SECTION 19 - PROCEDURE CODES 19.1 CPT CODES... 2 19.2 PROCEDURE CODES... 3 19.3 HCY PROCEDURE CODES FOR PARTICIPANTS 20 YEARS OLD AND UNDER... 14 1
SECTION 19-PROCEDURE CODES Procedure codes used by Medicaid are identified as HCPCS codes (Health Care Procedure Coding System). The HCPCS is divided into three subsystems, referred to as level I, level II and level III. Level I is comprised of Current Procedural Terminology (CPT) codes that are used to identify medical services and procedures furnished by physicians and other health care professionals. Level II is comprised of the HCPCS National Level II codes that are used primarily to identify products, supplies and services not included in the CPT codes. Level III codes have been developed by Medicaid State agencies for use in specific programs. NOTE: Replacement of level III codes is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Providers should reference bulletins for code replacement information. Reference materials regarding the Healthcare Common Procedure Coding System (HCPCS), and Current Procedural Terminology (CPT) may be obtained through the American Medical Association at: Order Department American Medical Association P.O. Box 930876 Atlanta, GA 31193-0876 Telephone Number: (800) 621-8335 AMA Members: (800) 262-3211 Fax Orders: (312) 464-5600 https://catalog.ama-assn.org/catalog/home.jsp 19.1 CPT CODES (text delete 9/08) 19.1 Participant Copay Participants eligible to receive certain MO HealthNet services are required to pay a small portion of the cost of the services. This amount is referred to as copay. The copay amount is paid by the participant at the time services are rendered. Some services of the Physician Program described in this manual are subject to a copay amount. The provider must accept in full the amounts paid by the state agency plus any copay amount required of the participant. When the MO HealthNet Maximum Allowed Amount for an office visit is equal to or less than the copay amount, the provider should charge the lesser amount of the Maximum Allowed Amount or the copay. 2
19.2 PROCEDURE CODES PROC CODE Exams DESCRIPTION 92557 Basic comprehensive audiometry hing exam, including the measuring of hing acuity and tests relating to air conduction, bone conduction, speech reception threshold, and speech discrimination. (The procedure must be ordered by a qualified physician and the diagnosis must be related to disease or trauma. Supporting documentation must be retained in the patient's file) 9255722 Basic comprehensive audiometry hing exam, including the measuring of hing acuity and tests relating to air conduction, bone conduction, speech reception threshold, and speech discrimination (in a nursing home). (The procedure must be ordered by a qualified physician and the diagnosis must be related to disease or trauma. Supporting documentation must be retained in the patient's file) 92620 Evaluation of central auditory function with report 1 st 60 minutes 92621 Evaluation of central auditory function with report each additional 15 minutes 92626 Evaluation of auditory rehabilitation status; first hour 92627 Evaluation of auditory rehabilitation status; add on 92630 Auditory rehabilitation; pre-lingual hing loss 92633 Auditory rehabilitation; post-lingual hing loss AGE LIMIT REQUIRED ATTACHMENTS RHAE # $20.00 PA/RHAE $20.00 $21.51 $5.55 0-20 $40.88 0-20 $10.31 0-20 $10.50 0-20 $10.50 REIMBURSEMENT AMOUNT 3
99429EP Unlisted preventive (hing) 0-20 $5.00 S9152 Speech therapy, re-evaulation $10.75 Hing Aids/Services V5011RT V5011LT Fitting/orientation/checking of hing aid, right Fitting/orientation/checking of hing aid, left V5011RT22 Post fitting evaluation, right (used to bill for the post fitting evaluation). (Refer to Section 13.9.D(1) and Section 13.9.D(2) for special billing instructions.) V5011LT22 Post fitting evaluation, left (used to bill for the post fitting evaluation). Refer to Section 13.9.D(1) and Section 13.9.D(2) for special billing instructions.) V5030RT V5030LT V5040 V5040RT V5040LT Hing aid, monaural; body worn, air conduction, right Hing aid, monaural; body worn, air conduction, left Hing aid, monaural; body worn, bone conduction Hing aid, monaural; body worn, bone conduction, right Hing aid, monaural; body worn, bone conduction, left $10.00 $10.00 $25.00 $25.00 PA/RHAE $385.00 PA/RHAE $385.00 PA/RHAE PA/RHAE $385.00 PA/RHAE $385.00 V5050RT Hing aid, monaural; in the, right V5050LT Hing aid, monaural; in the, left V5060RT V5060LT V5090RT Hing aid, monaural; behind the, right Hing aid, monaural; behind the, left Dispensing fee, unspecified hing aid, right (refer to Section 13.9.C(1) for special PA/RHAE $385.00 PA/RHAE $385.00 PA/RHAE $95.00 4
