Texas Medicaid - Welcome to TMHP · Texas Medicaid Bulletin, No. 180 2004 HCPCS Special Bulletin4 Effective for dates of service on or after July 1, 2004, the following procedure

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•Texas Medicaid

Please visit the Texas Medicaid & Healthcare Partnership (TMHP) website at www.tmhp.com. Through the website, providers can verify client eligibility, check claim status, and register for provider workshops.

2004 HCPCS Special Bulletin No. 180

Bulletin Contents, No. 180

All ProvidersADA/AMA Copyright Requirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22004 Clinical Laboratory Fee Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2HCPCS Additions, Changes, and Deletions . . . . . . . . . . . . . . . . . . . . . . . . . . 2Medicaid Provider Fee Schedule Mailout . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Injection Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

CSHCN ProvidersBotulinum Toxin Type A and Type B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Durable Medical Equipment (DME) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Orthotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Home Health Nursing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Hospital-Based Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Injection – Omalizumab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Inpatient Professional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Outpatient Professional Evaluation and Management Services . . . . . . . . . . . . . 4Renal Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Services Incidental to Surgery, Assistant Surgery, and Anesthesia . . . . . . . . . . . 4Surgery – Ambulatory or Day Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Transportation – Ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Vaccines/Toxoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42004 CSHCN Additions Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Renal Dialysis ProvidersNew Temporary G Codes for Dialysis Services . . . . . . . . . . . . . . . . . . . . . . . 12

ASC/HASC ProvidersASC/HASC Code Additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13ASC/HASC Group Rate Revisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

2004 HCPCS Changes2004 HCPCS Additions Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132004 HCPCS Deletions Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212004 HCPCS Short Definition Changes Table . . . . . . . . . . . . . . . . . . . . . . . 232004 HCPCS Long Definition Changes Index . . . . . . . . . . . . . . . . . . . . . . . 25

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

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All Providers

ADA/AMA Copyright RequirementThis bulletin is intended to notify providers of Medicaid and CSHCN coding changes. In some instances, code descriptions have changed. However, due to American Medical Association (AMA) and American Dental Association (ADA) copyright requirements, descriptions longer than 28 characters can no longer be published. Please contact the appro-priate copyright holder in order to obtain full proce-dure code descriptions. ■

2004 Clinical Laboratory Fee ScheduleThe National Limitation Amount (NLA) calculation for 2004 remains at 74 percent of the median of the local fees for tests for which NLAs were established before January 1, 2001. There is no annual update (economic index) to the local laboratory fees for 2004. ■

HCPCS Additions, Changes, and DeletionsThe procedure code and modifier changes, additions, and deletions effective for dates of service on or after July 1, 2004, are listed in the HCPCS Tables begin-ning on page 13. These tables include Current Proce-dural Terminology, fourth edition (CPT-4) and HCPCS national codes. The Texas Medicaid Program and CSHCN will accept 2004 deleted HCPCS proce-dure codes until October 1, 2004. ■

Medicaid Provider Fee Schedule MailoutThe 2004 Texas Medicaid Provider Fee Schedule will be mailed in September 2004. The specific mailing date will be provided in future bulletins. All providers will be able to obtain fee schedules at www.tmhp.com. Nonelectronic billing providers will receive a bound copy. Providers may request a paper copy of the appli-cable fee schedule. To request a fee schedule, please call the TMHP Contact Center at 1-800-925-9126. ■

Injection FeesEffective for dates of service on or after July 1, 2004, most injections are reimbursed at 10.5 percent off the average wholesale price (AWP) or at 89.5% of the AWP. HHSC reserves the option to utilize additional data services when the AWP results have been deter-mined to be unreasonable or inefficient. ■

CSHCN ProvidersThe following articles apply to providers enrolled with the Children with Special Health Care Needs pro-gram; policies and coverage described herein may dif-fer from that of Medicaid. ■

Botulinum Toxin Type A and Type BEffective for dates of service on or after July 1, 2004, procedure code 64680, Destruction by neurolytic, has been revised. ■

ChemotherapyEffective for dates on or after July 1, 2004, procedure code 95991, Refiling, has been added. ■

Durable Medical Equipment (DME)The CSHCN program requires DME to be autho-rized except for custom, manual or power wheelchairs, custom seating systems, and pediatric hospital cribs and their tops which must be prior authorized. ■

Effective for dates of service on or after July 1, 2004, the following procedure codes have been added:

Procedure Code Description

A9999 Miscellaneous DME supply

E0247 Transfer bench for tub

E0248 Transfer bench, heavy duty

E0300 Pediatric crib, hospital

E0301 Hospital bed, heavy duty

E0302 Hospital bed, extra heavy

E0303 Hospital bed, heavy duty

E0304 Hospital bed, extra heavy

E0638 Standing frame sys

E0955 W/c accessory, headrest

E0956 W/c accessory, lateral

E0957 W/c accessory, medial

E0960 W/c accessory, shoulder

E0981 W/c accessory, seat

E0982 W/c accessory, back

E0983 Manual w/c accessory


E0985 W/c accessory, seat lift


E1002 W/c accessory, power



Texas Medicaid Bulletin, No. 180 2004 HCPCS Special Bulletin2

OrthoticsEffective for dates of service on or after July 1, 2004, procedure code L3031, Foot, insert/plate, has been added. ■

Home Health Nursing ServicesEffective for dates of service on or after July 1, 2004, the procedure code S9123, Nursing care, in the home, has been revised. ■

Hospital-Based Emergency DepartmentEffective for dates of service on or after July 1, 2004, the following procedure codes have been revised:

Injection - OmalizumabEffective for dates of service on or after July 1, 2004, the following procedure code S0107, Injectable, omal-izumab, has been added. Prior authorization is required. ■

Inpatient Professional ServicesEffective for dates of service on or after July 1, 2004, the following procedure codes have been discontinued:






E1009 W/c accessory, addition

E1010 W/c accessory, addition



E1028 W/c accessory, manual

E1029 W/c accessory, ventilator

E1030 W/c accessory, ventilator





E2300 Power w/c accessory































Procedure code Current Description

36410 Venipuncture, child over age

99050 Services requested after


36488 Placement of central

36489 Placement of central


36555 Insertion of nontunneled


36568 Insertion of peripherally


36580 Replacement, complete


2004 HCPCS Special Bulletin Texas Medicaid Bulletin, No. 1803

Effective for dates of service on or after July 1, 2004, the following procedure code descriptions have been revised:

Laboratory ServicesEffective for dates of service on or July 1, 2004, the procedure code 84155, Protein; total except, has been revised. ■

Outpatient Professional Evaluation and Management ServicesEffective for dates of service on or July 1, 2004, the following procedure code 99050, Services requested, has been revised. ■

Renal DialysisEffective for dates of service on or after July 1, 2004, the procedure code 84155, Protein; total, except, has been revised. ■


Services Incidental to Surgery, Assistant Surgery, and AnesthesiaEffective for dates of service on or after July 1, 2004, the following procedure codes have been discontinued:


Surgery – Ambulatory or Day SurgeryEffective for dates of service on or after July 1, 2004, the following procedure code has been revised:

Transportation - AmbulanceNew procedure code A0800, Ambulance transport provided, is not a benefit, as only emergency trans-ports are available at those times. ■

Vaccines/ToxoidsEffective for dates of service on or after July 1, 2004, the procedure code 90659, Influenza virus vaccine, has been discontinued. ■

Effective for dates of service on or after July 1, 2004, the following procedure codes have been revised:


Procedure Code Current Description

36400 Femoral, jugular

36410 Venipuncture, 3 years old

43752 Gastric intubation

99295 Initial neonatal

99296 Subsequent neonatal


Q4054 Injection, darbepoetin

Q4055 Injection, epoetin alfa


36488 Placement of Central




Procedure Code Description36555 Insertion of nontunneled







36400 Venipuncture, under age

36410 Venipuncture, age 3 years


90657 Influenza virus vaccine

90658 Influenza virus vaccine

90703 Tetanus toxoid absorbed

90704 Mumps virus vaccine

90705 Measles virus vaccine

90706 Rubella virus vaccine

90707 Measles, mumps

90708 Measles and rubella

90718 Tetanus and diphtheria


90655 Influenza virus vaccine, split

90734 Meningococcal conjugate


2004 CSHCN Additions Table

The following codes are new.

