LOCAL CARRIER CODES HIPAA Non- Description X0031 Nursing care visit in home health setting per-visit X0037 Home health aide services (per 6-minute unit) Home health aide services in home health setting - hourly X0038 Physical therapy visit (prior authorization after 20 visits) Physical therapy visit in home health setting - per-visit X0039 Speech/language therapy visit (prior authorization after 20 visits) Speech/language therapy visit in home health setting - per-visit X0040 Occupational therapy visit (prior authorization after 20 visits) Occupational therapy visit in home health setting - per-visit X0146 BLS ambulance mileage per loaded mile nonemergency transport, one way X0174 Chair car mileage mileage per loaded mile - one way - add-on X0310 For urgent care in the office Mon to Fri, 5 p.m.to 6:59 a.m.; Sat 7a.m. to 4 p.m., in addition to basic service. Not for regularly scheduled appointments or well-visits. Encourages providers to treat member in office, rather than member presenting at ED for urgent care X0320 For urgent care in the office Sat 4:01 p.m. to Mon 6:59 a.m., in addition to basic service. Not for regularly scheduled appointments or well-visits. Encourages providers to treat member in the office, rather than member presenting at ED for urgent care Service Description* T1002, T1003 T1002: Registered nurse services, up to 15 T1003: LPN/LVN services, up to 15 G0156 Services of home health aide in home health setting, each 15 G0151 Services of physical therapist in home health setting, each 15 G0153 Services of speech and language pathologist in home health setting, each 15 G0152 Services of occupational therapist in home health setting, each 15 A0425 A0425 Ground mileage, per statute mile Ground mileage, per statute mile 99050 Services requested after office hours in addition to basic service 99054 Services requested on Sundays and holidays in addition to basic services X0401 Removal of the Norplant system of contraception 11976 Removal, implantable contraceptive capsules X0411 Multi-dose allergen extract/allergen immunotherapy this code is for the extract ONLY, multiple dose - injection code is billed separately 95165 Professional services for the supervision and provision of antigens for allergen immunotherapy, single or multiple antigens, (specify number of doses) X0425 Stationary compressed gaseous oxygen E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing X0430 Portable compressed gaseous oxygen E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing X0435 Portable liquid oxygen system E0434 Portable liguid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill, adaptor, contents gauge, cannula or mask, and tubing X0440 Stationary liquid oxygen system E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing X0441 Oxygen contents, gaseous, per unit E0424 Stationary compress gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing X0442 Oxygen contents, liquid, per unit E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing X0443 Oxygen contents, gaseous, per unit E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing X1041 X1053 NETWORK HEALTH COMPLIANT CODE CHART FOR MEDICAL SERVICES Contraceptives/family planning supplies. Oral contraceptive, all brands, maximum cost $2.00 per package Contraceptives/family planning supplies. Intrauterine device (IUD), all types S4993 S4989 Contraceptive pills for birth control Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies * Subject to change 1 Rev. 9/03
NETWORK HEALTH COMPLIANT CODE CHART FOR MEDICAL SERVICES HIPAA Non- Description LOCAL X1055 CARRIER Contraceptives/family CODES planning supplies. Oral contraceptive, all brands, cost $3.01-$4.00 per package X1068 Contraceptive injectable per 3-month dose (such as Depo-Provera) X1069 Contraceptives/family planning supplies. Injections/medications for family planning, with the exception of Depo-Provera S4993 J1055 J3490 Service Description* Contraceptive pills for birth control Injection, medroxyprogesterone acetate for contraceptive use, 150mg Unclassified drugs X1071 Medical follow-up visit, post abortion 99213 E/M code X1072 X1073 Induced abortion, by dilation and curettage or evacuation, 12.1-13.9 weeks gestation Induced abortion, by dilation and curettage or evacuation, 14.0-17.9 weeks gestation 59840, 59841 59840: Induced abortion, by dilation and curettage 59841: Induced abortion, by dilation and evacuation 59840 Induced abortion, by dilation and curettage X1616 Chiropractor, new