THIS WEBSITE IS FOR INFORMATIONAL PURPOSE ONLY. MEDICAID FEE FOR SERVICES: UPDATE JANUARY 1, 2018 Codes for Out-Patient Hospital Billing ONLY

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1 A4641 A9505 A9512 A9516 A9521 A9528 A9537 A9540 A9541 A9555 A9556 A9558 A9560 A9561 A9562 A9567 A9587 A9588 C1300 C1713 C1714 C1715 C1716 C1717 C1719 C1721 C1722 C1724 C1725 C1726 RADIOPHARMACEUTICAL, DIAGNOSTI THALLIUM TL-201 THALLOUS CHLOR TECHNETIUM TC-99M PERTECHNETAT IODINE I-123 SODIUM IODIDE, DI TECHNETIUM TC-99M EXAMETAZIME, IODINE I-131 SODIUM IODIDE CAP TECHNETIUM TC-99M MEBROFENIN, TECHNETIUM TC-99M MACROAGGREGA TECHNETIUM TC-99M SULFUR COLLO RUBIDIUM RB-82, DIAGNOSTIC, PE GALLIUM GA-67 CITRATE, DIAGNOS XENON XE-133 GAS, DIAGNOSTIC, TECHNETIUM TC-99M LABELED RED TECHNETIUM TC-99M OXIDRONATE, TECHNETIUM TC-99M MERTIATIDE, TECHNETIUM TC-99M PENTETATE, D GALLIUM GA-68, DOTATATE, DIAGN FLUCICLOVINE F-18, DIAGNOSTIC, HYPERBARIC OXYGEN UNDER PRESSU ANCHOR/SCREW FOR OPPOSING BONE CATHETER, TRANSLUMINAL ATHEREC BRACHYTHERAPY NEEDLE CARDIOVERTER-DEFIBRILLATOR, DU CARDIOVERTER-DEFIBRILLATOR, SI CATHETER, TRANSLUMINAL ATHEREC CATHETER, TRANSLUMINAL ANGIOPL CATHETER, BALLOON DILATATION, Page 1 of 13

2 C1727 CATHETER, BALLOON TISSUE DISSE C1728 CATHETER, BRACHYTHERAPY SEED A C1729 CATHETER, DRAINAGE C1730 CATHETER, ELECTROPHYSIOLOGY, D C1731 CATHETER, ELECTROPHYSIOLOGY, D C1732 CATHETER, ELECTROPHYSIOLOGY, D C1733 CATHETER, ELECTROPHYSIOLOGY, D C1749 ENDOSCOPE, RETROGRADE IMAGING/ C1750 CATHETER, HEMODIALYSIS, LONG-T C1751 CATHETER, INFUSION, INSERTED P C1752 CATHETER, HEMODIALYSIS, SHORT- C1753 CATHETER, INTRAVASCULAR ULTRAS C1754 CATHETER, INTRADISCAL C1755 CATHETER, INTRASPINAL C1756 CATHETER, PACING, TRANSESOPHAG C1757 CATHETER, THROMBECTOMY/EMBOLEC C1758 CATHETER, URETERAL C1759 CATHETER, INTRACARDIAC ECHOCAR C1760 CLOSURE DEVICE, VASCULAR (IMPL C1762 CONNECTIVE TISSUE, HUMAN (INCL C1763 CONNECTIVE TISSUE, NON-HUMAN ( C1764 EVENT RECORDER, CARDIAC (IMPLA C1765 ADHESION BARRIER C1766 INTRODUCER/SHEATH, GUIDING, IN C1767 GENERATOR, NEUROSTIMULATOR (IM C1768 GRAFT, VASCULAR C1769 GUIDE WIRE C1770 IMAGING COIL, MAGNETIC RESONAN C1771 REPAIR DEVICE, URINARY, INCONT C1772 INFUSION PUMP, PROGRAMMABLE (I Page 2 of 13

