered in inpatient setting only) EKG EEG Hospital Visit Consultation Private Duty Nurse (Not Covered) PATIENT CONVENIENCE ITEMS (Not Covered) (Not Covered) Cafeteria/Guest Tray (Not Covered) Private Linen Service (Not Covered) Telephone/Telegraph (Not Covered) TV/Radio (Not Covered) Nonpatient Room Rentals (Not Covered) Late Discharge Charge (Not Covered) Admissions Kits (Covered) Beauty Shop/Barber (Not Covered) Patient Convenience Items (Not Covered) Page 14 of 14 Last updated 10/24/2012

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