Procedure Code/Modifier

Description Allowable

0001F Blood pressure, measured

NC

0002F Tobacco use, smoking NC

0003F Tobacco use NC

0004F Tobacco use txmnt NC


0006F Statin therapy, prescribed

NC

0007F Beta-blocker thx NC

0008F Ace inhibitor thx NC

0009F Assess anginal symp-tom

NC

0010F Assess anginal symp-tom

NC

0011F Oral antiplat thx prescribed

NC

0045T Whole bodyphotography

NC

0046T Cath lavage, mammary NC


0048T Implant ventricular device

NC

0049T External circulation assist

NC

0050T Removal circulation assist

NC

0051T Implant total heart system

NC

0052T Replace component heart

NC


NC

0054T Bone surgery using NC



0057T Uppr gi scope w/thrml NC

0058T Cryopreservation, ovary

NC

0059T Cryopreservation NC

0060T Electrical impedance NC

0061T Destruction of tumor NC

00529 Anesth, for clsd proc 7=8 RVUs

01173 Anesth, for pelvis frac 7=8 RVUs

01958 Anesth, antepartum NC

20982 Ablate, bone tumor(s) NC

21685 Hyoid myotomy NC

22532 Lat thorax spine fusion 2=43.34 RVUs8=6.93 RVUsF=NC

22533 Lat lumbar spine fusion

2=40.41 RVUs8=6.47 RVUsF=NC

22534 Lat thor/lumb, add’l NC

31632 Bronchoscopy/lung NC

31633 Bronchoscopy/needle NC

34805 Endovasc abdo repair NC

35510 Artery bypass graft 2=35.24 RVUs8=5.64 RVUsF=NC




35697 Reimplant artery each NC

36555 Insert nontunnel cv cath

2=$162.408=NC

36556 Insert nontunnel cv cath

2=2.64 RVUs8=NC

36557 Insert tunneled cv cath 2=7.91 RVUs8=NC

36558 Insert tunneled cv cath NC






36568 Insert tunneled cv cath 2=$162.408=NC




GP=Group payment; MR=Manually reviewed for payment; NC= Noncovered service; **=Payable through TDH; *=Reactivated procedure code

