BILLING OF CPT THERAPY PROCEDURE CODES WHERE TIME IS … … · Unit Dose Form J0702 Betamethasone Acetate and 3 mg 1 cc Betamethasone Sodium Phosphate J0704 Betamethasone Sodium

February 2003 # 03-1

KKKKansansansansas as as as MMMMedical edical edical edical AAAAssistance ssistance ssistance ssistance PPPProgramsrogramsrogramsrograms

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BILLING OF C

Effective with date odesignated time willallow no more than This requires each ddate ranging. 9700 9700 9700 9700 9701 9701 9701 HCFA COMMO The following is a limanual due to HCPCJanuary 1, 2003. Ple J0287 J0289 J0592 J0636 J0637

HOSPITAL PROVIDERSPolicy and Procedure Update

is the fiscal agent and administrator of the Kansas Medicaid Program for the Kansas Department of Social and Rehabilitation Services

PT THERAPY PROCEDURE CODES WHERE TIME IS NOT DESIGNATED

f service, March 1, 2003, CPT Therapy Procedure Codes which have no be updated to one unit equals one visit. The procedures listed below will the maximum allowable price regardless of how many units are billed. ate of service to be billed as a separate line on the claim and eliminates

1 97016 97039 2 97018 97150 3 97020 92506 4 97022 92507 0 97024 92508 2 97026 97799 4 97028

______________________________

N PROCEDURE CODING SYSTEM (HCPC) CHANGES

st of procedure codes which have been added to the Hospital provider changes. These codes are effective with date of services on or after ase refer to your provider manual for the procedure code nomenclature.

J1051 J2788 J1094 J3315 J1564 J3487 J1652 J7633

R A

February 2003 Page Two The following codes have been non-covered and are no longer billable to Medicaid effective with dates of service on and after April 1, 2003. The replacement code is listed, if applicable. Non-Covered Replacement Code Code J0286 J0289 J0635 J0636 J1050 J1095 J1561 J1564 J1755 J1756 J1820 J1815 J2500 J2501 J2915 J2916 J7316

If you have any questio1-800-933-6593 (in-staMonday through Friday Bulletins and manualMedical Assistance prfor future reference.

HOSPITAL MANUAL REVISIONS

emove: Replace With:I-5 - AI-18 AI-5 - AI-18

ns, please contact the Medical Assistance Customer Service Center atte providers) or (785) 274-5990 between 7:30 a.m. - 5:30 p.m.,.

s constitute proof of notification of program changes to Kansasoviders. Please read these publications carefully and keep them

____________________________________ HOSPITAL PROVIDER MANUAL 02/03

APPENDIX I

AI - 5

PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY

J0285 Amphotericin B 50 mg - - - J0287 Amphotericin B lipid complex 10 mg J0289 Amphotericin B Liposome 10 mg J0290 Ampicillin Sodium 500 mg vial J0295 Ampicillin Sodium/Sulbactam 1.5 gm vial J0350 Anistreplase 30 units vial J7197 Antithrombin III (Human) - - - 1 unit

MCD Z2064 Antivenin Polyvant (crotalide) - - - 1 ml J9020 Asparaginase, Elspar up to 10,000 10 cc

units Z2775 Atracurium Besylate - - - 5 cc J2910 Aurothioglucose up to 50 mg 1 cc J7501 Azathioprine (e.g., Imuran)- 100 mg 20 ml

parenteral, vial J0456 Azithromycin 500 mg - - - Z2006 Aztreonam 500 mg 15 cc Z2654 Bacitracin 50,000 units vial

MCD J0475 Baclofen 10 mg - - - J0476 Baclofen, for intrathecal trial 50 mcg J9031 BCG Live (Intravesical) 50 mg vial J9050 BCNU, Bischlorethyl Nitrosourea, 100 mg vial

Carmustine J7622 Beclomethasome, Inhalation Solution per mg

Administered Through DME, Unit Dose Form

J0515 Benztropine 1 mg 1 cc J7624 Betamethasome, Inhalation Solution per mg


J0702 Betamethasone Acetate and 3 mg 1 cc Betamethasone Sodium Phosphate

J0704 Betamethasone Sodium Phosphate 4 mg 1 cc J0520 Bethanechol Chloride, up to 5 mg 1 cc