patient eval and mng visit 99201 Office or other outpatient visit for the evaluation and meeting of a new patient, which requires these three key components: a problemfocused history; a problem-focused examination; and straightforward medical decision making X1617 Chiropractor, established patient eval and mng visit 99212 Office or other outpatient visit for the evaluation and meeting of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision making X2200 X2312 X2313 X2314 X2315 X2316 X2317 X2318 X2319 Administration or dispensing of one dose of methadone provided in a non-hospital substance abuse treatment facility Early intervention is a federally mandated program for children 0-3 yrs of age. Use this code for billing for all individual child visits with POS modifier and max units (currently, this code is specific to daycare center EI visit, per 15-minute) Early intervention services, at hospital, per 15-minute unit Early intervention services, home visit (2 hour maximum), per 15-minute unit Early intervention services, center-based individual visit (2 hour maximum) per 15-minute unit Early intervention services, provided to groups of two or more children (center-based) Early intervention services, provided to two or more parents of children receiving EI Screening by early intervention clinicians to determine if child meets EI criteria Early intervention assessment - a comprehensive evaluation of child's developmental status and family situation conducted by EI clinicians to determine type and frequency of EI services needed H0020 H2015 H2015 Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) AH, AJ, GN, Comprehensive community support services, per 15 (see AH, AJ, GN, Comprehensive community support services, per 15 (see H2015 AH, AJ, GN, Comprehensive community support services, per 15 (see T1015 TL Clinic visit/encounter, all-inclusive (see modifiers on page 6) 96153 U1 Health and behavior intervention, each 15, face-to-face; group (two or more patients) (see modifiers on page 6) T1027 TL Family training and counseling for child development, per 15 (see modifiers on page 6) T1023 T1024 AH, AJ, GN, GO, GP, TD,, or HN AH, AJ, GN, GO, GP, TD,, or HN Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter (see modifiers on page 6) Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter (see modifiers on page 6) X3333 Drugs/devices supplied in physician office req PA J codes, J3490 J codes: Use drug/device-specific J-code J3490: Unclassified drugs X3402 Hearing aid batteries, size 13, 312, 675, package of 4 V5266 Battery for use in hearing device X5008 DME eye patch cloth deleted X5012 Personal emergency response system S5160, S5161, S5162 X5014 DME personal emergency response system, installation S5160 X5021 DME breast pump E0602, E0603, E0604 S5160: Emergency response system; installation and testing S5161: Emergency response system; service fee, per month (excludes installation and testing) S5162: Emergency response system; purchase only Emergency response system, installation, and testing E0602: Breast pump, manual, any type E0603: Breast pump, electric (AC and/or DC), any type E0604: Breast pump, heavy duty, hospital grade, piston operated, pulsatile vacuum suction/release cycles, vacuum regulator, supplies, transform electric (AC) X5045 DME first 6-oximeter E0445 Oximeter device for measuring blood oxygen levels non-invasively * Subject to change 2 Rev. 9/03
NETWORK HEALTH COMPLIANT CODE CHART FOR MEDICAL SERVICES HIPAA Non- Description Service Description* LOCAL X5050 CARRIER Peak CODES flow meter S8096 Portable peak flow meter X5053 After 6-oximeter, port deleted X5061 Walker heavy duty E0147 Heavy duty, multiple breaking systems, variable wheel resistance walker X5067 Tub stool or bench (intermediate) E0245 Tub stool or bench X5068 Transfer bench (standard seat) deleted X5069 DME transfer bench (intermediate) deleted X5156 Fastening hardware deleted X5256 Standard wheelchair fixed full K0001 Standard wheelchair X5267 DME gauze sterile strip A6219, A6220, A6221 X5272 Cotton tip applicator deleted X5276 Diapers, pediatric (96/case) A4529, A4530, A4531, A4532 A6219: Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing A6220: Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing A6221: Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing A4529: child-sized incontinence product, diaper, small/medium size, each A4530: large size, each A4531: child-sized incontinence product, brief, small/medium size, each