36569 Insert tunneled cv cath 2=2.64 RVUS8=NC



36575 Insert tunneled cv cath 2=$7.86 RVUs8=NC




36581 Replace tunneled cv 2=7.86 RVUs8=NC





36589 Removal tunneled cv 2=4.60 RVUs8=NC


36595 Mech remov tunneled cv

2=23.58 RVUs8=NC


2=5.19 RVUs8=NC

36597 Reposition venous NC

36838 Dist revas ligation, hemo

NC

37765 Phleb veins - extrem NC

37766 Phleb veins - extrem 20+

NC

43237 Endoscopic us exam 2=5.86 RVUs8=NC

43238 Uppr gi endoscopy w/us

2=6.68 RVUs8=NC

47140 Partial removal, donor NC





53500 Urethrlys, transvag 2=18.71 RVUs8=NC

57425 Laparoscopy, surg NC

59070 Transabdom amnioin-fus

NC

59072 Umbilical cord occlud NC

59074 Fetal fluid drainage w/us

NC

59076 Fetal shunt placement NC

59897 Fetal invas px w/us NC

61537 Removal of brain tissue 2=45.90 RVUs8=7.34 RVUsF=NC


61566 Removal of brain tissue NC

61567 Incision of brain tissue 2=60.15 RVUs8=9.62 RVUsF=NC

61863 Implant neuroelec-trode

2=31.48 RVUs8=NCF=NC


2=7.91 RVUs8=NCF=NC


NC


NC

63101 Removal of vertebral 2=56.98 RVUs8=9.12 RVUsF=NC


63103 Remove vertebral body NC

64449 N block inj, lumbar 2=4.07 RVUs8=NC

64517 N block inj, hypogas NC

64681 Injection treatment NC

65780 Ocular reconst NC



67912 Correction eyelid NC

68371 Harvest eye tissue NC





70557 Mri brain w/o dye NC


70559 Mri brain w/o & w/dye

NC

75998 Fluoroguide for vein NC

76082 Computer mammo-gram

NC

76083 Computer mammo-gram

NC

76514 Echo exam of eye NC

76937 Us guide, vascular access

NC

76940 Us guide, tissue abla-tion

4=4.49 RVUsI=2.81 RVUsT=1.68 RVUs

78804 Tumor imaging, whole 6=5.9 RVUsI=1.38RVUsT=4.52 RVUs

79403 Hematopoetic nuclear 6=7.78 RVUsT=3.25 RVUsI=4.43 RVUs

84156 Assay of protein, urine 5=$5.06I=NC

84157 Assay of protein, other 5=$5.06I=NC

85055 Reticulated platelet assay

5=$37.00I=NC

85396 Clotting assay, whole 5=$7.13I=NC

87269 Giardia ag 5=$16.58I=NC

87329 Giardia ag, eia 5=$16.58I=NC

87660 Trichomonas vagin, dir 5=$27.71I=NC

88112 Cytopath, cell enhance 5=3.24 RVUsI=1.75 RVUsT=1.49 RVUs

88361 Immunohistochemis-try

5=3.72 RVUsI=1.47 RVUsT=2.25 RVUs

89220 Sputum specimen 5=0.4 RVUsI=NC

89225 Starch granules, feces 5=$4.62I=NC

89230 Collect sweat for test 6=$12.00I=NC



89235 Water load test 5=$5.12I=NC

89240 Pathology lab proce-dure

5=$5.01I=NC

89268 Insemination NC

89272 Extended culture NC

89280 Assist oocyte fertiliza-tion

NC


NC

89290 Biopsy, oocyte polar NC

89291 Insemination of oocytes

NC

89335 Cryopreserve testicular NC

89342 Storage/year; embryo(s)

NC

89343 Storage/year; sperm/semen

NC

89344 Storage/year; reprod tissue

NC

89346 Storage/year; oocyte NC

89352 Thawing cryopresrved NC


89354 Thaw cryoprsvrd; reprod

NC


90655 Flu vaccine, 6-35 mo, im

NC

90698 Dtap-hib-ip vaccine, im

NC

90715 Tdap vaccine >7 im NC

90734 Meningococcal vac-cine, im

NC

91110 Gi tract capsule endoscopy

4=20.87 RVUsI=NCT=NC

95991 Spin/brain pump refil NC

97755 Assistive technology NC

99601 Home infusion/visit NC

99602 Home infusion, each addtl

NC

A0800 Amb trans 7pm-7am NC

A4216 Sterile water/saline NC

A4217 Sterile water/saline NC

A4248 Chlorhexidine antisept NC





A4366 Ostomy vent NC

A4416 Ost pch clsd w/barrier NC

A4417 Ost pch w/bar/bltin-conv

NC

A4418 Ost pch clsd w/o bar 9-$1.81J-NC

A4419 Ost pch for bar w/flange

NC

A4420 Ost pch clsd for bar w/lk

9-$2.71J-NC

A4423 Ost pch for bar w/lk fl NC

A4424 Ost pch drain w/bar NC

A4425 Ost pch drain for bar-rier

NC

A4426 Ost pch drain 2 piece NC

A4427 Ost pch drain/barr lk flng

NC

A4428 Urine ost pouch w/faucet

9-$6.51J-NC

A4429 Urine ost pouch NC

A4430 Ost urine pch w/b/bltin conv

NC

A4431 Ost pch urine w/bar-rier

NC

A4432 Os pch urine w/bar/fange

NC

A4433 Urine ost pch bar NC

A4434 Ost pch urine w/lock NC

A4638 Repl batt pulse gen sys NC

A4671 Disposable cycler set NC

A4672 Drainage ext line NC

A4673 Ext line w/easy lock NC

A4674 Chem/antisept solu-tion

NC

A4728 Dialysate solution NC

A6407 Packing strips $1.81

A6441 Pad band w/>=3”<5”/yd

$0.67

A6442 Conform band n/s $0.17



A6445 Conform band s w/<3” $0.32

A6446 Conform band s w/>=3”

$0.41



A6447 Conform band s w/>=5”

$0.67

A6448 Lt compres band <3”/yd

$1.16

A6449 Lt compres band >=3”<5”/

$1.75

A6450 Lt compres band >=5”/yd

$1.08

A6451 Mod compres band w/>=3”

$0.99

A6452 High compres band $4.72

A6453 Self-adher band w/<3” $0.61

A6454 Self-adher band w>=3” $0.70

A6455 Self-adher band >=5”/yd

$0.70

A6456 Zinc paste band w/>=3”