Myotonachol or Urecholine J9040 Bleomycin Sulfate 15 units amp J0585 Botulinum Toxin Type A per unit - - - J0587 Botulinum Toxin Type B per 100 units J7626 Budesonide Inhalation Solution 0.25 mg to

Administered Through DME, 0.50 mg Unit Dose Form

________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I AI -6

PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J7633 Budesonide Inhalation Solution 0.25 mg Administered through DME, Concentrated form

Z2595 Bupivacaine Hydrochloride 0.5 % - - - J0592 Buprenorphine Hydrochloride 0.1 mg Z2571 Butorphanol Tartrate 1 mg 1 cc J0706 Caffeine Citrate 5 mg J0630 Calcitonin Salmon up to 400 - - -

Units J0636 Calcitriol 0.1mcg

Z2709 Calcium Chloride 1 gm 10 cc Z2581 Calcium Gluceptate standard 5 cc J0610 Calcium Gluconate 10% 10 cc J9045 Carboplatin 50 mg vial J0637 Caspofungin Acetate 5 mg Z2005 Cefamandole Nafate 500 mg - - - J0690 Cefazolin Sodium 500 mg 10 cc J0692 Cefepime Hydrochloride 500 mg Z2007 Cefoperazone, Cefobid up to 1 gm - - - J0698 Cefotaxime Sodium 1 gm vial Z2126 Cefotetan Disodium (Cefotan) 1 gm vial J0694 Cefoxitin up to 1 gm 10 cc J0713 Ceftazidime 500 mg J0715 Ceftazidime Sodium 500 mg - - - J0696 Ceftriaxone Sodium 250 mg vial J1890 Cephalothin Sodium up to 1 gm 10 cc J0710 Cephapirin Sodium up to 1 gm vial J0720 Chloramphenicol Sodium up to 1 gm - - -

Siccomate J1205 Chlorothiazide Sodium 500 mg 20 cc J3230 Chlorpromazine HCL up to 50 mg - - - 90725 Cholera standard 1 cc J0725 Chorionic Gonadotropin 100 units - - - J0743 Cilastatin Sodium; Imipenem 250 mg vial J0744 Ciprofloxacin for Intravenous Infusion 200 mg J9060 Cisplatin 10 mg vial J9062 Cisplatin 50 mg - - - Z2016 Clindamycin up to 300 mg - - - J0745 Codeine Phosphate 30 mg 1 cc J0760 Colchicine up to 2 mg 2 cc

________________________________ HOSPITAL PROVIDER MANUAL 02/03

APPENDIX I

AI -7


J0770 Colistimethate Sodium up to 150 mg 2 cc J0835 Cosyntropin 0.25 mg - - - J9070 Cyclophosphamide 100 mg 10 cc J9080 Cyclophosphamide 200 mg 20 cc J9090 Cyclophosphamide 500 mg 30 cc J9091 Cyclophosphamide 1 gm - - - J9092 Cyclophosphamide 2 gm - - - J9093 Cyclophosphamide, Lyophilized 100 mg - - - J9094 Cyclophosphamide, Lyophilized 200 mg - - - J9095 Cyclophosphamide, Lyophilized 500 mg - - - J9096 Cyclophosphamide, Lyophilized 1.0 gm - - - J9097 Cyclophosphamide, Lyophilized 2.0 gm - - - J7516 Cyclosporine (e.g., Sandimmune)- 250 mg - - -

Parentera J9100 Cytarabine 100 mg - - - J9110 Cytarabine 500 mg - - - J9130 Dacarbazine 100 mg 10 cc J9140 Dacarbazine 200 mg 10 cc J7513 Daclizumab, parenteral 25 mg J9120 Dactinomycin, Actinomycin D 0.5 mg 3 cc