3 C1773 RETRIEVAL DEVICE, INSERTABLE ( C1776 JOINT DEVICE (IMPLANTABLE) C1777 LEAD, CARDIOVERTER-DEFIBRILLAT C1778 LEAD, NEUROSTIMULATOR (IMPLANT C1779 LEAD, PACEMAKER, TRANSVENOUS V C1780 LENS, INTRAOCULAR (NEW TECHNOL C1781 MESH (IMPLANTABLE) C1782 MORCELLATOR C1783 OCULAR IMPLANT, AQUEOUS DRAINA C1784 OCULAR DEVICE, INTRAOPERATIVE, C1785 PACEMAKER, DUAL CHAMBER, RATE- C1786 PACEMAKER, SINGLE CHAMBER, RAT C1787 PATIENT PROGRAMMER, NEUROSTIMU C1788 PORT, INDWELLING (IMPLANTABLE) C1789 PROSTHESIS, BREAST (IMPLANTABL C1813 PROSTHESIS, PENILE, INFLATABLE C1814 RETINAL TAMPONADE DEVICE, SILI C1815 PROSTHESIS, URINARY SPHINCTER C1816 RECEIVER AND/OR TRANSMITTER, N C1817 SEPTAL DEFECT IMPLANT SYSTEM, C1818 INTEGRATED KERATOPROSTHESIS C1819 SURGICAL TISSUE LOCALIZATION A C1820 GENERATOR, NEUROSTIMULATOR (IM C1821 INTERSPINOUS PROCESS DISTRACTI C1822 GENERATOR, NEUROSTIMULATOR (IM C1830 POWERED BONE MARROW BIOPSY NEE C1840 LENS, INTRAOCULAR (TELESCOPIC) C1841 RETINAL PROSTHESIS, INCLUDES A C1874 STENT, COATED/COVERED, WITH DE C1875 STENT, COATED/COVERED, WITHOUT Page 3 of 13

4 C1876 C1877 C1878 C1880 C1881 C1882 C1883 C1884 C1885 C1886 C1887 C1888 C1891 C1892 C1893 C1894 C1895 C1896 C1897 C1898 C1899 C1900 C2613 C2614 C2615 C2616 C2617 C2618 C2619 C2620 STENT, NON-COATED/NON-COVERED, STENT, NON-COATED/NON-COVERED, MATERIAL FOR VOCAL CORD MEDIAL VENA CAVA FILTER DIALYSIS ACCESS SYSTEM (IMPLAN CARDIOVERTER-DEFIBRILLATOR, OT ADAPTOR/EXTENSION, PACING LEAD EMBOLIZATION PROTECTIVE SYSTEM CATHETER, TRANSLUMINAL ANGIOPL CATHETER, EXTRAVASCULAR TISSUE CATHETER, GUIDING (MAY INCLUDE CATHETER, ABLATION, NON-CARDIA INFUSION PUMP, NON-PROGRAMMABL INTRODUCER/SHEATH, GUIDING, IN INTRODUCER/SHEATH, GUIDING, IN INTRODUCER/SHEATH, OTHER THAN LEAD, CARDIOVERTER-DEFIBRILLAT LEAD, CARDIOVERTER-DEFIBRILLAT LEAD, NEUROSTIMULATOR TEST KIT LEAD, PACEMAKER, OTHER THAN TR LEAD, PACEMAKER/CARDIOVERTER-D LEAD, LEFT VENTRICULAR CORONAR LUNG BIOPSY PLUG WITH DELIVERY PROBE, PERCUTANEOUS LUMBAR DIS SEALANT, PULMONARY, LIQUID STENT, NON-CORONARY, TEMPORARY PROBE/NEEDLE, CRYOABLATION PACEMAKER, DUAL CHAMBER, NON R PACEMAKER, SINGLE CHAMBER, NON Page 4 of 13

5 C2621 C2622 C2623 C2624 C2625 C2626 C2627 C2628 C2629 C2630 C2631 C2634 C2635 C2636 C2637 C2638 C2639 C2640 C2641 C2642 C2643 C2644 C2645 C2698 C2699 C5271 C5272 C5273 C5274 C5275 PACEMAKER, OTHER THAN SINGLE O PROSTHESIS, PENILE, NON-INFLAT CATHETER, TRANSLUMINAL ANGIOPL IMPLANTABLE WIRELESS PULMONARY STENT, NON-CORONARY, TEMPORARY INFUSION PUMP, NON-PROGRAMMABL CATHETER, SUPRAPUBIC/CYSTOSCOP CATHETER, OCCLUSION INTRODUCER/SHEATH, OTHER THAN CATHETER, ELECTROPHYSIOLOGY, D REPAIR DEVICE, URINARY, INCONT BRACHYTHERAPY LINEAR SOURCE, N BRACHYTHERAPY SOURCE, STRANDED BRACHYTHERAPY SOURCE, STRANDED BRACHYTHERAPY SOURCE, STRANDED BRACHYTHERAPY SOURCE, CESIUM-1 BRACHYTHERAPY PLANAR SOURCE, P BRACHYTHERAPY SOURCE, STRANDED Page 5 of 13