V5090LT billing instructions.) Dispensing fee, unspecified hing aid, left (refer to Section 13.9.C(1) for special billing instructions.) PA/RHAE $95.00 V5100RT Hing aid, bilateral, body worn, right PA/RHAE $385.00 V5100LT Hing aid, bilateral, body worn, left PA/RHAE $385.00 V5110RT Dispensing fee, bilateral, right PA/RHAE $95.00 V5110LT Dispensing fee, bilateral, left PA/RHAE $95.00 V5120RT Binaural; body, right PA/RHAE $385.00 V5120LT Binaural; body. left PA/RHAE $385.00 V5130RT Binaural; in the, right V5130LT Binaural; in the, left V5140RT Binaural; behind the, right PA/RHAE $385.00 V5140LT Binaural; behind the, left PA/RHAE $385.00 V5160RT Dispensing fee, binaural, right PA/RHAE $95.00 V5160LT Dispensing fee, binaural, left PA/RHAE $95.00 V5170 Hing aid, CROS; in the PA/RHAE V5170RT Hing aid, CROS; in the, right V5170LT Hing aid, CROS; in the, left V5180 Hing aid, CROS; behind the PA/RHAE V5180RT Hing aid, CROS; behind the, right PA/RHAE $385.00 V5180LT Hing aid, CROS; behind the, left PA/RHAE $385.00 V5200RT Dispensing fee, CROS, right PA/RHAE $95.00 V5200LT Dispensing fee, CROS, left PA/RHAE $95.00 V5210 Hing aid, bicros; in the PA/RHAE V5210RT Hing aid, bicros; in the, right V5210LT Hing aid, bicros; in the, left V5220 Hing aid, bicros; behind the PA/RHAE V5220RT Hing aid, bicros; behind the, right PA/RHAE $385.00 V5220LT Hing aid, bicros; behind the, left PA/RHAE $385.00 5
V5240RT Dispensing fee, bicros, right PA/RHAE $95.00 V5240LT Dispensing fee, bicros, left PA/RHAE $95.00 V5241RT V5241LT V5242RT V5242LT V5243RT V5243LT V5244RT V5244LT Dispensing fee, monaural hing aid, any type, right Dispensing fee, monaural hing aid, any type, left Hing aid, analog, monaural, completely in the canal, right Hing aid, analog, monaural, completely in the canal, left Hing aid, analog, monaural, in the canal, right Hing aid, analog, monaural, in the canal, left Hing aid, digitally programmable analog, monaural, completely in the canal, right Hing aid, digitally programmable analog, monaural, completely in the canal, left V5244RTEP Hing aid, digitally programmable analog, monaural, completely in the canal, right V5244LTEP Hing aid, digitally programmable analog, monaural, completely in the canal, left V5245RT V5245LT Hing aid, digitally programmable analog, monaural, in the canal, right Hing aid, digitally programmable analog, monaural, in the canal, left V5245RTEP Hing aid, digitally programmable analog, monaural, in the canal, right PA/RHAE $95.00 PA/RHAE $95.00 0-20(1) PA/RHAE/IofC 6
V5245LTEP Hing aid, digitally programmable analog, monaural, in the canal, left V5246RT V5246LT Hing aid, digitally programmable analog, monaural, in the, right Hing aid, digitally programmable analog, monaural, in the, left V5246RTEP Hing aid, digitally programmable analog, monaural, in the, right V5246LTEP Hing aid, digitally programmable analog, monaural, in the, left V5247RT V5247LT Hing aid, digitally programmable analog, monaural, behind the, right Hing aid, digitally programmable analog, monaural, behind the, left V5247RTEP Hing aid, digitally programmable analog, monaural, behind the, right V5247LTEP Hing aid, digitally programmable analog, monaural, behind the, left V5248RT V5248LT V5249RT V5249LT V5250RT Hing aid, analog, binaural, completely in the canal, right Hing aid, analog, binaural, completely in the canal, left Hing aid, analog, binaural, in the canal, right Hing aid, analog, binaural, in the canal, left Hing aid, digitally programmable analog, binaural, completely in the canal, right RHAE/PA $385.00 RHAE/PA $385.00 0-20 RHAE 0-20 RHAE 7
V5250LT Hing aid, digitally programmable analog, binaural, completely in the canal, left V5250RTEP Hing aid, digitally programmable analog, binaural, completely in the canal, right V5250LTEP Hing aid, digitally programmable analog, binaural, completely in the canal, left V5251RT V5251LT Hing aid, digitally programmable analog, binaural, in the canal, right Hing aid, digitally programmable analog, binaural, in the canal, left V5251RTEP Hing aid, digitally programmable analog, binaural, in the canal, right V5251LTEP Hing aid, digitally programmable analog, binaural, in the canal, left V5252RT V5252LT Hing aid, digitally programmable, binaural, in the, right Hing aid, digitally programmable, binaural, in the, left V5252RTEP Hing aid, digitally programmable, binaural, in the, right V5252LTEP Hing aid, digitally programmable, binaural, in the, left V5253RT V5253LT Hing aid, digitally programmable, binaural, behind the, right Hing aid, digitally programmable, binaural, behind the, left PA/RHAE $385.00 PA/RHAE $385.00 8