MCD J1645 Dalteparin Sodium 2500 IU - - - J0880 Darbepoetin Alfa 5mcg

J9150 Daunorubicin 10 mg vial J9151 Daunorubicin Citrate 10 mg

Liposomal Formulation J0895 Deferoxamine Mesylate 500 mg amp J9160 Denileukin Diftitox 300 mcg Z2728 Depandrogyn standard 1 cc J1000 Depo-Estradiol Cypionate up to 5 mg 1 cc J1094 Dexamethasone Acetate 1 mg J1100 Dexamethasone Sodium 1 mg 1 cc

Phosphate Z2665 Dexamethasone Acetate .5 cc and standard - - -

Mepivacaine Hydrochloride 1% .5 cc J1190 Dexrazoxane HCL 250 mg - - - Z2097 Dextrose 50% 1 ml J0500 Dicyclomine up to 20 mg 2 cc J9165 Diethylstilbestrol Diphosphate 250 mg - - - J1160 Digoxin up to 0.5 mg 1 cc J1110 Dihydroergotamine up to 0.1 mg 1 cc Z2400 Diltiazem 5 mg/ml 1 ml

MCD J1240 Dimenhydrinate up to 50 mg - - - J1200 Diphenhydramine HCL up to 50 mg 1 cc

________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I AI -8


90701 Diphtheria and Tetanus Toxoids - - - .5 cc and Pertussis Vaccine (DTP); Immunization, Active

90720 Diphtheria, Tetanus, and Pertussis standard - - - (DTP) and Hemophilus Influenza B

(HIB) Vaccine 90723 Diphtheria, Tetanus Toxoids, Pertussis,

Hepatitis B, and Poliovirus, Inactivated (DTAP-HEPB-IPV) for intramuscular use

J1245 Dipyridamole 10 mg 2 ml J1250 Dobutamine HCL 250 mg 1 cc J9170 Docetaxel (Taxotere) 20 mg 1 ml J1260 Dolasetron Mesylate 10 mg J1270 Doxercalciferol 1 mcg J9000 Doxorubicin HCL 10 mg vial J9001 Doxorubicin HCL, all lipid formulations 10 mg - - - Z2018 Doxycycline Hyclate I.V. up to 100 mg vial J1810 Droperidol and Fentanyl Citrate up to 2 ml amp J3520 Edetate Disodium 150 mg - - - Z2776 Edrophonium Chloride 10 mg 1 ml

MCD J1650 Enoxaparin Sodium 30mg 1 ml Z2703 Epinephrine Hydrochloride 1:200 mg 0.3 cc J9180 Epirubicin HCL 50 mg

MCD J1325 Epoprostenol 0.5 mg - - - J1330 Ergonovine Maleate up to 0.2 mg 1 cc J1364 Erythromycin Lactobionate 500 mg - - - Q0136 Epoetin Alpha 1000 units - - - Q9920 Epoetin Alpha, at patient HCT of 20 or less 1000 units Q9921 Epoetin Alpha, at patient HCT of 21 1000 units Q9922 Epoetin Alpha, at patient HCT of 22 1000 units Q9923 Epoetin Alpha, at patient HCT of 23 1000 units Q9924 Epoetin Alpha, at patient HCT of 24 1000 units Q9925 Epoetin Alpha, at patient HCT of 25 1000 units Q9926 Epoetin Alpha, at patient HCT of 26 1000 units Q9927 Epoetin Alpha, at patient HCT of 27 1000 units Q9928 Epoetin Alpha, at patient HCT of 28 1000 units Q9929 Epoetin Alpha, at patient HCT of 29 1000 units Q9930 Epoetin Alpha, at patient HCT of 30 1000 units Q9931 Epoetin Alpha, at patient HCT of 31 1000 units