6 C5276 C5277 C5278 C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8921 C8922 C8923 C8924 C8925 C8926 C8927 C8928 C8929 MAGNETIC RESONANCE IMAGING WIT MAGNETIC RESONANCE IMAGING WIT MAGNETIC RESONANCE IMAGING WIT MAGNETIC RESONANCE IMAGING WIT MAGNETIC RESONANCE IMAGING WIT MAGNETIC RESONANCE IMAGING WIT TRANSESOPHAGEAL ECHOCARDIOGRAP TRANSESOPHAGEAL ECHOCARDIOGRAP TRANSESOPHAGEAL ECHOCARDIOGRAP Page 6 of 13

7 C8930 C8931 C8932 C8933 C8934 C8935 C8936 C8957 IV INFUS FOR THER/DIAG PROLONG C9021 INJECTION, OBINUTUZUMAB, 10 MG C9113 INJECTION, PANTOPRAZOLE SODIUM C9132 PROTHROMBIN COMPLEX CONCENTRAT C9248 INJECTION, CLEVIDIPINE BUTYRAT C9250 HUMAN PLASMA FIBRIN SEALANT 2 C9275 INJECTION, HEXAMINOLEVULINATE C9285 LIDOCAINE 70 MG/TETRACAINE 70 C9290 INJECTION, BUPIVACAINE LIPOSOM C9293 INJECTION, GLUCARPIDASE, 10 UN C9352 MICROPOROUS COLLAGEN IMPLANTAB C9353 MICROPOROUS COLLAGEN IMPLANTAB C9354 ACELLULAR PERICARD TISSUE MATR C9355 COLLAGEN NERVE CUFF PER 0.5 CE C9356 TENDON, POROUS MATRIX OF CROSS C9358 DERMAL SUBSTITUTE, NATIVE, NON C9359 POROUS PURIFIED COLLAGEN MATRI C9360 DERMAL SUBSTITUTE, NATIVE, NON C9361 COLLAGEN MATRIX NERVE WRAP PER C9362 POROUS PURIFIED COLLAGEN MATRI C9363 SKIN SUBSTITUTE, INTEGRA MESHE C9364 PORCINE IMPLANT, PERMACOL,PER C9367 SKIN SUBSTITUTE, ENDOFORM DERM Page 7 of 13

8 C9399 UNCLASSIFIED DRUGS OR BIOLOGIC C9441 INJECTION, FERRIC CARBOXYMALTO C9447 INJECTION, PHENYLEPHRINE AND K C9460 INJECTION, CANGRELOR, 1 MG C9497 LOXAPINE, INHALATION POWDER, 1 C9600 PERCUTANEOUS TRANSCATHETER PLA C9601 PERCUTANEOUS TRANSCATHETER PLA C9602 PERCUTANEOUS TRANSLUMINAL CORO C9603 PERCUTANEOUS TRANSLUMINAL CORO C9604 PERCUTANEOUS TRANSLUMINAL REVA C9605 PERCUTANEOUS TRANSLUMINAL REVA C9606 PERCUTANEOUS TRANSLUMINAL REVA C9607 PERCUTANEOUS TRANSLUMINAL REVA C9608 PERCUTANEOUS TRANSLUMINAL REVA C9716 CREATIONS OF THERMAL ANAL LESI C9725 PLACEMENT OF ENDORECTAL INTRAC C9726 PLACEMENT & REMOV APPLIC IN BR C9727 INSERTION OF IMPLANTS INTO SOF C9728 PLACEMENT OF INTERSTITIAL DEVI C9733 NON-OPHTHALMIC FLUORESCENT VAS C9735 ANOSCOPY: WITH DIRECTED SUBMUC C9739 CYSTOURETHROSCOPY, W/TRANSPROS C9740 CYSTOURETHROSCOPY W/TRANSPROST G0008 INJECT INFLUENZA VACCINE G0009 INJECT PNEUMOCOCCAL VACCINE G0108 DIABETES OP SELF MNGMT TX SERV G0109 DIABETES SELF MNGMT SERV GRP S G0123 SCR CYTO C/V THIN PREP AUTO G0129 OCCUPATIONAL THERAPY SERVICES G0175 SCHEDULED INTERDISCIPLINARY TE Page 8 of 13