A4532: large size, each X5277 Diapers, youth (100/case) A4533 Youth-sized incontinence product, diaper, each X5278 Diapers, adult (100/case), small A4521 Adult-sized incontinence product diaper, small size, each X5279 Diapers, adult (96/case), medium A4522 Adult-sized incontinence product diaper, medium size, each X5280 Diapers, adult (96/case) large A4523 Adult-sized incontinence product, diaper, large size, each X5281 Diapers, adult (72/case) extra large A4524 Adult-sized incontinence product, diaper, extra large size, each X5282 Liners, standard (100/case) A4535 Disposable liner/shield or incontinence, each X5283 Liners, intermediate A4535 Disposable liner/shield or incontinence, each X5284 Primary surgical dressing kit deleted X5285 Primary surgical dressing kit deleted X5294 Hearing aid accessories/options costing $35.00 or less. Accessories/options are those items, including circuitry, that are not intrinsic components of the basic hearing aid unit, but do not include non-essential items such as carrying cases V5267 Hearing aid supplies/accessories X5296 Hearing aid tubing replacement 99499 Unlisted evaluation and management service X5298 Earmold(s) for hearing aid(s), costing $35.00 or less per V5264, V5265 V5264: Ear mold/insert, not disposable, any type unit V5265: Ear mold/insert, disposable, any type X5299 Earmold(s) for hearing aid(s), costing more than $35.00 per unit X5300 Hearing aid accessories/options costing more than $35.00. Accessories/options are those items, including circuitry, that are not intrinsic components of the basic hearing aid unit, but do not include non-essential items such as carrying cases V5264, V5265 V5264: Ear mold/insert, not disposable, any type V5265: Ear mold/insert, disposable, any type V5267 Hearing aid supplies/accessories X5301 Ear impression(s) for hearing aids V5275 Ear impression, each X5356 Tracheostomy or laryngectomy tube A4622 Tracheostomy or laryngectomy tube X5358 DME tracheostomy Velcro collar A4621 Tracheostomy mask or collar X5360 DME resuscitator S8999 Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event) X5377 DME first 6-oximetry monitor E0445 Oximeter device for measuring blood oxygen levels non-invasively X5386 Catheter care parenteral S5502, S5517, S5518, S5523 S5502: Home infusion therapy, catheter care/maintenance, implanted access device, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment S5517: Home infusion therapy, all supplies necessary X5391 Total parenteral nutrition B4164-B5200 Parenteral nutrition solutions and supplies X5392 Unlisted enteral solutions B9998 NOC for enteral supplies X5393 DME Ensure, 8oz. can B4151 BO B4151: Enteral formula; category I: natural intact protein/protein * Subject to change 3 Rev. 9/03
NETWORK HEALTH COMPLIANT CODE CHART FOR MEDICAL SERVICES HIPAA Non- Description Service Description* LOCAL X5396 CARRIER Enfamil CODES B4151 BO B4151: Enteral formula; category I: natural intact protein/protein X5406 DME Pediasure B4151 BO B4151: Enteral formula; category I: natural intact protein/protein X5407 Polycose Powder B4155 BO B4155: Enteral formulae; category V: modular components, administered through an enteral feeding tube, 100 calories = 1 unit; BO: orally administered nutrition, not by feeding tube X5411 Sustacal, 8oz. Can B4151 BO B4151: Enteral formula; category I: natural intact protein/protein X5413 DME enteral bags B4035 Enteral feeding supply kit; pump fed, per day only if the "S" codes are not being used X5417-X5420 Hospital bed w/side rails and total electric E0250 - E0373 Hospital beds and accessories X5422 DME standard wheelchair deleted X5423 Wheelchair, detachable arms deleted X5424 Wheelchair, detachable arms deleted X5430 DME after 6-interim asst dev deleted X5432 Early intervention services, community group (same as X2316, but in community) X5506 Observation room services (0-6 hours) deleted X5507 Observation room services (6 hours 1 minute to 12 hours) X5552 For administration of VFC pediatric vaccines for individuals 18 yrs and under. Necessary to meet federal requirements of $15.78 per vaccine 96153 U2 Health and behavior intervention, each 15, face-to-face; group (two or more patients) (see modifiers on page 6) deleted 90471, 90472, 90473, 90474 Immunization administration codes X5555 Enhanced global delivery C-sect, pelvic 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care X5582 Urgent care visit 99050 Services requested after office hours in addition to basic service X5613 