$1.14

A6550 Neg pres wound ther $27.42

A6551 Neg press wound ther $24.53

A7046 Repl water chamber NC

A7520 Trach/laryn tube $45.01

A7521 Trach/laryn tube cuffed

$45.01

A7522 Trach/laryn tube stainless

$45.01

A7523 Tracheostomy shower $6.77

A7524 Tracheostoma stent/stud

NC

A7525 Tracheostomy mask $1.40

A7526 Tracheostomy tube $1.40

A9280 Alert device, noc NC

A9525 Low/iso-osmolar contrast

NC

A9526 Ammonia N-13 NC

A9528 Dx I131 so iodide cap NC

A9529 Dx I131 so iodide sol NC

A9530 Th I131 so iodide sol NC

A9531 Dx I131 so iodide NC

A9532 I-125 serum albumin NC

A9533 I-131 tositumomab NC


A9999 DME supply or accessory

NC





C1814 Retinal tamp, silicone oil

NC

C1818 Integrated NC

C8918 MRA w/cont, pelvis NC

C8919 MRA w/o cont, pelvis NC

C8920 MRA w/o fol w/cont NC

C9123 Transcyte, per 247 sq cm

NC

C9202 Octafluoropropane NC

C9203 Perflexane lipid micro NC

C9208 Injection, agalsidase NC

C9209 Injection, laronidase NC

E0118 Crutch substitute NC

E0140 Walker w/trunk sup-port

9/L-NCJ-$360.71

E0190 Positioning cushion 9/L-NCJ-$34.44

E0240 Bath/shower chair 9/L-NCJ-MR

E0247 Trans bench w/wo comm

9/L-NCJ-64.72

E0248 HDtrans bench w/wo open

9/L-NCJ-109.68

E0300 Enclosed ped crib hosp 9/L-NCJ-$2,838.62

E0301 HD hosp bed NC

E0302 Ex hd hosp bed >600 NC

E0303 Hosp bed hvy dty x 9-NCJ-MRL-$290.81

E0304 Hosp bed xtra hvy dty 9-NCJ-MRL-$290.81

E0470 RAD w/o backup non 9-NCJ-$1,296.95L-$256.60

E0471 RAD w/backup non inv

9/J-NCL-$395.22

E0472 RAD w/backup inva-sive

9/J-NCL-$395.22

E0561 Humidifier nonheated 9-NCJ-$107.00L-$10.69

E0562 Humidifier heated used

9-NCJ-$299.73L-$28.72



E0637 Sit-stand w/seatlift NC

E0638 Standing frame sys 9/L-NCJ-$853.57

E0675 Pneumatic compres-sion

NC

E0955 Cushioned headrest 9-NCJ-$202.18L-$20.25

E0956 W/c leteral trunk/hip 9/L-NCJ-$98.58

E0957 W/c medial thigh support

9/L-NCJ-$137.93

E0960 W/c shoulder harness 9/L-NCJ-$90.98

E0981 Seat upholstery 9/L-NCJ-$35.29

E0982 Back upholstery 9/L-NCJ-$51.53

E0983 Add pwr joystick NC

E0984 Add pwr tiller NC

E0985 W/c seat lift mecha-nism

NC

E0986 Man w/c push-rim pow

NC

E1002 Pwr seat tilt 9/L-NCJ-$4,113.02

E1003 Pwr seat recline 9/L-NCJ-$4,391.30

E1004 Pwr seat recline mech 9/L-NCJ-$4,869.05

E1005 Pwr seat recline pwr 9/L-NCJ-$5,270.36

E1006 Pwr seat combo w/o 9/L-NCJ-$6,455.70

E1007 Pwr seat combo 9/L-NCJ-$8,741.27

E1008 Pwr seat combo pwr 9/L-NCJ-$8,742.05

E1009 Add mech leg elevation NC

E1010 Add pwr leg elevation NC

E1019 HD feature power seat 9/L-NCJ-$447.26

E1021 Ex hd feature power seat

9/L-NCJ-$324.16

E1028 W/c manual swing away

9/L-NCJ-$206.54





E1029 W/c vent tray fixed 9/L-NC

J-$369.54

E1030 W/c vent tray gim-baled

NC

E1391 Oxygen concentrator NC

E1634 Peritoneal dialysis clamp

NC

E2120 Pulse gen sys tx endolymp

NC

E2201 Man w/c acc seat 9/L-NCJ-$373.10

E2202 Seat width 24-27 9/L-NCJ-$473.98

E2203 Frame depth less than 22

9/L-NCJ-$479.05

E2204 Frame depth 22 to 25 9/L-NCJ-$813.40

E2300 Pwr seat elevation sys NC

E2301 Pwr standing NC

E2310 Electro connect btw NC

E2311 Electro connect btw 2 sys

NC

E2320 Hand chin control NC

E2321 Hand interface joystick NC

E2322 Mult mech switches NC

E2323 Special joystick handle NC

E2324 Chin cup interface NC

E2325 Sip and puff interface NC

E2326 Breath tube kit NC

E2327 Head control interface NC

E2328 Head/extremity con-trol

NC

E2329 Head control NC

E2330 Head control proxim-ity

NC

E2331 Attendant control NC

E2340 W/c wdth 20-23 in seat

9/L-NCJ-$314.22

E2341 W/c wdth 24-27 in seat

9/L-NCJ-$462.97

E2342 W/c dpth 20-21 in seat 9/L-NCJ-$448.03

E2343 W/c dpth 22-25 in seat 9/L-NCJ-$259.27



E2351 Electronic SGD interface

NC

E2360 22nf nonsealed leadacid

NC

E2361 22nf sealed leadacid J-$139.47

E2362 GR24 nonsealed leadacid

NC

E2363 GR24 sealed leadacid 9/L-NCJ-$186.00

E2364 U1nonsealed leadacid NC

E2365 U1 sealed leadacid battery

NC

E2366 Battery charger 9/L-NCJ-$263.62

E2367 Battery charger NC

E2399 Noc interface NC

E2402 Neg press wound therapy

9/J-NCL-$1,716.46

E2500 SGD digitized pre-rec <=8

J-$391.06**L-$34.71**

E2502 SGD prerec msg >8 min

J-$1,195.80**L-$119.59*


J-$1,446.05**L-$144.60**


J-$1,446.05**L-$144.60**

E2508 SGD spelling phys contact

J-$3,421.71**L-$342.18**

E2510 SGD w/multi methods J-$6,475.12**L-$647.51**

E2511 SGD sftwre prgrm for J-$1,242.67**L-$452.59**

E2512 SGD accessory J-$578.10**L-$57.81**

E2599 SGD accessory noc J-MR**L-MR**

G0296 PET imge restag thy-rod

NC

G0297 Insert single chamber/cd

NC

G0298 Insert dual chamber/cd NC

G0299 Inser/repos single icd NC

G0300 Insert reposit lead dual NC

G0302 Pre-op service LVRS NC

G0303 Pre-op service LVRS 10

NC