9 G0176 G0177 G0239 G0269 G0283 G0339 G0340 G0378 G0410 G0411 G0463 G9017 G9147 J7336 J7512 J7599 J7699 J8540 J8540 P9604 Q0091 Q0092 Q0162 Q4100 Q4101 Q4103 Q4103 Q4104 Q4104 Q4106 ACTIVITY THERAPY, SUCH AS MUSI TRAINING AND EDUCATIONAL SERVI THERAPEUTIC PROCEDURES TO IMPR PLACEMENT OF OCCLUSIVE DEVICE ELECTRICAL STIMULATION (UNATTE IMAGE-GUIDED ROBOTIC LINEAR AC IMAGE-GUIDED ROBOTIC LINEAR AC HOSPITAL OBSERVATION SERVICE, GROUP PSYCHOTHERAPY OTHER THAN INTERACTIVE GROUP PSYCHOTHERAP HOSPITAL OUTPATIENT CLINIC VIS AMANTADINE HYDROCHLORIDE, ORAL OUTPATIENT INTRAVENOUS INSULIN CAPSAICIN 8% PATCH, PER SQUARE PREDNISONE, IMMEDIATE RELEASE IMMUNOSUPPRESSIVE DRUG, NOT OT NOC DRUGS, INHALATION SOLUTION DEXAMETHASONE, ORAL, 0.25 MG DEXAMETHASONE, ORAL, 0.25 MG TRAVEL ALLOWANCE ONE WAY IN CO SCREENING PAPANICOLAOU SMEAR: SET UP PORTABLE XRAY ONDANSETRON 1 MG. ORAL SKIN SUBSTITUTE, NOT OTHERWISE APLIGRAF, PER SQUARE CENTIMETE OASIS BURN MATRIX, PER SQUARE OASIS BURN MATRIX, PER SQUARE INTEGRA BILAYER MATRIX WOUND D INTEGRA BILAYER MATRIX WOUND D DERMAGRAFT, PER SQUARE CENTIME Page 9 of 13

10 Q4106 Q4107 Q4107 Q4108 Q4108 Q4110 Q4110 Q4111 Q4111 Q4112 Q4112 Q4113 Q4113 Q4114 Q4114 Q4122 Q4123 Q4124 Q4125 Q4126 Q4127 Q4128 Q4130 Q4131 Q4132 Q4133 Q4134 Q4135 Q4136 Q4150 DERMAGRAFT, PER SQUARE CENTIME GRAFTJACKET, PER SQUARE CENTIM GRAFTJACKET, PER SQUARE CENTIM INTEGRA MATRIX, PER SQUARE CEN INTEGRA MATRIX, PER SQUARE CEN PRIMATRIX, PER SQUARE CENTIMET PRIMATRIX, PER SQUARE CENTIMET GAMMAGRAFT, PER SQUARE CENTIME GAMMAGRAFT, PER SQUARE CENTIME CYMETRA, INJECTABLE, 1CC CYMETRA, INJECTABLE, 1CC GRAFTJACKET XPRESS, INJECTABLE GRAFTJACKET XPRESS, INJECTABLE INTEGRA FLOWABLE WOUND MATRIX, INTEGRA FLOWABLE WOUND MATRIX, DERMACELL, PER SQUARE CENTIMET ALLOSKIN RT, PER SQUARE CENTIM OASIS ULTRA TRI-LAYER WOUND MA ARTHROFLEX, PER SQUARE CENTIME MEMODERM, DERMASPAN, TRANZGRAF TALYMED, PER SQUARE CENTIMETER FLEX HD, ALLOPATCH HD, OR MATR STRATTICE TM, PER SQUARE CENTI EPIFIX OR EPICORD, PER SQUARE GRAFIX CORE, PER SQUARE CENTIM GRAFIX PRIME, PER SQUARE CENTI HMATRIX, PER SQUARE CENTIMETER MEDISKIN, PER SQUARE CENTIMETE EZ-DERM, PER SQUARE CENTIMETER ALLOWRAP DS OR DRY, PER SQUARE Page 10 of 13

