MA Bulletin 01-06-06 Keystone Mercy Health Plan is implementing the following changes:

September 1, 2006 Dear Keystone Mercy Provider: Effective July 17, 2006, the Pennsylvania Department of Public Welfare (DPW) has end-dated several local procedure codes pertaining to services offered in Medical Rehabilitation Units of General and Rehabilitation Hospitals. These local procedures codes were cross-walked to national procedure codes already listed on the Medical Assistance (MA) Program Fee Schedule. However, in some cases, the correlating national procedure code requires the addition of a modifier. modifiers should be placed in the 1 st modifier position, with informational modifiers placed in the subsequent position. Failure to use the appropriate national procedure code and modifier(s) combination will result in inappropriate claim payment or denial. Additionally, payment for the correlating national procedure code may be reimbursed at a higher or lower amount than its counterpart. As a result of the changes outlined by DPW in MA Bulletin 01-06-06 Keystone Mercy Health Plan is implementing the following changes: If your facility currently bills for services using any of the local codes appearing on Attachment A, you may continue to bill using the local procedure code for services rendered on or before September 30, 2006. When billing for services rendered on or after October 1, 2006, you will need to begin using the corresponding national procedure code along with any pricing or informational modifier as it appears on Attachment A. If you have any questions regarding this change in reimbursement, please contact your Provider Account Executive, or call Provider Services at (800) 521-6007. Thank you for your participation in our network and your commitment to Keystone Mercy Health Plan members. Sincerely, William C. Morsell Senior Vice President Provider Network Management Attachment 200 Stevens Drive Philadelphia, PA 19113 215 937 8000 www.keystonemercy.com

to Procedure Cross Walk Definition Definition W0644 General medical exam, pre-admission assessment program T1015 U7 Clinic visit/encounter, all-inclusive W0663 Outpatient hospital physical therapy T1015 U8 GP Clinic visit/encounter, all-inclusive W0664 Outpatient hospital occupational T1015 U8 GO Clinic visit/encounter, all-inclusive W0665 Outpatient hospital speech therapy T1015 U8 GN Clinic visit/encounter, all-inclusive W0666 Outpatient hospital physical therapy T1015 U7 GP Clinic visit/encounter, all-inclusive W0667 Outpatient hospital occupational T1015 U7 GO Clinic visit/encounter, all-inclusive W0668 Outpatient hospital speech therapy T1015 U7 GN Clinic visit/encounter, all-inclusive W9049 Hospital outpatient clinic visit (enrollment approval required) T1015 U5 Clinic visit/encounter, all-inclusive W9051 Basic hospital outpatient clinic visit T1015 U4 Clinic visit/encounter, all-inclusive W9064 Medical school clinic visit (enrollment approval required) T1015 U5 Clinic visit/encounter, all-inclusive W9416 Peak expiratory flow rate (PERF) 94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without W9591 W9592 W9593 Electromyography, including nerve conduction velocites, one extremity and related para-spinal area Electromyography, including nerve conduction velocites, two extremities and related para-spinal area Electromyography, including nerve conduction velocites, three extremities and related para-spinal area 95860 95861 95863 maximal voluntary ventilation Needle electromyography, one extremity with or without related paraspinal areas Needle electromyography, two extremities with or without related paraspinal areas Needle electromyography, three extremities with or without related paraspinal areas W9630 General medical examination T1015 U7 Clinic visit/encounter, all-inclusive 1

to Procedure Cross Walk W9633 Definition Comprehensive medical examination by general practitioner when requested by the Department to determine eligibility Definition T1015 U7 Clinic visit/encounter, all-inclusive 96408 96410 96412 96414 96420 96422 96423 Chemotherapy administration, intravenous; push technique Chemotherapy administration, intravenous; infusion technique, up to one hour Chemotherapy administration, intravenous; infusion technique, one to eight hours, each additional hour Chemotherapy administration, intravenous, infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump Chemotherapy administration, intraarterial; push technique Chemotherapy administration, intraarterial; infusion technique, up to one hour Chemotherapy administration, intraarterial; infusion technique, one to eight hours, each additional hour 96425 Chemotherapy administration, intraarterial; infusion technique, initiation of prolonged infusion (more than 8 hours) requiring the use of a portable or implantable pump W9715 Physical therapy, two or more modalities and/or two or more procedures; initial 30 minutes T1015 U7 GP Clinic visit/encounter, all-inclusive 2