G0304 Pre-op service LVRS 1-9

NC

G0305 Post op service LVRS NC

G0306 CBC/diffwbc 5=$10.74I=NC

G0307 CBC without platelet 5=$8.95I=NC

G3001 Crisis interven svc NC

J0152 Adenosine injection NC

J0215 Alefacept NC

J0583 Bivalirudin NC

J0595 Butorphanol tartrate NC

J1335 Ertapenem injection $28.82

J1595 Injection glatiramer NC

J2001 Lidocaine injection NC

J2185 Meropenem $7.09

J2280 Inj, moxifloxacin $0.51

J2353 Octreotide injection NC

J2354 Octreotide inj, non NC

J2505 Injection, pegfilgrastim 1-$2,507.50

J2783 Rasburicase NC

J3411 Thiamine hcl 100mg NC

J3415 Pyridoxine hcl 100mg NC

J3465 Injection, voriconazole NC

J3486 Ziprasidone mesylate NC

J7303 Contraceptive vaginal NC

J7621 (Levo) albuterol/Ipra NC

J9098 Cytarabine liposome NC

J9178 Inj, epirubicin hcl, 2mg

NC

J9263 Oxaliplatin NC

J9395 Injection, Fulvestrant NC

K0606 AED garment w/elec NC

K0607 Repl batt for AED NC

K0608 Repl garment for AED NC

K0609 Repl electrode for AED

NC

K0618 TLSO 2 piece rigid shell

NC

K0619 TLSO 3 piece rigid shell

NC

K0620 Tubular elastic dressing $1.14



L0112 Cranial cervical ortho-sis

NC

L0861 Halo repl liner/inter-face

NC

L1831 Knee orth pos locking $238.21

L1907 AFO supramalleolar $445.42

L1951 AFO spiral prefabri-cated

NC

L1971 AFO w/ankle joint $379.36

L3031 Foot lamin/prepreg $57.56

L3917 Prefab metacarpl fx NC

L5673 Socket insert w/lock $587.53

L5679 Socket insert w/o lock $489.59

L5681 Intl custm cong/latyp $1,066.68

L5683 Initial custom socket $1,066.68

L8511 Indwelling trach insert NC

L8512 Gel cap for trach voice NC

L8513 Trach pros cleaning NC

L8514 Repl trach puncture NC

L8631 MCP joint repl 2 pc NC

L8659 Interphalangeal joint NC

P9051 Blood, l/r, cmv-neg 0=$102.76

P9052 Platelets, hla-m, l/r 0=$51.44

P9053 Plt, pher, l/r cmv-neg 0=$56.44

P9054 Blood, l/r, froz/degly 0=$104.15

P9055 Plt, aph/pher, l/r, cmv 0=$51.44

P9056 Blood, l/r, irradiated 0=$45.00

P9057 RBC, frz/deg/wsh, l/r 0=$109.15

P9058 RBC, l/r, cmv-neg, irrad

0=$109.15

P9059 Plasma, frz between 8-24

0=$77.33

P9060 Fr frz plasma donor 0=$77.33

Q0137 Darbepoetin alfa, non-esrd

NC

Q0182 Nonmetabolic act d/e NC

Q4054 Darbepoetin alfa, esrd $4.24

Q4055 Epoetin alfa, esrd use $11.96

Q4075 Acyclovir, 5mg NC

Q4076 Dopamine hcl, 40mg NC

Q4077 Treprostinil, 1mg NC

S0107 Inj, omalizumab 25mg $411.76

S0115 Bortezomib 3.5mg NC





S0163 Risperdone 12.5mg NC

S0317 Diseasemgmt per diem NC

S2070 Cysto laser tx ureteral NC

S2085 Laparoscop gastric NC

S2095 Transcath emboliz NC


S2135 Neurolysis interspace foot

NC

S2213 Implant gastric stim NC

S2225 Myringotomy laser-assist

NC

S2230 Implant semi-imp hear NC

S2235 Implant auditory brain NC

S2362 Kyphoplasty, first NC

S2363 Kyphoplasty, each addl NC

S3625 Maternal triple screen NC

S3840 DNA analysis RET NC

S3841 Gene test retinoblas-toma

NC

S3842 Gene test Hippel-Lindau

NC

S3843 DNA analysis factor v NC

S3844 DNA analysis deafness NC

S3845 Gene test alpha NC

S3846 Gene test beta NC

S3847 Gene test Tay-Sachs NC

S3848 Gene test Gaucher NC

S3849 Gene test Niemann-Pick

NC

S3850 Gene test sickle cell NC

S3851 Gene test canavan NC

S3852 DNA analysis APOE NC

S3853 Gene test myo musclr NC

S5550 Insulin rapid 5 u NC

S5551 Insulin most rapid 5 u NC

S5552 Insulin intermed 5 u NC

S5553 Insulin long acting 5 u NC

S5560 Insulin reuse pen 1.5 ML

NC

S5561 Insulin reuse pen 3 ML NC

S5565 Insulin cartridge 150 u NC




S5570 Insulin dispos pen 1.5 ML

NC

S5571 Insulin dispos pen 3 ML

NC

S8075 CAD of digital mammogr

NC

S8120 O2 contents gas cubic ft

NC

S8121 O2 contents liquid lb NC

S8948 Low-level laser trmt 15 NC

S9335 HT hemodialysis diem NC

S9434 Mod Solid Food Supl NC

S9476 Vestibular rehab NC

T2010 PASARR Level I NC

T2011 PASARR Level II NC

T2012 Habil ed waiver NC


T2014 Habil prevoc waiver NC


T2016 Habil res waiver NC


T2018 Habil sup empl waiver NC


T2020 Day habil waiver NC


T2022 Case management NC

T2023 Targeted casemgmt NC

T2024 Serv asmnt/care plan NC

T2025 Waiver service, nos NC

T2026 Special childcare waiver

NC

T2027 Spec childcare waiver 15

NC

T2028 Special cupply, NOS NC

T2029 Special med equip, NOS

NC

T2030 Assist living waiver NC


T2032 Res care, NOS waiver NC

T2033 Res, NOS waiver NC

T2034 Crisis interven waiver NC

T2035 Utility services waiver NC

T2036 Camp overnite waiver NC





Renal Dialysis Providers

New Temporary G Codes for Dialysis ServicesThe CMS has created separate temporary G codes that describe procedures or services for patients under

dialysis care. These codes should not be used to bill the Medicaid program. Medicaid providers should continue to use the 909XX codes for dialysis care. ■