11 Q4151 AMNIOBAND OR GUARDIAN, PER SQU Q4152 DERMAPURE, PER SQUARE CENTIMET Q4153 DERMAVEST AND PLURIVEST, PER S Q4154 BIOVANCE, PER SQUARE CENTIMETE Q4155 NEOXFLO OR CLARIXFLO, 1 MG Q4156 NEOX 100, PER SQUARE CENTIMETE Q4157 REVITALON, PER SQUARE CENTIMET Q4158 MARIGEN, PER SQUARE CENTIMETER Q4159 AFFINITY, PER SQUARE CENTIMETE Q4160 NUSHIELD, PER SQUARE CENTIMETE Q9962 HIGH OSMOLAR CONTRAST MAT 300- Q9962 HIGH OSMOLAR CONTRAST MAT 300- S0596 PHAKIC INTRAOCULAR LENS FOR CO S1090 MOMETASONE FUROATE SINUS IMPLA RADIATION THERAPY DELIVERY RADIATION THERAPY DELIVERY GUIDANCE FOR LOCALIZATION OF T INTERACTIVE COMPLEXITY (LIST S INTERACT PSYCH DIAG INTERV EXA PSYCHOTHERAPY FOR CRISIS: EACH FAMILY PSYCHOTHERAPY, 50 MINUT MULTI-FAMILY PSYCHOTHERAPY., PHARMACOLOGIC MANAGEMENT, INCL PSYCHIATRIC EVAL OF HOSPITAL R PREPARATION OF REPORT OF PATIE BIOFEEDBACK TRAINING BY ANY MO SPEECH,LANGUAGE/HEARING THERAP TORSION SWING TEST, WITH RECOR SPEECH AUDIOMETRY,THRESHOLD/DI EVOKED OTOACOUSTIC EMISSIONS, Page 11 of 13

12 92579 VISUAL REINFORCEMENT AUDIOMETR EVAL RX NON-SPEECH GEN AUG COM THERAP SERV NON-SPEECH-GENERAT EVALUATION FOR PRESCRIPTION OF AMBULATORY B/P MONITORING...RE AMBULATORY B/P MONITORING PHYSICIAN OR OTHER QUALIFIED H NONPRESSURED INHALATION TX CPAP,INITATION/MANAGEMENT MANIPULATION CHEST WALL...INIT P.T. TX TO 1 AREA:HOT/COLD PAC P.T. TX-1 AREA:TRACTION,MECHAN P.T. TX-1 AREA:ELECTRICAL STIM P.T. TX-1 AREA:PNEUMATIC DEVIC P.T. TX-1 AREA:PARAFFIN BATH P.T. TX-1 AREA: WHIRLPOOL P.T. TX-1 AREA: DIATHERMY P.T. TX-1 AREA: INFRARED PHY.MED.TX TO 1 AREA:ULTRAVIOL APPICATION OF MODALITY ELECTRI MODALITY APPLICATION/IONTOPHOR MODALITY APPLICATION/CONTRAST MODALITY APPLICATION/ULTRASOUN MODALITY APPLICATION/HUBBARD T UNLISTED MODALITY (SPECIFY) P.T. THER PROC,1 OR MORE AREAS P.T. TX-1 AREA:NEUROMUSCULAR R AQUATIC THERAPY P.T. TX-1 AREA:GAIT TRAINING P.T. TX-1 AREA: MASSAGE Page 12 of 13

13 97139 UNLISTED P.T. PROCEDURE (SPECI MANUAL THERAPY TECHNIQUES GROUP THERAPEUTIC PROCEDURE THERAPEUTIC ACTIVITIES, DIRECT DEVELOPMENT OF COGNITIVE SKILL SENSORY INTEGRATIVE TECHNIQUES COMMUNITY/WORK REINTEGRATION T WHEELCHAIR MNGMNT/PROPUL TX EA WORK HARDENING/CONDITION INIT WORK HARDENING/CONDITION EA AD REM REVIT TISSUE NON SELECT DE PHYSICAL PERFORMANCE TEST ASSISTIVE TECHNOLOGY ASSESSMEN ORTHOTIC(S) MANAGEMENT AND TRA PROSTHETIC TRAINING, UPPER AND CHECKOUT FOR ORTHOTIC/PROSTHET PHYSICIAN OR OTHER QUALIFIED H MODERATE SEDATION SERVICES BY Page 13 of 13