Medical Rehabilitation Units of General Hospital Rehabilitation Hospitals to Procedure Cross Walk Definition Definition X1101 Debridement of Ulcer, foot; initial 11040 Debridement; skin, partial thickness X1101 Debridement of Ulcer, foot; initial 11041 Debridement; skin, full thickness X1101 Debridement of Ulcer, foot; initial 11042 Debridement; skin, subcutaneous tissue X1101 Debridement of Ulcer, foot; initial 11043 Debridement; skin, subcutaneous tissue and muscle X1101 Debridement of Ulcer, foot; initial 11044 X1102 Debridement of Ulcer, foot; subsequent 11000 X1102 Debridement of Ulcer, foot; subsequent 11001 X1166 X1166 X1167 X1167 Debridement of hypertrophic nails; initial, multiple Debridement of hypertrophic nails; initial, multiple Debridement of hypertrophic nails; subsequent, multiple Debridement of hypertrophic nails; subsequent, multiple 11720 11721 11720 11721 X1172 Avulsion of nail, partial, one nail 11730 X1172 Avulsion of nail, partial, one nail 11732 X1175 Excision of nail and nail matrix; partial, one nail 11750 T1-T9, TA, F1- F9, FA T1-T9, TA, F1- F9, FA T1-T9, TA, F1- F9, FA Debridement; skin, subcutaneous tissue, muscle and bone Debridement of extensive eczematous or infected skin; up to 10% of body surface Debridement of extensive eczematous or infected skin; each additional 10% of the body surface Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Debridement of nail(s) by any method(s); one to five Debridement of nail(s) by any method(s); six or more Avulsion of nail plate, partial or complete, simple; single Avulsion of nail plate, partial or complete, simple; single; each additional nail plate Exclusion of nail or nail matrix, partial or complete, (e.g. ingrown or deformed nail) for permanent removal 3

to Procedure Cross Walk X1177 X1720 Definition Excision of nail and nail matrix; complete, one nail Plantar verruca or verrucae, removal by any method except excision, such as superficial cutting or paring, chemotherapy, etc; subsequent treatment 11750 17000 T1-T9, TA, F1- F9, FA Definition Exclusion of nail or nail matrix, partial or complete, (e.g. ingrown or deformed nail) for permanent removal Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; first lesion X1720 Plantar verruca or verrucae, removal by any method except excision, such as superficial cutting or paring, chemotherapy, etc; subsequent treatment 17003 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; second through 14 lesions, each (list separately in addition to code for first lesion) X1720 Plantar verruca or verrucae, removal by any method except excision, such as superficial cutting or paring, chemotherapy, etc; subsequent treatment 17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratoses) other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions X3643 Y7030 Transfusion, blood or blood components; direct Radiology diagnostic, both mandible and temporomandibular joints, panoramic views 36430 70330 Transfusion, blood or blood components Radiologic examination, temporomandibular joint, open and closed mouth; bilateral 4

to Procedure Cross Walk Y7100 Y7101 Y7200 Y7211 Definition Radiologic examination, chest, two views, posterantherior and lateral, routine service, asymptomatic patient Radiologic examination, chest, two views, frontal and lateral; three views Radiologic examination, spine; scoliosis study, complete, minimum of four views three three three three three three three Radiologic diagnostic, lumbal spine and pelvis; complete lumbal spine with anteroposterior views of pelvis 71020 71020 72090 72040 72050 72072 72074 72100 72110 72120 72010 Definition Radiologic examination, chest, two views, frontal and lateral Radiologic examination, chest, two views, frontal and lateral Radiologic examination, spine; scoliosis study, including supine and erect studies cervical; two or three views cervical; minimum of four views thoracic, three views thoracic, minimum of four views lumbosacral; two or three views lumbosacral; minimum of four views lumbosacral, bending views only, minimum of four views entire, survey study, anteroposterior and lateral Y7308 Radiologic examination, elbow, comprehensive, minimum of five views 73080 RT, LT 50 Radiologic examination, elbow, complete, minimum of three views Y7310 Radiologic examination, wrist; comprehensive, minimum of five views 73110 RT, LT 50 Radiologic examination, wrist, complete, minimum of three views Y7311 Y7311 Radiology diagnostic, hand and wrist; limited, fewer that three views Radiology diagnostic, hand and wrist; limited, fewer that three views 73100 RT, LT 50 73120 RT, LT 50 Radiologic examination, wrist; two views Radiologic examination, hand; two views 5