______________________________________ HOSPITAL PROVIDER MANUAL 02/03

APPENDIX I

AI - 9


Q9932 Epoetin Alpha, at patient HCT of 32 1000 units Q9933 Epoetin Alpha, at patient HCT of 33 1000 units Q9934 Epoetin Alpha, at patient HCT of 34 1000 units Q9935 Epoetin Alpha, at patient HCT of 35 1000 units Q9936 Epoetin Alpha, at patient HCT of 36 1000 units Q9937 Epoetin Alpha, at patient HCT of 37 1000 units Q9938 Epoetin Alpha, at patient HCT of 38 1000 units Q9939 Epoetin Alpha, at patient HCT of 39 1000 units Q9940 Epoetin Alpha, at patient HCT of 40 or above 1000 units J1380 Estradiol Valerate up to 10 mg 1 cc J1390 Estradiol Valerate up to 20 mg 1 cc J0970 Estradiol Valerate up to 40 mg 1 cc J1410 Estrogen Conjugated 25 mg - - - J1435 Estrone 1 mg - - - J1438 Etanercept 25 mg - - - Z2626 Ethacrynic Acid 50 mg 1 cc J1436 Etidronate Disodium 300 mg 6 ml amp J9181 Etoposide 10 mg 2.5 cc J9182 Etoposide 100 mg 5 cc J7190 Factor VIII (Antihemophilic Factor per i.u. - - -

(NDC and product name/description must be provided) J7191 Factor VIII (Antihemophilic Factor per i.u. - - -

[Porcine]) J7192 Factor VIII (Antihemophilic Factor per unit - - -

[Recombinant]) J7193 Factor IX (Antihemophilic Factor, per i.u.

Purified, Non-Recombinant) J7195 Factor IX (Antihemophilic Factor, per i.u.

Recombinant) MCD Z2094 Famotidine 10 mg/ml 1 ml

J3010 Fentanyl Citrate 0.1 mg 2 cc MCD J1440 Filgrastim (G-CSF) 300 mcg - - - MCD J1441 Filgrastim (G-CSF) 480 mcg - - -

J9200 Floxuridine 500 mg 5 cc J1450 Fluconazole 200 mg - - - J9185 Fludarabine Phosphate 50 mg 1 ml Z2095 Flumazenil 0.1 mg/ml 1 ml J7641 Flunisolide, Inhalation Solution per mg


____________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I AI - 10


J9190 Fluorouracil 500 mgm amp J2680 Fluphenazine Decanoate up to 25 mg 1 cc Z2712 Folic Acid B9 5 mg 1 cc J1452 Fomivirsen Sodium, Intraocular 1.65 mg J1652 Fondaparinux Sodium 0.5 mg J1455 Foscarnet Sodium 1000 mg vial Z2134 Fosphenytoin Sodium (Cerebyx) 50 mg PE/ML per ml J1940 Furosemide up to 20 mg 2 cc J1460 Gamma Globulin, Intramuscular standard 1 cc J1470 Gamma Globulin, Intramuscular standard 2 cc J1480 Gamma Globulin, Intramuscular standard 3 cc J1490 Gamma Globulin, Intramuscular standard 4 cc J1500 Gamma Globulin, Intramuscular standard 5 cc J1510 Gamma Globulin, Intramuscular standard 6 cc J1520 Gamma Globulin, Intramuscular standard 7 cc J1530 Gamma Globulin, Intramuscular standard 8 cc J1540 Gamma Globulin, Intramuscular standard 9 cc J1550 Gamma Globulin, Intramuscular standard 10 cc J1560 Gamma Globulin, Intramuscular standard 10 cc J1570 Ganciclovir Sodium 500 mg vial J1580 Garamycin, Gentamycin up to 80 mg 2 cc J1590 Gatifloxacin 10 mg J9201 Gemcitabine HCL 200 mg - - - J9300 Gemtuzumab, Ozogamicin 5 mg J1610 Glucagon Hydrochloride 1 mg 1 cc J1600 Gold Sodium Thiomaleate up to 50 mg 1 ml J1620 Gonadorelin Hydrochloride 100 mcg - - - J9202 Goserelin Acetate Implant 3.6 mg 1

MCD J1626 Granisetron Hydrochloride 100 mcg 1 ml J1631 Haloperidol Decanoate 50 mg 1 cc J1642 Heparin Sodium (Heparin 10 units tubex

Lock Flush) J1644 Heparin Sodium 1000 units vial 90632 Hepatitis A Vaccine

Adult Dosage, For Intramuscular Use 90636 Hepatitis A and Hepatitis B Vaccine (HEPA-HEPB)

Adult Dosage, For Intramuscular Use 90740 Hepatitis B, dialysis or immunosuppressed patient