V5253RTEP Hing aid, digitally programmable, binaural, behind the, right V5253LTEP Hing aid, digitally programmable, binaural, behind the, left V5254RT V5254LT Hing aid, digital, monaural, completely in the canal, right Hing aid, digital, monaural, completely in the canal, left V5254RTEP Hing aid, digital, monaural, completely in the canal, right V5254LTEP Hing aid, digital, monaural, completely in the canal, left V5255RT V5255LT Hing aid, digital, monaural, in the canal, right Hing aid, digital, monaural, in the canal, left V5255RTEP Hing aid, digital, monaural, in the canal, right V5255LTEP Hing aid, digital, monaural, in the canal, left V5256RT V5256LT Hing aid, digital, monaural, in the, right Hing aid, digital, monaural, in the, left V5256RTEP Hing aid, digital, monaural, in the, right 0-20 RHAE 0-20 RHAE 9
V5256LTEP Hing aid, digital, monaural, in the, left V5257RT V5257LT Hing aid, digital, binaural, behind the, right Hing aid, digital, binaural, behind the, left V5257RTEP Hing aid, digital, binaural, behind the, right V5257LTEP Hing aid, digital, binaural, behind the, left V5258RT V5258LT Hing aid, digital, binaural, completely in the canal, right Hing aid, digital, binaural, completely in the canal, left V5258RTEP Hing aid, digital, binaural, completely in the canal, right V5258LTEP Hing aid, digital, binaural, completely in the canal, left V5259RT V5259LT Hing aid, digital, binaural, in the canal, right Hing aid, digital, binaural, in the canal, left V5259RTEP Hing aid, digital, binaural, in the canal, right V5259LTEP Hing aid, digital, binaural, in the canal, left PA/RHAE $385.00 PA/RHAE $385.00 10
V5260RT V5260LT Hing aid, digital, binaural, in the, right Hing aid, digital, binaural, in the, left V5260RTEP Hing aid, digital, binaural, in the, right V5260LTEP Hing aid, digital, binaural, in the, left V5261RT V5261LT Hing aid, digital, binaural, behind the, right Hing aid, digital, binaural, behind the, left V5261RTEP Hing aid, digital, binaural, behind the, right V5261LTEP Hing aid, digital, binaural, behind the, left V5264RT V5264LT Ear mold/insert, not disposable, any type, right (a maximum of 4 may be billed on the same date of service) Ear mold/insert, not disposable, any type, left (a maximum of 4 may be billed on the same date of service) PA/RHAE $385.00 PA/RHAE $385.00 0-20 RHAE 0-20 RHAE $25.00 $25.00 V5267 Hing aid supplies/accessories 0-20 V5275RT Ear impression, right (a maximum of 4 may be billed on the same date of service) V5275LT Ear impression, left (a maximum of 4 may be billed on the same date of service) Repairs $5.00 $5.00 11
L7510(2) L8615 L8616 L8617 L8618 L8619(2) L8621 L8622 L8623 L8624 Repair of prosthetic device, repair or replace minor parts Replacement headset/piece for cochl implant Replacement microphone for cochl implant Replacement transmitting coil for cochl implant Replacement transmitter cable for cochl implant Cochl implant external speech processor, replacement Replacement zinc air battery for cochl implant each Alkaline battery for use with cochl implant, any size, replacement, each Lithium ion battery for use with cochl implant device speech processor; other than level, replacement each Lithium ion battery for use with cochl implant device speech processor; level, replacement each V5014RT22 Repair to hing aids which are not covered by the one y warranty. V5014LT22 Repair to hing aids which are not covered by the one y warranty. V5014RT Y5014LT Repair/modification of a hing aid (No longer under warranty Repair/modification of a hing aid (No longer under warranty Special Otorhinolaryngologic Services 92507(2) Treatment of speech, language, voice, communication, and/or auditory disorder includes aural rehabilitation; individual. $10.50 12