ASC/HASC Providers

ASC/HASC Code AdditionsAdditions for ambulatory surgical center/hospital ambulatory surgical center (ASC/HASC) facilities will be effective for dates of service on or after July 1, 2004. They are listed with appropriate group payments in the HCPCS Additions Table below. ■

ASC/HASC Group Rate RevisionsThe ASC/HASC group rates implemented by Medicare on October 1, 2003 will be adopted by the Texas Medicaid Program. ■

2004 HCPCS Changes

2004 HCPCS Additions Table

The following codes are new.

T2037 Camp day waiver NC

T2038 Comm trans waiver NC

T2039 Vehicle mod waiver/service

NC

T2040 Financialmgt waiver NC

T2041 Support broker waiver NC

T2042 Hospice routine home NC

T2043 Hospice continuous NC

T2044 Hospice respite care NC

T2045 Hospice general care NC

T2046 Hospice long term care NC

T2048 Bh ltc res r&b NC

T2101 Breast milk NC

T5001 Special position seat NC

T5999 Supply, nos NC

V2121 Lenticular lens, single $70.46**

V2221 Lenticular lens, bifocal $71.90**

V2321 Lenticular lens, trifocal $91.53**

V2745 Tint, any color/solid NC

V2756 Eye glass case NC

V2761 Mirror coating NC

V2762 Polarization, any lens $48.34**

V2782 Lens, 1.54-1.65p/1.60 $52.20**

V2783 Lens, >=1.66p/>=1.80g

$58.86**

V2784 Lens polycarb or equal $38.28**

V2786 Occupational multifo-cal

NC

V2797 Vis item/svc in other NC

UN Two patients served

UP Three patients served

UQ Four patients served

UR Five patients served

US Six or more patients

KZ New coverage





UN Two patients served

UP Three patients served

UQ Four patients served

UR Five patients served

US Six or more patients

0001F Blood pressure, measured

NC

0002F Tobacco use, smoking NC

0003F Tobacco use NC



0006F Statin therapy, prescribed

NC

0007F Beta-blocker thx NC

0008F Ace inhibitor thx NC

0009F Assess anginal symptom NC

0010F Assess anginal symptom NC

0011F Oral antiplat thx prescribed

NC



0045T Whole body photography

NC



0048T Implant ventricular device

NC

0049T External circulation assist

NC

0050T Removal circulation assist

NC

0051T Implant total heart system

NC


NC


NC




0057T Uppr gi scope w/thrml NC

0058T Cryopreservation, ovary NC

0059T Cryopreservation NC

0060T Electrical impedance NC

0061T Destruction of tumor NC

00529 Anesth, for clsd proc 7=8 RVUs

01173 Anesth, for pelvis frac 7=8 RVUs

01958 Anesth, antepartum 7=5 RVUs

20982 Ablate, bone tumor(s) NC

21685 Hyoid myotomy NC

22532 Lat thorax spine fusion 2=43.34 RVUs8=6.93 RVUsF=NC

22533 Lat lumbar spine fusion 2=40.41 RVUs8=6.47 RVUsF=NC

22534 Lat thor/lumb, add’l NC

31632 Bronchoscopy/lung NC

31633 Bronchoscopy/needle NC

34805 Endovasc abdo repair NC







35697 Reimplant artery each NC

36555 Insert nontunnel cv cath 2=$162.408=NC

36556 Insert nontunnel cv cath 2=2.64 RVUs8=NC









36569 Insert tunneled cv cath 2=2.64 RVUS8=NC



















2=23.58 RVUs8=NC


2=5.19 RVUs8=NC

36597 Reposition venous NC

36838 Dist revas ligation, hemo

NC

37765 Phleb veins - extrem NC

37766 Phleb veins - extrem 20+ NC

43237 Endoscopic us exam 2=5.86 RVUs8=NC

43238 Uppr gi endoscopy w/us 2=6.68 RVUs8=NC




53500 Urethrlys, transvag 2=18.71 RVUs8=NC

57425 Laparoscopy, surg 2=19.71 RVUs8=3.15 RVUs

59070 Transabdom amnioinfus NC

59072 Umbilical cord occlud NC

59074 Fetal fluid drainage w/us NC

59076 Fetal shunt placement NC

59897 Fetal invas px w/us MR



61566 Removal of brain tissue NC

61567 Incision of brain tissue 2=60.15 RVUs8=9.62 RVUsF=NC

61863 Implant neuroelectrode 2=31.48 RVUs8=NCF=NC



61864 Implant neuroelectrode 2=7.91 RVUs8=NCF=NC

61867 Implant neuroelectrode NC

61868 Implant neuroelectrode NC



63103 Remove vertebral body NC

64449 N block inj, lumbar 2=4.07 RVUs8=NC

64517 N block inj, hypogas NC

64681 Injection treatment NC




67912 Correction eyelid NC

68371 Harvest eye tissue NC



70559 Mri brain w/o & w/dye NC

75998 Fluoroguide for vein NC

76082 Computer mammogram NC

76083 Computer mammogram NC

76514 Echo exam of eye NC

76937 Us guide, vascular access NC

76940 Us guide, tissue ablation 4=4.49 RVUsI=2.81 RVUsT=1.68 RVUs

78804 Tumor imaging, whole 6=5.9 RVUsI=1.38 RVUsT=4.52 RVUs

79403 Hematopoetic nuclear 6=7.68 RVUsT=3.25 RVUsI=4.43 RVUs

84156 Assay of protein, urine 5=$5.06I=NC

84157 Assay of protein, other 5=$5.06I=NC

85055 Reticulated platelet assay 5=$37.00I=NC

85396 Clotting assay, whole 5=$7.13I=NC





87269 Giardia ag 5=$16.58I=NC

87329 Giardia ag, eia 5=$16.58I=NC

87660 Trichomonas vagin, dir 5=$27.71I=NC

88112 Cytopath, cell enhance 5=3.24 RVUsI=1.75 RVUsT=1.49 RVUs

88361 Immunohistochemistry 5=3.72 RVUsI=1.47 RVUsT=2.25 RVUs

89220 Sputum specimen 5=0.4 RVUsI=NC

89225 Starch granules, feces 5=$4.62I=NC

89230 Collect sweat for test 6=$12.00I=NC

89235 Water load test 5=$5.12I=NC

89240 Pathology lab procedure 5=$5.01I=NC

89268 Insemination NC

89272 Extended culture NC


NC


NC

89290 Biopsy, oocyte polar NC

89291 Insemination of oocytes NC

89335 Cryopreserve testicular NC

89342 Storage/year; embryo(s) NC

89343 Storage/year; sperm/semen

NC

89344 Storage/year; reprod tissue

NC

89346 Storage/year; oocyte NC



89354 Thaw cryoprsvrd; reprod

NC


90655 Flu vaccine, 6-35 mo, im

NC

90698 Dtap-hib-ip vaccine, im NC

90715 Tdap vaccine >7 im NC



90734 Meningococcal vaccine, im

NC

91110 Gi tract capsule endos-copy

4=20.87 RVUsI=NCT=NC

95991 Spin/brain pump refil NC

97755 Assistive technology NC

99601 Home infusion/visit NC

99602 Home infusion, each addtl

NC

A0800 Amb trans 7pm-7am NC

A4216 Sterile water/saline 9-$0.46J-NC

A4217 Sterile water/saline 9-$3.27J-NC

A4248 Chlorhexidine antisept NC

A4366 Ostomy vent NC

A4416 Ost pch clsd w/barrier NC

A4417 Ost pch w/bar/bltinconv NC

A4418 Ost pch clsd w/o bar NC

A4419 Ost pch for bar w/flange NC

A4420 Ost pch clsd for bar w/lk NC

A4423 Ost pch for bar w/lk fl NC

A4424 Ost pch drain w/bar NC

A4425 Ost pch drain for barrier NC

A4426 Ost pch drain 2 piece NC

A4427 Ost pch drain/barr lk flng

NC

A4428 Urine ost pouch w/faucet

NC

A4429 Urine ost pouch NC

A4430 Ost urine pch w/b/bltin conv

NC

A4431 Ost pch urine w/barrier NC

A4432 Os pch urine w/bar/fange

NC

A4433 Urine ost pch bar NC

A4434 Ost pch urine w/lock NC

A4638 Repl batt pulse gen sys NC

A4671 Disposable cycler set NC

A4672 Drainage ext line NC

A4673 Ext line w/easy lock NC

A4674 Chem/antisept solution NC

A4728 Dialysate solution NC





A6407 Packing strips $1.88

A6441 Pad band w/>=3”<5”/yd $0.67




A6445 Conform band s w/<3” $0.32

A6446 Conform band s w/>=3” $0.41

A6447 Conform band s w/>=5” $0.67

A6448 Lt compres band <3”/yd $1.16

A6449 Lt compres band >=3”<5”/

$1.75

A6450 Lt compres band >=5”/yd

NC

A6451 Mod compres band w/>=3”