(3 dose schedule) for intramuscular use

________________________________ HOSPITAL PROVIDER MANUAL 02/03

APPENDIX I

AI -11


90746 Hepatitis B Vaccine; standard vial Adult Dosage

90747 Hepatitis B Vaccine; dialysis or - - - - - - immunosuppressed patient, any age (4 dose schedule)

J3470 Hyaluronidase up to 150 units 1 cc J0360 Hydralazine HCL up to 20 mg amp J1700 Hydrocortisone Acetate, up to 25 mg 1 cc J1720 Hydrocortisone Sodium Succinate up to 100 mg 2 cc J1710 Hydrocortisone Sodium Phosphate up to 50 mg 1 cc J1170 Hydromorphone up to 4 mg 1 cc J3410 Hydroxyzine HCL up to 25 mg 1 cc

* J7320 Hylan G-F (Synvisc®) 16 mg MCD J9211 Idarubicin Hydrochloride 5 mg vial

J9208 Ifosfomide per gm 1 gm vial MCD J1785 Imiglucerase - - - unit J1564 Immune Globulin 10 mg

J1563 Immune Globulin Intravenous(Human)10% 1 gms - - - MCD J1745 Infliximab (Remicade) 10 mg vial

90657 Influenza Virus Vaccine, Split Virus 6-36 Months Dosage, For Intramuscular or Jet Injection Use

90658 Influenza Virus Vaccine, Split Virus 3 Years and Above Dosage, For Intramuscular or Jet Injection Use

90659 Influenza Virus Vaccine, Whole Virus For Intramuscular or Jet Injection Use

J1815 Insulin, per 5 units J9213 Interferon, Alfa-2A, Recombinant 3 mill. units vial J9214 Interferon, Alfa-2B, Recombinant 1 mill. units - - - J9215 Interferon, Alfa-N3 (Human 250,000 units - - -

Leukocyte Derived) J9212 Interferon, Alfacon-1, Recombinant 1 mcg J1825 Interferon Beta-1A 33 mcg

MCD J1830 Interferon Beta 1-B 0.25 mg - - - J9216 Interferon, Gamma 1-B 3 mill. units vial

*Second series requires prior authorization

_____________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I AI - 12


J9206 Irinotecan HCI 20 mg/ml 1 ml J1750 Iron Dextran 50 mg - - - J1756 Iron Sucrose 1 mg J7658 Isoproterenol Hydrochloride per mg

conc. form J7659 Isoproterenol Hydrochloride per mg

unit dose form (NDC and product name/description must be provided) J1835 Itraconazole 50 mg J1840 Kanamycin Sulfate up to 500 mg 2 cc J1850 Kanamycin Sulfate up to 75 mg 2 cc Z2684 Ketamine Hydrochloride 10 mg 1 cc Z2685 Ketamine Hydrochloride 50 mg 1 cc J1885 Ketorolac Tromethamine 15 mg ml J1910 Kutapressin up to 2 ml - - - J0640 Leucovorin Calcium 50 mg vial J1950 Leuprolide Acetate (For Depot) 3.75 mg - - -

Suspension) J9218 Leuprolide Acetate 1 mg 1 ml J9217 Leuprolide Acetate, For Depot 7.5 mg/ml 1.5 ml

Suspension J9219 Leuprolide Acetate Implant 65 mg

(NDC and product name/description must be provided) J1956 Levofloxacin 250 mg - - - Z2694 Levothyroxine Sodium 500 mcg 10 cc J2000 Lidocaine HCL 1% 50 cc J2010 Lincomycin HCL up to 300 mg 1 cc

MCD Z2127 Lidocaine HCL 1 - 0.0005 per ml (Lidocaine HCL w/epinephrine)

J2020 Linezolid 200 mg Z2809 Loxitane 50 mg 1 ml J7511 Lymphocyte Immune Globulin, 25 mg

Antihymocyte Globulin, Rabbit, Parenteral J3475 Magnesium Sulfate 500 mg - - - J2150 Mannitol 25% 50 ml J9230 Mechlorethamine HCL (Nitrogen 10 mg 20 cc