Structured outpatient addiction program (SOAP) H0015 Alcohol and/or drug services; intensive outpatient X5902 Individual medical visit in a CHC T1015 Clinic visit/encounter, all-inclusive X5904 Group visit T1015 Clinic visit/encounter, all-inclusive X8012 Centrifuging and mailing of specimen to independent laboratory X8051 Dispensing fee for a complete new frame 92340 (with X8070); 92341-92342 (with X8071) X8070 X9164 X9335 Dispensing fee for any pair of single vision glass/plastic lenses, per pair - initial dispensing Psychological testing. Intellectual and personality evaluation, including, but not limited to, the tests listed under intelligence testing and personality evaluation Titmus screening test. Specific screening device/instrument with series of tests for visual acuity, eye muscle, and color. Required in EPSDT program 99000 Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory 92340: Fitting of spectacles, except for aphakia; monofocal 93241: Fitting of spectacles, except for aphakia; bifocal 92342: Fitting of spectacles, except for aphakia; multifocal, other than bifocal 92340 Fitting of spectacles, except for aphakia; monofocal 96100 Psychological testing (includes psychodiagnostic assessment of personality, psychopathology, emotionality, intellectual abilities, eg, WAIS-R, Rorschach, MMPI) with interpretation and report, per hour 99173 Screening test of visual acuity, quantitative, bilateral X9642 Speech group, each additional 15 min (max 30 min) 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); group, two or more individuals X9653 Speech/lang therapy eval child <21 (per hour max 3 hours) X9653 Comprehensive pediatric speech/language evaluation (age 21 and younger) 92506 Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status 92506 HA 92506: Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status (child/adolescent program); HA - child/adolescent program Y9214 Cardiac monitor 93224-93237, Electrocardiographic monitoring codes 93268-93272 Y9858 DME repair labor per hour only E1340 Repair or non-routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 min PROPRIETARY CODES * Subject to change 4 Rev. 9/03
NETWORK HEALTH COMPLIANT CODE CHART FOR MEDICAL SERVICES HIPAA Non- HIPAA Non- Description LOCAL BIRTH CARRIER Childbirth CODES class S9436, S9439, DOULA Ante-partum, intra-partum, post-partum S9436, S9439, PARENT Parenting class S9436, S9439, BREAST Breast feeding class S9436, S9439, Service Description* S9442: Birthing classes, non-physician S9444: Parenting classes, non-physician S9442: Birthing classes, non-physician S9444: Parenting classes, non-physician S9442: Birthing classes, non-physician S9444: Parenting classes, non-physician S9442: Birthing classes, non-physician S9444: Parenting classes, non-physician Definitions Clinician Clinician Modifier Description Modifier CPT code Current procedural terminology. A procedure code set maintained and copyrighted by AH Clinical psychologist the AMA, and that as been selected for use under HIPAA for non-institutional and nondental professional transactions. HCPCS code HCFA Common Procedural Coding System. A medical code set that identifies health AJ Clinical social worker care procedures, equipment, and supplies for claim submission purposes. It has been selected for use in HIPAA transactions. Local carrier code Alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local" codes, and must have "W", "X", "Y", or "Z" in the first position. GN Speech language pathologist Modifier A two-digit code that has been selected for use in HIPAA transactions that indicates GO Occupational therapist services or procedures have been altered by some specific circumstance. Modifiers do not change the definition of the reported procedure codes. Proprietary code s that are used to describe a service, drug, supply, or medical equipment delivered GP Physical therapist to or distributed to a member. These codes are created by entities because no other code exists in the standard code sets established by the industry. Revenue code A three-digit numeric code that has been selected for use in HIPAA transactions that HN Bachelor's degree level (use for Educator, bachelor's level or higher) describes the type of service provided. TD Registered nurse TL U1 U2 Licensed practical nurse Early intervention Medicaid level of care 1 (use this modifier for EI-only child groups) Medicaid level of care 2 (use this modifier for community child groups) * Subject to change 5 Rev. 9/03