NC

A6452 High compres band $4.72

A6453 Self-adher band w/<3” $0.61

A6454 Self-adher band w>=3” $0.70

A6455 Self-adher band >=5”/yd $0.70

A6456 Zinc paste band w/>=3” $1.14



A7046 Repl water chamber NC

A7520 Trach/laryn tube $45.01

A7521 Trach/laryn tube cuffed $45.01

A7522 Trach/laryn tube stainless

$45.01

A7523 Tracheostomy shower $6.77

A7524 Tracheostoma stent/stud NC

A7525 Tracheostomy mask $1.40

A7526 Tracheostomy tube $1.40

A9280 Alert device, noc NC

A9525 Low/iso-osmolar con-trast

NC

A9526 Ammonia N-13 NC

A9528 Dx I131 so iodide cap NC

A9529 Dx I131 so iodide sol NC

A9530 Th I131 so iodide sol NC

A9531 Dx I131 so iodide NC

A9532 I-125 serum albumin NC





A9999 DME supply or accessory

NC

C1814 Retinal tamp, silicone oil

NC

C1818 Integrated NC

C8918 MRA w/cont, pelvis NC

C8919 MRA w/o cont, pelvis NC

C8920 MRA w/o fol w/cont NC

C9123 Transcyte, per 247 sq cm

NC

C9202 Octafluoropropane NC

C9203 Perflexane lipid micro NC

C9208 Injection, agalsidase NC

C9209 Injection, laronidase NC

E0118 Crutch substitute NC

E0140 Walker w/trunk support 9/L-NCJ-$360.71

E0190 Positioning cushion NC

E0240 Bath/shower chair NC

E0247 Trans bench w/wo comm

NC

E0248 HDtrans bench w/wo open

NC

E0300 Enclosed ped crib hosp 9/L-NCJ-$2,838.62

E0301 HD hosp bed NC

E0302 Ex hd hosp bed >600 NC

E0303 Hosp bed hvy dty x 9-NCJ-MRL-$290.81

E0304 Hosp bed xtra hvy dty 9-NCJ-MRL-$290.81

E0470 RAD w/o backup non 9/L-NCJ-MR

E0471 RAD w/backup non inv 9/J-NCL$395.22

E0472 RAD w/backup invasive NC

E0561 Humidifier nonheated 9-NCJ-$107.00L-$10.69

E0562 Humidifier heated used 9-NCJ-$299.73L-28.72

E0637 Sit-stand w/seatlift NC





E0638 Standing frame sys 9/L-NCJ-$853.57

E0675 Pneumatic compression NC

E0955 Cushioned headrest 9-NCJ-$202.18L-$20.25

E0956 W/c leteral trunk/hip 9/J-NCL-$9.87

E0957 W/c medial thigh sup-port

9/L-NCJ-$137.93

E0960 W/c shoulder harness NC

E0981 Seat upholstery 9/L-NCJ-$35.29

E0982 Back upholstery 9/L-NCJ-$51.53

E0983 Add pwr joystick NC

E0984 Add pwr tiller NC

E0985 W/c seat lift mechanism NC

E0986 Man w/c push-rim pow NC

E1002 Pwr seat tilt 9/L-NCJ-$4,113.02

E1003 Pwr seat recline 9/L-NCJ-$4,391.30

E1004 Pwr seat recline mech 9/L-NCJ-$4,869.05

E1005 Pwr seat recline pwr NC

E1006 Pwr seat combo w/o NC

E1007 Pwr seat combo NC

E1008 Pwr seat combo pwr NC

E1009 Add mech leg elevation NC

E1010 Add pwr leg elevation NC

E1019 HD feature power seat 9-L-NC J-$447.26

E1021 Ex hd feature power seat NC

E1028 W/c manual swing away NC

E1029 W/c vent tray fixed NC

E1030 W/c vent tray gimbaled NC

E1391 Oxygen concentrator NC

E1634 Peritoneal dialysis clamp NC

E2120 Pulse gen sys tx endolymp

NC

E2201 Man w/c acc seat NC

E2202 Seat width 24-27 NC

E2203 Frame depth less than 22

NC



E2204 Frame depth 22 to 25 NC

E2300 Pwr seat elevation sys NC

E2301 Pwr standing NC

E2310 Electro connect btw NC

E2311 Electro connect btw 2 sys

NC

E2320 Hand chin control NC

E2321 Hand interface joystick NC

E2322 Mult mech switches NC

E2323 Special joystick handle NC

E2324 Chin cup interface NC

E2325 Sip and puff interface NC

E2326 Breath tube kit NC

E2327 Head control interface NC

E2328 Head/extremity control NC

E2329 Head control NC

E2330 Head control proximity NC

E2331 Attendant control NC

E2340 W/c wdth 20-23 in seat NC

E2341 W/c wdth 24-27 in seat NC

E2342 W/c dpth 20-21 in seat NC

E2343 W/c dpth 22-25 in seat NC

E2351 Electronic SGD interface

NC

E2360 22nf nonsealed leadacid NC

E2361 22nf sealed leadacid NC

E2362 GR24 nonsealed leadacid

NC

E2363 GR24 sealed leadacid 9/L-NCJ-$186.00

E2364 U1 nonsealed leadacid NC

E2365 U1 sealed leadacid battery

NC

E2366 Battery charger 9/L-NCJ-$263.62

E2367 Battery charger NC

E2399 Noc interface NC

E2402 Neg press wound therapy

9/J-NCL-$1,716.46

E2500 SGD digitized pre-rec <=8

9-NCJ-$391.06L-$34.71





E2502 SGD prerec msg >8 min 9-NCJ-$1,195.80L-$119.59


9-NCJ-$1,446.05L-$144.60


9-NCJ-$1,446.05L-$144.60

E2508 SGD spelling phys con-tact

9-NCJ-$3,421.71L-$342.18

E2510 SGD w/multi methods 9-NCJ-$6,475.12L-$647.51

E2511 SGD sftwre prgrm for 9-NCJ-$1,242.67L-$452.59

E2512 SGD accessory 9-NCJ-$578.10L-$57.81

E2599 SGD accessory noc 9-NCJ/L-MR

G0296 PET imge restag thyrod NC

G0297 Insert single chamber/cd NC

G0298 Insert dual chamber/cd NC

G0299 Inser/repos single icd NC

G0300 Insert reposit lead dual NC

G0302 Pre-op service LVRS NC

G0303 Pre-op service LVRS 10 NC

G0304 Pre-op service LVRS 1-9 NC

G0305 Post op service LVRS NC

G0306 CBC/diffwbc 5=$10.74I=NC

G0307 CBC without platelet 5=$8.95I=NC

G3001 Crisis interven svc NC

J0152 Adenosine injection NC

J0215 Alefacept NC

J0583 Bivalirudin NC

J0595 Butorphanol tartrate NC

J1335 Ertapenem injection NC

J1595 Injection glatiramer NC

J2001 Lidocaine injection NC

J2185 Meropenem NC

J2280 Inj, moxifloxacin NC



J2353 Octreotide injection NC

J2354 Octreotide inj, non NC

J2505 Injection, pegfilgrastim 1-$2,507.50

J2783 Rasburicase NC

J3411 Thiamine hcl 100mg NC

J3415 Pyridoxine hcl 100mg NC

J3465 Injection, voriconazole NC

J3486 Ziprasidone mesylate NC

J7303 Contraceptive vaginal NC

J7621 (Levo) albuterol/Ipra NC

J9098 Cytarabine liposome NC

J9178 Inj, epirubicin hcl, 2mg NC

J9263 Oxaliplatin NC

J9395 Injection, Fulvestrant NC

K0606 AED garment w/elec NC

K0607 Repl batt for AED NC

K0608 Repl garment for AED NC

K0609 Repl electrode for AED NC

K0618 TLSO 2 piece rigid shell NC

K0619 TLSO 3 piece rigid shell NC

K0620 Tubular elastic dressing NC

L0112 Cranial cervical orthosis NC

L0861 Halo repl liner/interface NC

L1831 Knee orth pos locking NC

L1907 AFO supramalleolar NC

L1951 AFO spiral prefabricated NC

L1971 AFO w/ankle joint NC

L3031 Foot lamin/prepreg NC

L3917 Prefab metacarpl fx NC

L5673 Socket insert w/lock $587.53

L5679 Socket insert w/o lock $489.59

L5681 Intl custm cong/latyp $1,066.68

L5683 Initial custom socket $1,066.68

L8511 Indwelling trach insert NC

L8512 Gel cap for trach voice NC

L8513 Trach pros cleaning NC

L8514 Repl trach puncture NC

L8631 MCP joint repl 2 pc NC

L8659 Interphalangeal joint NC

P9051 Blood, l/r, cmv-neg 0=$102.76

P9052 Platelets, hla-m, l/r 0=$51.44

P9053 Plt, pher, l/r cmv-neg 0=$56.44





P9054 Blood, l/r, froz/degly 0=$104.15

P9055 Plt, aph/pher, l/r, cmv 0=$51.44

P9056 Blood, l/r, irradiated 0=$45.00

P9057 RBC, frz/deg/wsh, l/r 0=$109.15

P9058 RBC, l/r, cmv-neg, irrad 0=$109.15

P9059 Plasma, frz between 8-24

0=$77.33

P9060 Fr frz plasma donor 0=$77.33

Q0137 Darbepoetin alfa, non-esrd

NC

Q0182 Nonmetabolic act d/e NC

Q4054 Darbepoetin alfa, esrd $4.24

Q4055 Epoetin alfa, esrd use $11.96

Q4075 Acyclovir, 5mg NC

Q4076 Dopamine hcl, 40mg NC

Q4077 Treprostinil, 1mg NC

S0107 Inj, omalizumab 25mg NC

S0115 Bortezomib 3.5mg NC

S0163 Risperdone 12.5mg NC

S0317 Diseasemgmt per diem NC

S2070 Cysto laser tx ureteral NC

S2085 Laparoscop gastric NC



S2135 Neurolysis interspace foot

NC

S2213 Implant gastric stim NC

S2225 Myringotomy laser-assist

NC

S2230 Implant semi-imp hear NC

S2235 Implant auditory brain NC

S2362 Kyphoplasty, first NC

S2363 Kyphoplasty, each addl NC

S3625 Maternal triple screen NC

S3840 DNA analysis RET NC

S3841 Gene test retinoblastoma

NC

S3842 Gene test Hippel-Lindau

NC

S3843 DNA analysis factor v NC

S3844 DNA analysis deafness NC

S3845 Gene test alpha NC