Mustard), HN2 J1051 Medroxyprogesterone Acetate 50 mg

J1055 Medroxyprogesterone Acetate 150 mg 1 cc For Contraceptive Use



J1056 Medroxyprogesterone Acetate/ Estradiol Cypionate, 5 mg/25 mg

J2180 Meperidine and Promethazine HCL up to 50 mg 2 cc J2175 Meperidine 100 mg 1 cc J0670 Mepivacaine 1% 1 cc J9209 Mesna 200 mg vial Z2635 Mesoridazine Besylate 25 mg 1 cc J0380 Metaraminol up to 10 mg 1 cc J2800 Methocarbamol up to 10 ml 10 cc Z2683 Methohexital Sodium 500 mg 50 cc J9250 Methotrexate 5 mg - - - J9260 Methotrexate Sodium Mix 50 mg 2 cc J2210 Methylergonovine Maleate up to 0.2 mg 1 cc J1020 Methylprednisolone Acetate 20 mg 1 cc J1040 Methylprednisolone Acetate 80 mg 2 cc J2920 Methylprednisolone Sodium up to 40 mg 1 cc

Succinate J2930 Methylprednisolone Sodium up to 125 mg 2 cc

Succinate J2765 Metoclopramide HCL up to 10 mg 2 cc Z2019 Metronidazole up to 500 mg 100 ml J2260 Milrinone Lactate 5 mg J9280 Mitomycin 5 mg - - - J9290 Mitomycin 20 mg - - - J9291 Mitomycin 40 mg - - - J9293 Mitoxantrone HCL 5 mg 10 ml

MCD Z2129 Mivacurium Chloride (Mivacron) 2 mg per ml J2270 Morphine Sulfate up to 10 mg 1 cc J2271 Morphine Sulfate 100 mg - - -

MCD J2275 Morphine Sulfate, preservative-free 10 mg ml sterile solution)

J2300 Nalbuphine HCL 10 mg 2 cc J2310 Naloxone HCL 1 mg 1 cc J2320 Nandrolone Decanoate up to 50 mg 0.5 cc J2321 Nandrolone Decanoate up to 100 mg 1 cc J2322 Nandrolone Decanoate up to 200 mg 2 cc Z2717 Neostigmine Bromide 1:1000 (1 mg) 1 cc J2710 Neostigmine Methylsulfate up to 0.5 mg 1 cc J2324 Nesiritide 0.5 mg


PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY Z2098 Nitroglycerine 5 mg/ml 1

J2352 Octreotide Acetate 1 mg amp MCD J2405 Ondansetron Hydrochloride 1 mg 0.5 ml

J2355 Oprelvekin 5 mg J2700 Oxacillin Sodium up to 250 mg vial J2410 Oxymorphone HCL up to 1 mg 1 cc J2460 Oxytetracycline HCL up to 50 mg 1 ml Z2552 Oxytetracycline HCL 500 mg 10 cc J2590 Oxytocin up to 10 units 1 cc J9265 Paclitaxel 30 mg 5 ml

KBH,PA 90378 Palivizumab (Synagis) up to 50 mg vial J2430 Pamidronate Dissodium 30 mg vial J2440 Papaverine HCL up to 60 mg 2 cc J2501 Paricalacitol 1 mcg J0530 Penicillin G Benzathine & Penicillin up to 600,000 1 cc

G Procaine units J0540 Penicillin G Benzathine & Penicillin up to 1,200,000 2 cc

G Procaine units J0550 Penicillin G Benzathine & Penicillin up to 2,400,000 4 cc

G Procaine units J0560 Penicillin G Benzathine up to 600,000 1 cc

units J0570 Penicillin G Benzathine up to 1,200,000 2 cc

units J0580 Penicillin G Benzathine up to 2,400,000 4 cc

units J2540 Penicillin G Potassium up to 600,000 1 cc

units J2510 Penicillin G Procaine, Aqueous up to 600,000 1 cc 94642 Pentamidine, aerosol inhalation 300 mg vial J3070 Pentazocine 30 mg 1 cc J2515 Pentobarbital Sodium 50 mg 1 cc J3310 Perphenazine up to 5 mg 1 cc

units J2560 Phenobarbital Sodium up to 120 mg 2 cc J1165 Phenytoin Sodium 100 mg 2 cc J2543 Piperacillin Sodium/Tazobactum Sodium 1 gm/0.125 gm vial J9270 Plicamycin (Mithramycin) 2.5 mg - - -

