PROCEDURE/DIAGNOSIS/REVENUE CODES
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1 PROCEDURE/DIAGNOSIS/REVENUE CODES TAKE CHARGE offers a limited benefit package of services which includes professional services, outpatient services, and laboratory/radiology and pharmaceutical services. With the exception of the services billed by pharmacists, all services must be billed using one of the diagnosis codes listed below. Diagnosis Code V25.01 Prescription of Oral Contraceptives V25.02 Initiation of Other Contraceptive Measures V25.03 Encounter for Emergency Contraceptive Counseling and Prescription V25.09 Other V25.11 Insertion of Intrauterine Contraceptive Device V25.12 Removal of Intrauterine Contraceptive Device V25.13 Removal and Reinsertion of Intrauterine Contraceptive Device V25.2 Sterilization V25.3 Menstrual Extraction V25.40 Contraceptive Surveillance, Unspecified V25.41 Contraceptive Pill V25.42 Intrauterine Contraceptive Device V25.43 Implantable Sub Dermal Contraceptive V25.49 Other Contraceptive Method V25.5 Insertion of Implantable Sub Dermal Contraceptive V25.9 Unspecified Contraceptive Management Revenue Codes HR250 HR258 HR259 HR260 HR270 HR271 HR272 HR300 HR301 HR302 HR305 HR306 HR307 HR309 Pharmacy, General Classification Pharmacy, IV Solutions Pharmacy, Other Pharmacy IV Therapy Med/Surg Supply/Device-Gen. Cls Tempkit/Probe Covers/Service Sterile Supply Laboratory-Gen Classification* Chemistry* Immunology* Hematology* Laboratory-Hematology* Laboratory-Urology* Laboratory-Other Laboratory* Page 1 of 5
2 HR310 HR311 HR312 HR490 HR510 HR514 HR517 HR760 HR920 Lab Pathological/Gen Classification* Laboratory Pathologic/Cytology* Lab Pathologic/Histology*** Ambulatory Surgical Care General Outpatient Clinics OB-GYN Clinic* Family Practice Clinic* Treatment/Observation Room Other Diag Serv Gen Classification** *Bill with appropriate FPW HCPC code (see list) **Bill with appropriate but non-specific HCPC code Procedure Code Anes; Tubal Ligation/Transection Insertion or Reinsertion, Implantabl Removal without Reinsertion, Implantbl Removal with Reinsertion, Implantabl Venipuncture Multiple Patients Diaphragm Fitting With Instructions Insert Intrauterine Device Remove Intrauterine Device Division of Fallopian Tube Occlusion of Fallopian Tube, Device Laparoscopy, Tubal Cautery Laparoscopy, Tubal Block Inject Spine L/S (Cd) Inject Spine W/Cath L/S (Cd) Chest Single View Chest Two Views Basic Metabolic Panel General Health Screen Panel Electrolyte Panel Lipid Profile Urinalysis with Microscopy Urinalysis, Auto, W/Scope Routine Urine Analysis Urinalysis, By Dip Stick or Tablet R Urinalysis Urine Pregnancy Test, By Visual Colo Stick Assay of Blood Glucose Glucose, Blood, By Glucose Monitoring Page 2 of 5
3 83020 Assay Hemoglobin Assay Bun Assay Blood Uric Acid Gonadotropin, Chronic, Quantitative Gonadotropin, Chronic, Qualitative Blood Count Blood Count Other Than Spun Hematocr Hemoglobin, Colorimetric Syphilis Test(S), Qualitative Syphilis Test, Quantitative Antibody Antibody Htlvi, Antibody Detection;Immunoassa Antibody Confirmatory Test Antibody Antibody Antibody Culture Specimen, Bacteria Culture Specimen, Bacteria Bacteria Culture Screen Culture, Chlamydia Smear, Stain & Interpret Chylmd Trach Ag, Dfa Chylmd Trach Ag, Eia Hiv-1 Ag, Eia Hiv-2 Ag, Eia Candida, Dna, Dir Probe Candida, Dna, Amp Probe Chylmd Trach, Dna, Dir Probe Chylmd Trach, Dna, Amp Probe N.Gonorrhoeae, Dna, Dir Prob N.Gonorrhoeae, Dna, Amp Prob Hpv, Dna, Dir Probe Hpv, Dna, Amp Probe Chylmd Trach Assay W/Optic N. Gonorrhoeae Assay W/Optic Cytopathology, Fluids, Washings or B Cytopath Cerv/Vag Interpret Cytopath Cerv/Vag Thin Layers Cytpath C/Vag T/Layer Redo Cytpath C/Vag Automated Cytpath C/Vag Auto Rescreen Page 3 of 5