to Procedure Cross Walk Definition Definition Y7312 Radiology diagnostic, hand and wrist; complete, fewer that three views 73110 RT, LT 50 Radiologic examination, wrist; complete, minimum of three views Y7312 Y7322 Y7323 Y7324 Y7325 Y7360 Y7419 Y7600 Radiology diagnostic, hand and wrist; complete, fewer that three views Magnetic Resonance (e.g., Proton) Imaging, upper extremity, other that joint with contrast material Magnetic Resonance Imaging, upper extremity, other that joint, without contrast materials, followed by contrast material Magnetic Resonance (e.g., Proton) Imaging, any joint of upper extremity; with contrast material Magnetic resonance imaging, any joint of upper extremity without contrast material, followed by contrast materials Radiologic examination, ankle; comprehensive, minimum of five views Magnetic resonance imaging, abdomen; without contrast material, followed by contrast material Extended room time with periodic fluoroscopy (radiological guidance), per 30 minutes 73130 RT, LT 50 73219 RT, LT 50 73220 RT, LT 50 73222 RT, LT 50 73223 RT, LT 50 73610 RT, LT 50 74183 76001 Z0832 Pregnancy Test 81025 Radiologic examination, hand; complete, minimum of three views Magnetic resonance imaging, upper extremity, other that joint with contrast materials Magnetic resonance imaging, upper extremity, other that joint, without contrast materials and further sequencing Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; with contrast material(s) Magnetic resonance imaging, any joint of upper extremity without contrast material, followed by contrast material(s) and further sequences Radiologic examination, ankle, complete, minimum of 3 views Magnetic resonance imaging, abdomen; without contrast material, followed by contrast material(s) and further sequences Fluoroscopy, physician time more than one hour, assisting a nonradiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) Urine pregnancy test, by visual color comparison methods 6

Medical Rehabilitation Units of General Hospital Rehabilitation Hospitals to Procedure Cross Walk Definition Z0832 Pregnancy Test 84702 Z0832 Pregnancy Test 84703 Z2100 Z2101 Z2102 Z2103 Z2105 Z2106 Alcohol (Ethanol), blood; quantitative (all methods) Alcohol(ethanol), urine; quantitative (all methods) Alcohol(ethanol), urine; quantitative (all methods) Drug screen (amphetamines, barbiturates, benzodiazepine, cocaine, methadone, methaqualone, opiates, phencyclidine (PCP), propoxyphene, THC (all methods) 1-5 Drug screen, fentanyl, fentanyl derivatives (all methods) Drug screen (amphetamines, barbiturates, benzodiazepine, cocaine, methadone, methaqualone, opiates, phencyclidine (PCP), propoxyphene, THC (all methods) 6-10 82055 82055 82055 80100 80101 80100 U7 86689 Definition Gonadotropin, chronic (hcg); quantitative Gonadotropin, chronic (hcg); qualitative Alcohol (ethanol); any specimen except breath Alcohol (ethanol); any specimen except breath Alcohol (ethanol); any specimen except breath Drug screen, qualitative; multiple drug classes chromatographic method, each procedure Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class 86701 Antibody; HIV-1 86702 Antibody; HIV-2 86703 7 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot) Anti-body; HIV-1 and HIV-2, single assay