____________________________________

HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I

AI - 15


90732 Pneumococcal Vaccine, Polysaccharide - - - - - - 23-Valent, adult or immunosuppressed Patient, for subcutaneous or intramuscular use

90712 Poliovirus Vaccine, Live, Oral - - - - - - (any types); Immunization, Active

Z2069 Polymyxin B Sulfate 500,000 units vial J9600 Porfimer Sodium 75 mg - - - J3480 Potassium Chloride 2 meq - - - J2650 Prednisolone Acetate up to 1 ml - - - Z2687 Prilocaine Hydrochloride 1% 1 cc Z2688 Prilocaine 2% 1 cc Z2045 Primaxin 250 mg - - - J2690 Procainamide HCL up to 1 gm 2 cc J0780 Prochlorperazine up to 10 mg 2 cc Z2636 Prolixin Enanthate 25 mg 1 cc J2550 Promethazine HCL up to 50 mg 1 cc J1800 Propranolol HCL up to 1 mg 1 cc J2720 Protamine Sulfate 10 mg - - - Z2675 Pyridoxine Hydrochloride 100 mg 1 cc Z2702 Quinidine 80 mg 1 cc 90675 Rabies Vaccine

For Intramuscular Use 90676 Rabies Vaccine

For Intradermal Use 90375 Rabies Immune Globulin (RIG), Human

For Intramuscular and/or Subcutaneous Use 90376 Rabies Immune Globulin, Heat-Treated (RIG-HT), Human

For Intramuscular and/or Subcutaneous Use J2780 Ranitidine HCL 25 mg J1565 Resp Sync Vir Immug (Respigam) 50 mg/ml 1 ml 90378 Resp Sync Vir Immug (RSV-IGIM)

for intramuscular use * Administration only

____________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I AI - 16


J2993 Reteplase 18.1 mg (two single use vials)

90384 RHO (D) Immune Globulin (RHIG), Human, Full-Dose For Intramuscular Use

J2788 RHO (D) Immune Globulin, Human, Mini-Dose 50 mg 90385 RHO (D) Immune Globulin (RHIG), Human, Mini-Dose

For Intramuscular Use 90386 RHO (D) Immune Globulin (RHIGIV), Human,

For Intravenous Use J2792 RHO D Immune Globulin, Human 100 IU

Solvent Detergent Z2806 Ritodrine Hydrochloride 50 mg 10 mg/ml,

5 ml amp or vial

J9310 Rituximab 100 mg MCD J2820 Sargramostin (GM-CSF) 50mcg vial

Z2691 Scopolamine Hydrobromide .3 mg/1 ml 1 cc Z2598 Sodium Bicarbonate 7.5% 50 cc J2912 Sodium Chloride 0.9% 2 ml J2916 Sodium Ferric Gluconate 12.5 mg

PA,KBH J2940 Somatrem 1 mg J2941 Somatropin 1 mg J3320 Spectinomycin Dihydrochloride up to 2 gm 3.2 cc J0697 Sterile Cefuroxime Sodium 750 mg vial J7051 Sterile saline or water up to 5 cc vial Z2800 Sterile Ticarcillin Disodium and 3.1 gm vial

Clavulanate J2995 Streptokinase 250,000 unit vial J0330 Succinycholine Chloride up to 20 mg vial J3030 Sumatriptan Succinate 6 mg - - - J7525 Tacrolimus, Parenteral 5 mg J3100 Tenecteplase 50 mg Z2116 Teniposide - - - 1 ml

____________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I

AI - 17

PROCEDURE

COV. CODE NOMENCLATURE STRENGTH QUANTITY

J3105 Terbutaline Sulfate up to 1 mg - - - J3140 Testosterone Suspension up to 50 mg 1 cc J1060 Testosterone Cypionate & up to 1 ml 1 ml

