Grouping Revenue Code Description

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1 Pharmacy 0250 General Classification Pharmacy 0251 Generic Drugs Pharmacy 0252 Non-Generic Drugs Pharmacy 0254 Drugs incident to other Diagnostic Services Pharmacy 0255 Drugs incident to Radiology Pharmacy 0257 Non-prescription Pharmacy 0258 IV Solutions Pharmacy 0259 Other Pharmacy IV Therapy 0260 General Classification IV Therapy 0261 Infusion Pump IV Therapy 0262 IV Therapy/Pharmacy Services IV Therapy 0263 IV Therapy/Drug/Supply Delivery IV Therapy 0264 IV Therapy/Supplies IV Therapy 0269 Other IV Therapy Oncology 0280 General Classification Oncology 0289 Other Oncology Laboratory 0300 General Classification Laboratory 0301 Chemistry Laboratory 0302 Immunology Laboratory 0304 Non-Routine Dialysis Laboratory 0305 Hematology Laboratory 0306 Bacteriology & Microbiology Laboratory 0307 Urology Laboratory 0309 Other Laboratory Laboratory Pathology 0310 General Classification Laboratory Pathology 0311 Cytology Laboratory Pathology 0312 Histology Laboratory Pathology 0314 Biopsy Laboratory Pathology 0319 Other: Laboratory Pathology Diagnostic 0320 General Classification Diagnostic 0321 Angiocardiography Diagnostic 0322 Arthrography Diagnostic 0323 Arteriography Diagnostic 0324 Chest X-ray 1

2 Diagnostic 0329 Other Diagnostic Therapeutic 0330 General Classification Therapeutic 0331 Chemotherapy - Injected Therapeutic 0332 Chemotherapy - Oral Therapeutic 0333 Radiation Therapy Therapeutic 0335 Chemotherapy - IV Therapeutic 0339 Other: Therapeutic Nuclear Medicine 0340 General Classification Nuclear Medicine 0341 Diagnostic Nuclear Medicine 0342 Therapeutic Nuclear Medicine 0349 Other CT Scan 0350 General Classification CT Scan 0351 Head Scan CT Scan 0352 Body Scan CT Scan 0359 Other CT Scan Operating Room Services 0360 General Classification Operating Room Services 0361 Minor Surgery Anesthesia 0370 General Classification Anesthesia 0371 Anesthesia Incident to Radiology Anesthesia 0372 Anesthesia Incident to Services Anesthesia 0379 Other Anesthesia Blood 0380 General Classification Blood 0381 Packed Red Cells Blood 0382 Whole Blood Blood 0383 Plasma Blood 0384 Platelets Blood 0385 Leucocytes Blood 0386 Other components Blood 0387 Other Derivatives (Cryopricipitates) Blood 0389 Other Blood 2

3 Services 0400 General Classification Services 0401 Diagnostic Mammography Services 0402 Ultrasound Services 0403 Screening Mammography Services 0404 Postron Emission Tomography Services 0409 Services Respiratory Services 0410 General Classification Respiratory Services 0412 Inhalation Services Respiratory Services 0413 Hyperbaric Oxygen Therapy Respiratory Services 0419 Other Respiratory Services Physical Therapy 0420 General Classification Physical Therapy 0421 Visit Charge Physical Therapy 0423 Group Rate Physical Therapy 0424 Evaluation or Re-evaluation Physical Therapy 0429 Other Physical Therapy Occupational Therapy 0430 General Classification Occupational Therapy 0431 Visit Charge Occupational Therapy 0433 Group Rate Occupational Therapy 0434 Evaluation or Re-evaluation Occupational Therapy 0439 Other Physical Therapy Pathology 0440 General Classification Pathology 0441 Visit Charge Pathology 0443 Group Rate Pathology 0444 Evaluation or Re-evaluation Pathology 0449 Other Physical Therapy Emergency Room 0450 General Classification Emergency Room 0456 Urgent Care Emergency Room 0459 Other Emergency Room Pulmonary Function 0460 General Classification Pulmonary Function 0469 Other Pulmonary Function 3

4 Audiology 0470 General Classification Audiology 0471 Diagnostic Audiology 0472 Treatment Audiology 0479 Other Audiology Cardiology 0480 General Classification Cardiology 0481 Cardiac Cath Lab Cardiology 0482 Stress Test Cardiology 0483 Echocardiology Cardiology 0489 Other Cardiology Ambulatory Surgical Care 0490 General Classification Ambulatory Surgical Care 0499 Other Ambulatory Surgical Care Outpatient Services 0500 General Classification Outpatient Services 0509 Other Outpatient Services Clinic 0510 General Classification Clinic 0511 Chronic Pain Center Clinic 0512 Dental Clinic Clinic 0513 Psychiatric Clinic Clinic 0514 OB-GYN Clinic Clinic 0515 Pediatric Clinic Clinic 0516 Urgent Care Clinic Clinic 0517 Family Practice Clinic Clinic 0519 Other Clinic MRI 0610 General Classification MRI 0611 Brain (including brainstem) MRI 0612 Spinal Cord (including Spine) MRI 0614 MRI - other MRI 0615 MRI - head & neck MRI 0616 MRI - lower extremities MRI 0618 MRI - other MRI 0619 Other MRI Cast Room 0700 General Classification (Electrocardiogram) 0730 General Classification (Electrocardiogram) 0731 Holter monitor 4

5 (Electrocardiogram) 0732 Telemetry (Electrocardiogram) 0739 Other EEG (Electroencephalogra m) 0740 General Classification Gastro-Intestinal Services 0750 General Classification Treatment/Observatio n Room 0761 Treatment Room Preventive Care Services 0770 General Classification Preventive Care Services 0771 Vaccine Administration Preventive Care Services 0779 Other Preventive Care Services Lithotripsy 0790 General Classification Organ Acquisition 0810 General Classification Organ Acquisition 0811 Living Donor ical Treatments 0900 General Classification ical Treatments 0901 Electroshock Treatment ical Treatments 0902 Milieu Therapy ical Treatments 0903 Play Therapy ical Treatments 0904 Activity Therapy ical Services 0911 Rehabilitation ical Services 0914 Individual Therapy ical Services 0915 Group Therapy ical Services 0916 Family Therapy 0917 Bio Feedback 5

6 ical Services ical Services 0918 Testing ical Services 0919 Other Services 0920 General Classification Services 0921 Peripheral Vascular Lab Services 0922 Electromyelogram Services 0923 Pap Smear Services 0924 Allergy Test Services 0925 Pregnancy Test Services 0929 Services Services 0940 General Classification Services 0941 Recreational Therapy Services 0942 Education/Training Services 0943 Cardiac Rehabilitation Services 0944 Drug Rehabilitation Services 0945 Alcohol Rehabilitation Services 0949 Services Services: extension of 094X 0952 Kinesiotherapy Emergency Room Pro-Fee 0981 ER Pro-fee Alternative Therapy Services 2100 General Classification Alternative Therapy Services 2109 Other Alternative Therapy Services 6

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