Z8227 Medical Rehabilitation Units of General Hospital Rehabilitation Hospitals to Procedure Cross Walk Definition Blood; occult feces, screening - asymptomatic patient 87390 87391 82270 Definition Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV-1 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV-2 Blood occult, by peroxidase activity (e.g., guaiac), qualitative; feces, 1-3 simultaneous determinations Z8294 Glucose; 2 hour postprandial 82947 Glucose; quantitative, blood (except reagent strip) Z8309 Haldol (Haloperidol) 80173 Haloperidol Z8374 Ludiomil (Maprotiline) 80299 Quantitation of drug, not elsewhere Z8391 Norpace (Disopryamide) 80299 Z8503 Z8503 Z8555 Z8555 Z8556 Blood count, hemogram, manual, completed CBC (RBC, WBC, Hgb, Hct, Differential and Indicies) - Asymptomatic patient Blood count, hemogram, manual, completed CBC (RBC, WBC, Hgb, Hct, Differential and Indicies) - Asymptomatic patient Blood cont; hematocrit - asymptomatic patient Blood cont; hematocrit - asymptomatic patient Blood count; Hematocrit and Hemoglobin (Hct and Hgb) 85027 91 85027 specified Quantitation of drug, not elsewhere specified 85014 91 Blood count; hematocrit (Hct) 85014 Blood count; hematocrit (Hct) 85025 91 8

Z8556 Z8557 Z8557 Definition Blood count; Hematocrit and Hemoglobin (Hct and Hgb) - asymptomatic patient Blood count; Hematocrit and Hemoglobin (Hct and Hgb) Blood count; Hematocrit and Hemoglobin (Hct and Hgb) Medical Rehabilitation Units of General Hospital Rehabilitation Hospitals to Procedure Cross Walk 85025 85025 91 85025 Z8604 Anti-Parietal AB 86255 Z8627 Z8627 Z8627 Z8631 Antibody; Epstein-Barr Virus (EBV), Complete Evaluation Antibody; Epstein-Barr Virus (EBV), Complete Evaluation Antibody; Epstein-Barr Virus (EBV), Complete Evaluation Immunoassay for Prostate Specific Antigen (PSA); Asymptomatic Patient 86663 86664 86665 84153 Z8636 Mast Allergy Test; up to 5 antigens 86003 Z8637 Mast Allergy Test; 6 or more antigens 86003 Definition Fluorescent noninfectious agent antibody; screen, each antibody Antibody; Epstein-Barr (EB) virus, early antigen (EA) Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA) Epstein-Barr (EB) virus, viral capsid (VCA) Prostate specific antigen (PSA); total Allergen specific IgE; quantitative or semiquantitative, each allergen Allergen specific IgE; quantitative or semiquantitative, each allergen Z8704 Campylobacter Culture, feces 86625 Antibody; campylobacter Z8708 Culture, screening for organism including sensitivity study, sources other than blood 87081 Z8708 Culture, screening for organism including sensitivity study, sources other than blood 87181 Culture, presumptive, pathogenic organisms, screening only Susceptibility studies, antimicrobial agent, agar, dilution method, per agent (e.g., antibiotic gradient strip) Z8708 Culture, screening for organism including sensitivity study, sources other than blood 87190 Susceptibility studies, antimicrobial agent, mycobacteria, proportion method, each agent 9

to Procedure Cross Walk Z8712 Definition Culture, urine; quantitative, with colony count including sensitivity study, screening 87086 Definition Culture, bacteria; quantitative colony count urine Z8712 Culture, urine; quantitative, with colony count including sensitivity study, screening 87181 Susceptibility studies, antimicrobial agent, agar, dilution method, per agent (e.g., antibiotic gradient strip) Z8712 Culture, urine; quantitative, with colony count including sensitivity study, screening 87190 Susceptibility studies, antimicrobial agent, mycobacteria, proportion method, each agent Z8713 Z8713 Culture urine; definitive and sensitivity study for specific microorganisms, with isolation of organism Culture urine; definitive and sensitivity study for specific microorganisms, with isolation of organism 87086 87088 Culture, bacteria; quantitative colony count urine Culture, bacteria; with isolation and presumptive identification of isolates, urine 10