Estradiol Cypionate J1070 Testosterone Cypionate up to 100 mg 1 cc J1080 Testosterone Cypionate 200 mg 1 cc J3120 Testosterone Enanthate up to 100 mg .5 cc J3130 Testosterone Enanthate up to 200 mg 1 cc J0900 Testosterone Enanthate and up to 1 cc - - -

Estradiol Valerate J3150 Testosterone Propionate up to 100 mg 2 cc 90389 Tetanus Immune Globulin (TIG), Human, For Intramuscular Use 90703 Tetanus Toxoid; Immunization, Active - - - .5 cc 90784 Therapeutic or diagnostic injection

(NDC and product name/description must be provided) J3280 Thiethylperazine Maleate up to 10 mg 2 cc J9340 ThioTepa 15 mgm - - - J1655 Tinzaparin Sodium 1000 IU J3260 Tobramycin Sulfate up to 80 mg 2 cc

MCD J9350 Topotecan HCL (Hycamtin) 4 mg vial J9355 Trastuzumab (Herceptin) 10 mg J3302 Triamcinolone Diacetate 5 mg/ml 1 ml J3303 Triamcinolone Hexacetonide 5 mg/ml 1 ml J3400 Triflupromazine HCL up to 20 mg 1 cc J3250 Trimethobenzamide HCL up to 200 mg 2 cc J3315 Triptorelin Pamoate 3.75 mg Z2777 Tubo-Curarine - - - 1 cc 90690 Typhoid Vaccine, Live, Oral 90691 Typhoid Vaccine, VI Capsular

Polysaccharide (VICPS), For Intramuscular Use 90692 Typhoid Vaccine, Heat- and Phenol-Inactivated (H-P)

For Subcutaneous or Intradermal Use J3364 Urokinase 5000 units 1 ml J9357 Valrubicin, intravesical 200 mg J3370 Vancomycin HCL 500 mg 10 cc Z2605 Verapamil Hydrochloride 5 mg/2 ml 2 ml J3395 Verteporfin 15 mg J9360 Vinblastine Sulfate 1 mg 1 cc J9370 Vincristine Sulfate 1 mg/ml 1 ml vial

____________________________________ HOSPITAL PROVIDER MANUAL 02/03 APPENDIX I

AI - 18


J9375 Vincristine Sulfate 2 mg 2 ml vial J9380 Vincristine Sulfate 5 mg 5 ml vial J9390 Vinorelbine Tartrate 10 mg 1 ml J3420 Vitamin B-12 Cyanocobalamin up to 1000 mcg - - - J3430 Vitamin K, Phytonadione, up to 10 mg 1 cc

Menadione, Menadiol Sodium Diphosphate

J3487 Zoledronic Acid 1 mg

IV INFUSIONS

PROCEDURE CODE NOMENCLATURE DOSE J7030 Infusion, normal saline soln. 1000 cc J7040 Infusion, normal saline soln. 500 ml J7042 5% dextrose/normal saline 500 ml J7050 Infusion, normal saline soln. 250 cc J7051 Sterile saline or water up to 5 cc J7060 5% dextrose/Water 500 ml = 1 unit J7070 Infusion, D5W 1000 cc

MCD J7100 Infusion, Dextran 40 500 ml MCD J7110 Infusion, Dextran 75 500 ml

J7120 Ringers lactate infusion up to 1000 cc J7130 Hypertonic saline soln 50 or 100 meq., 20 cc vial

NOT OTHERWISE CLASSIFIED INJECTIONS

J3490 Unclassified drugs J7599 Immunosuppressive drug, not otherwise classified J8499 Prescription drug, oral, non-chemotherapeutic, not otherwise classified J8999 Prescription drug, oral, chemotherapeutic, not otherwise classified J9999 Antineoplastic drug, not otherwise classified

NOTE: The NDC and drug name must be included on the claim or the claim will deny.

Documents

BILLING OF CPT THERAPY PROCEDURE CODES WHERE TIME IS … … · Unit Dose Form J0702 Betamethasone Acetate and 3 mg 1 cc Betamethasone Sodium Phosphate J0704 Betamethasone Sodium