4 8150 Cytopathology, Pap smear Cytopath Cerv/Vag Auto Cytpath C/Vag Redo Cytpath C/Vag Select Cytopath, (Pap); W/ Def.Hormonal Eval Cytopathology Cytopath; Prep,Screen,Interp Cytopath..; Ext.Study, +5 Slides, Multi Cytpath Tbs C/Vag Manual Cytpath Tbs C/Vag Redo Cytpath Tbs C/Vag Auto Redo Cytpath Tbs C/Vag Select Fine Needle Aspirate..;INterp/Report Cytopathology, Cervial or Vaginal Col Cytopathology with Screening Surgical Pathology, Gross Surgical Pathology, Complete Special Stains Special Stains Routine Ecg W/At Least 12 Leads Office, New, Problem, Straightforward Office, New Pt, Expanded, Straightfowd Office, New Pt, Detailed, Low Complex Office, New Pt, Comprehen, Mod Complx Office, New Pt, Comprehen, High Compx Office, Est. Pt, Minimal Problems Office, Est. Pt, Problem, Straitforwd Office, Est. Pt, Expanded, Low Complex Office, Est. Pt, Detailed, Mod Complx Office, Est. Pt, Comprehen, High Complx Off Consult, Nre Pt, Prblm, Strtfwd Off Conslt, Nre Pt, Xpnd Pblm, Strtfwd Off Cnslt, Nre Pt, Dtld, Lo Cmplxy Off Cnslt, Nre Pt, Cmphsv, Mod Cmplxy Off Cnslt, Nre Pt, Cmphsv, Hi Cmplxy A4267 Contracep Supply/Male Condom, Each (Restricted To Provider Type 71) A4268 Contracep Supply/Female Condom, Each (Restricted To Provider Type 71) A4269 Contraceptive Supply, Spermacide (Restricted To Provider Type 71) J1055 Depo-Provera Inj 150mg J1056 Lunelle Monthly Contraception Inj J7300 Intrauterine Copper Contraceptive J7302 Mirena Q0111 Wet Mounts, Preparations of Vaginal Page 4 of 5
5 Q0112 Potassium Mydroxide Preparations S4993 Contracep Pills/Birth Control-1 Mth00851 (Restricted to provider type 71) Page 5 of 5
South Carolina North Carolina Louisiana. Norplant implant removal. Diaphragm fitting with instructions
P a g e 1 00840 00851 00921 Anesthesia, intraperitoneal procedure, lower abdomen, Including laparoscopy; tubal ligation/transection Anesthesia for vaginal procedure 00952 (including biopsy of labia, vagina,
LEGEND. COLUMN 6. MED REV (Medical Review): Claims with some codes pend to Medical Review for review of the attachments or for manual pricing.
RUN: 12/31/2014 13:44:06 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LEGEND ------------------------------------------------------------------------------------------------------------------------------------
Medicaid Family Planning Waiver Services CPT Codes and ICD-10 Diagnosis Codes
CPT Code Description of Covered Codes Evaluation and Management 99384FP 99385FP Family planning new visit 99386FP 99394FP 99395FP Family planning established visit 99396FP 99401FP HIV counseling (pre-test)
Listed below is an explanation of the types of service found on this schedule.
RUN: 04/20/18 08:03:54 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LEGEND ------------------------------------------------------------------------------------------------------------------------------------
Listed below is an explanation of the types of service found on this schedule.
RUN: 12/20/16 08:55:28 DEPARTMENT OF HEALTH AND HOSPITALS - BUREAU OF HEALTH SERVICES - FINANCING PAGE: LEGEND ------------------------------------------------------------------------------------------------------------------------------------
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The following lesson on contraception (birth control) is not intended to infer that you will be sexually active as a teen. This is information that
The following lesson on contraception (birth control) is not intended to infer that you will be sexually active as a teen. This is information that may be used in the future Abstinence Choosing not to
IN-NETWORK MEMBER PAYS. Contract Year Plan Deductible (Deductible is combined for health services and prescription drugs) $5,000 Individual
HMO-OA-CNT-HSA-5000I/10000F-07 Contract Year Benefit Summary (E) Point-Of-Service Open Access High Deductible Health Plan (HDHP) for use with a Health Savings Account (HSA) This is a brief summary of benefits.
LABORATORY PROCEDURES IMAGING/RADIOLOGY PROCEDURES THERAPY GVH EMERGENCY DEPARTMENT PROCECURES
PROCEDURE CHARGES / HOSPITAL may vary depending on circumstances. Prices subject to change. LABORATORY PROCEDURES Basic Metabolic Panel $112.00 80048 Comprehensive Metabolic Panel $140.00 80053 UA Micro
NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.
Policy name: Preventive Health Guidelines - Men The following chart contains procedure and diagnosis code combinations that identify services covered under HMSA's Preventive Health s policy. * For professional