Maximum quantity per day is 16 units. (a unit is up to 15 minutes). 92601(3) Diagnostic analysis of cochl implant, patient under 7 ys of age; with programming. Maximum quantity per day is 16 units. (a unit is up to 15 minutes) 92602(3) Diagnostic analysis of cochl implant, patient under 7 ys of age; subsequent reprogramming. Maximum quantity per day is 16 units. (a unit is up to 15 minutes). Do not report in addition to 92601 on the same date of service 92603(3) Diagnostic analysis of cochl implant, patient 7 ys or older; with programming. Maximum quantity per day is 16 units. (a unit is up to 15 minutes) 92604(3) Diagnostic analysis of cochl implant, patient 7 ys or older; subsequent reprogramming. Maximum quantity per day is 16 units. (a unit is up to 15 minutes) Do not report 92604 in addition to 92603 on the same date of service. $10.50 $10.50 $10.50 $10.50 Special Tests (Covered Only When Prescribed by a Physician) The physician must indicate in Section "B" on the RHAE form, why the tests are being ordered. 92562 Loudness balance test, alternate binaural or monaural (retrocochl vs. cochl) $3.30 92563 Tone Decay Test $3.30 92564 Short Increment Sensitivity Index (SISI) $3.30 92567 Tympanometry (impedance testing) $5.00 92568 Acoustic Reflex Testing $5.00 92569 Acoustic Reflex Decay Test $5.00 Healthy Children and Youth (HCY) for Recipients 20 and Under Only V5266 Battery for use in hing device (When billing for batteries, list the number of batteries dispensed in Field #24 of the 0-20 $1.56 13
HCFA-1500 claim form.) V5298RT(3) Hing aid, not otherwise classified, right V5298LT(3) Hing aid, not otherwise classified, left 0-20 V5299 Hing service, miscellaneous (includes FM Systems, noncovered testing, repair to hing equipment other than hing aids, etc. Not to be used for hing aids. ) 0-20 0-20 RHAE, Report of Hing Aid Evaluation; PA, Prior Authorization; t;, Manually priced; MNF, Certificate of Medical Necessity maintained in the provider's file # A copy of the completed RHAE form must be attached to the claim if it is the only procedure being billed for all recipients aged 21 and over. (1) Not covered for recipients under the age of 13 except for medically necessary reasons, e.g., no external, psychological reasons, etc. (2) Age restriction for this code is 0-20 ys for dates of service prior to 7/1/03. (3) Covered for dates of service on or after 7/1/03. 19.3 HCY PROCEDURE CODES FOR PARTICIPANTS 20 YEARS OLD AND UNDER Many of the HCY procedure codes require a Certificate of Medical Necessity form. For information on medical necessity, including a sample Certificate of Medical Necessity form, reference Section 7. PROC DESCRIPTION CODE 92506 Evaluation of speech, language, voice communication, auditory processing and/or aural rehabilitation status. Maximum quantity per day is 16 units (a unit is up to 15 minutes). REQUIRED ATTACHMENT REIMBURSEMENT AMOUNT $10.50 92531 Spontaneous nystagmus, including gaze MNF $18.85 92532 Positional nystagmus MNF $21.90 92533 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) MNF $24.45 14
92534 Optokinetic nystagmus MNF $27.10 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542 Positional nystagmus test, minimum of 4 positions, with recording 92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording 92544 Optokinetic nystagmus test, bidirectional foveal or peripheral stimulation, with recording MNF $20.00 MNF $20.00 MNF $35.00 MNF $10.00 92545 Oscillating tracking test, with recording MNF $10.00 92546 Sinusoidal vertical axis rotational testing MNF $15.00 92547 Use of vertical electrodes in any or all of above tests counts as one additional test MNF $15.00 92551 Screening test, pure tone, air only $5.00 92552 Pure tone audiometry (threshold); air only $8.00 92553 Pure tone audiometry (threshold); air and bone $11.00 92555 Speech audiometry threshold $5.00 92556 Speech audiometry threshold; with speech recognition $5.00 92565 Stenger test, pure tone $40.00 92572 Staggered spondaic word test $76.00 92577 Stenger test, speech $30.00 92579 Visual reinforcement audiometry (VRA) $20.00 92582 Conditioning play audiometry $20.00 92583 Select picture audiometry $5.00 92584 Electrocochleography PA $80.00 92585 Auditory evoked potentials for evoked response audiometry and/or testing of the $140.00 15
central nervous system; comprehensive 92586 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited. 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 92588 Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies) $35.43 $70.00 $95.00 RHAE, Report of Hing Aid Evaluation; PA, Prior Authorization;, Manually priced; MN, Certificate of Medical Necessity; MNF, Certificate of Medical Necessity maintained in the provider's file Copay required END OF SECTION TOP OF PAGE 16