S3846 Gene test beta NC



S3847 Gene test Tay-Sachs NC

S3848 Gene test Gaucher NC

S3849 Gene test Niemann-Pick NC

S3850 Gene test sickle cell NC

S3851 Gene test canavan NC

S3852 DNA analysis APOE NC

S3853 Gene test myo musclr NC

S5550 Insulin rapid 5 u NC

S5551 Insulin most rapid 5 u NC

S5552 Insulin intermed 5 u NC

S5553 Insulin long acting 5 u NC

S5560 Insulin reuse pen 1.5 ML

NC

S5561 Insulin reuse pen 3 ML NC



S5570 Insulin dispos pen 1.5 ML

NC

S5571 Insulin dispos pen 3 ML NC

S8075 CAD of digital mammogr

NC

S8120 O2 contents gas cubic ft NC

S8121 O2 contents liquid lb NC

S8948 Low-level laser trmt 15 NC

S9335 HT hemodialysis diem NC

S9434 Mod Solid Food Supl NC

S9476 Vestibular rehab NC

T2010 PASARR Level I NC

T2011 PASARR Level II NC











T2022 Case management NC

T2023 Targeted casemgmt NC

T2024 Serv asmnt/care plan NC

T2025 Waiver service, nos NC





2004 HCPCS Deletions TableThe following codes have been discontinued by CMS.

T2026 Special childcare waiver NC

T2027 Spec childcare waiver 15 NC

T2028 Special cupply, NOS NC

T2029 Special med equip, NOS NC



T2032 Res care, NOS waiver NC

T2033 Res, NOS waiver NC

T2034 Crisis interven waiver NC

T2035 Utility services waiver NC

T2036 Camp overnite waiver NC

T2037 Camp day waiver NC

T2038 Comm trans waiver NC

T2039 Vehicle mod waiver/service

NC

T2040 Financialmgt waiver NC

T2041 Support broker waiver NC

T2042 Hospice routine home NC

T2043 Hospice continuous NC

T2044 Hospice respite care NC

T2045 Hospice general care NC

T2046 Hospice long term care NC

T2048 Bh ltc res r&b NC

T2101 Breast milk NC

T5001 Special position seat NC

T5999 Supply, nos NC

V2121 Lenticular lens, single $70.46

V2221 Lenticular lens, bifocal $71.90

V2321 Lenticular lens, trifocal $91.53

V2745 Tint, any color/solid NC

V2756 Eye glass case NC

V2761 Mirror coating NC

V2762 Polarization, any lens $48.34

V2782 Lens, 1.54-1.65p/1.60 $52.20

V2783 Lens, >=1.66p/>=1.80g $58.86

V2784 Lens polycarb or equal $38.28

V2786 Occupational multifocal NC

V2797 Vis item/svc in other NC



Procedure Code Short Description

00544 Anesth, chest lining removal

00869 Lid reconstr w/graft nec

36488 Insertion of catheter, vein




36493 Repositioning of cvc

36530 Insertion of infusion pump

36531 Revision of infusion pump

36532 Removal of infusion pump

36533 Insertion of access device

36534 Revision of access device

36535 Removal of access device

36536 Remove cva device obstruct

36537 Remove cva lumen obstruct

47134 Partial removal, donor liver

61862 Implant neurostimul, subcort

76085 Computer mammogram add-on

76490 Us for tissue ablation

89252 Assist oocyte fertilization

89256 Prepare cryopreserved embryo

89350 Sputum specimen collection

89355 Exam feces for starch

89360 Collect sweat for test

89365 Water load test

89399 Pathology lab procedure

90659 Flu vaccine, whole, im

99025 Initial surgical evaluation

99551 Home infuse, painmgmt, iv/sc

99552 Home infuse painmgmt, epid/ith

99553 Home infuse, tocolytic tx

99554 Home infuse, hormone/platelet

99555 Home infuse, chemotheraphy

99556 Home infuse, antibio/fung/vir

99557 Home infuse, anticoagulant

99558 Home infuse, immunotherapy

99559 Home infuse, periton dialysis

99560 Home infuse, entero nutrition

99561 Home infuse, hydration tx



99562 Home infuse, parent nutrition

99563 Home admin, pentamidine

99564 Home infuse, antihemophil agnt

99565 Home infuse, proteinase inhib

99566 Home infuse, IV therapy

99567 Home infuse, sympath agent

99568 Home infuse, misc drug, daily

99569 Home infuse, each addl tx

A4214 30 cc sterile water/saline

A4319 Sterile h2o irrigation solution

A4323 Saline irrigation solution

A4621 Tracheotomy mask or collar

A4622 Tracheostomy or larngectomy

A4631 Wheelchair battery

A4644 Contrast 100-199mgs iodine



A4712 Sterile water inj per 10 ML

A6421 Pad bandage >=3 <5in w/roll

A6422 Conf bandage ns >=3<5" w/roll

A6424 Conf bandage ns >=5" w/roll

A6426 Conf bandage s >=3<5" w/roll

A6428 Conf bandage s >=5" w/roll

A6430 Lt compres bdg >=3<5" w/roll

A6432 Lt compres bdg >=5" w/roll

A6434 Mo compres bdg >=3<5" w/roll

A6436 Hi compres bdg >=3<5" w/roll

A6438 Self-adher bdg >=3<5" w/roll

A6440 Zinc paste bdg >=3<5" w/roll

A7019 Saline solution dispenser

A7020 Sterile h2o or nss w/lgv neb

A9518 I-131 sodium iodide solution

C1015 Platelets, pheresis, leukocyte

C1020 Red blood cells, frozen

C1021 Red blood cells, leukocyte

C1022 Plasma, frozen within 24

C9116 Injection, ertapenem sodium,

C9119 Injection, pegfilgrastim,

C9120 Injection, fulvestrant, per 50mg

E0142 Walker rigid wheeled with se

E0145 Walker wheeled seat/crutch att

E0146 Folding walker wheels w/seat

E0165 Commode chair stationry det

E0943 Cervical pillow


E0975 Wheelchair reinforced seat u

E0976 Wheelchair reinforced back u

E0979 Wheelchair belt with velcro

E0991 Wheelchair upholstry seat

E0993 Wheelchair back upholstery

E1066 Wheelchair battery charger

E1069 Wheelchair deep cycle batter

E1091 Wheelchair youth

G0110 Nett pulm-rehab educ; ind

G0111 Nett pulm-rehab educ; group

G0112 Nett; nutrition guid, initial

G0113 Nett; nutrition guid, subseqnt

G0114 Nett; psychosocial consult

G0115 Nett; psychological testing

G0116 Nett; psychosocial counsel

G0167 Hyperbaric oz tx; no md reqrd

G0236 Digital film convert diag ma

G0262 Sm intestinal image capsule

G0272 Naso/oro gastric tube pl md

G0273 Pretx planning, non-hodgkins

G0274 Radiopharm tx, non-hodgkins

J0151 Adenosine injection

J1910 Kutapressin injection

J2000 Lidocaine injection

J2352 Octreotide acetate injection

J7508 Tacrolimus oral per 5mg

J9180 Epirubicin hcl injection

K0016 Detach adjust armrst cmplete

K0022 Reinforced back upholstery

K0025 Hook-on headrest extension

K0026 Back upholst lgtwt whlchr

K0027 Back upholst other whlchr

K0028 Manual fully reclining back

K0029 Reinforced seat upholstery

K0030 Solid plnr seat sngl dnsfoam

K0031 Safety belt/pelvic strap

K0032 Seat uphols lgtwt whlchr

K0033 Seat upholstery other whlchr

K0035 Heel loop with ankle strap

K0036 Toe loop each

K0048 Elevate legrest complete

K0049 Calf pad each

K0054 Seat wdth 10-12/15/17/20 wc

K0055 Seat dpth 15/17/18 ltwt wc

K0057 Seat wdth 19/20 hvy dty wc



K0058 Seat wdth 19/20 hvy dty wc

K0062 Handrim 8-10 vert/obliq proj

K0063 Hndrm 12-16 vert/obliq proj

K0079 Wheel lock extension pair

K0080 Anti-rollback device pair

K0082 22 nf deep cycl acid battery

K0083 22 nf gel cell battery each

K0084 Grp 24 deep cycl acid battery

K0085 Group 24 gel cell battery

K0086 U-1 lead acid battery each

K0087 U-1 gel cell battery each

K0088 Battery chrgr acid/gel cell

K0089 Battery charger dual mode

K0100 Battery charger dual mode

K0103 Transfer board <25"

K0107 Wheelchair tray

K0112 Trunk vest supprt innr frame

K0113 Trunk vest suprt w/o inr frm

K0268 Humidifier nonheated w/pap

K0460 Wc power add-on joystick

K0461 Wc power add-on tiller cntrl

K0531 Heated humidifier used w/pap

K0532 Noninvasive assist w/o backup

K0533 Noninvasive assist w/backup

K0534 Invasive assist w/backup

K0538 Neg pressure wnd thrpy pump

K0539 Neg pres wnd thrpy dsg set

K0540 Neg pres wnd thrp canister

K0541 Speech generating device

K0542 Sgd prerecorded msg >8 min

K0543 Sgd msg formed by spelling

K0544 Sgd w/multi methods msg/accs

K0545 Sgd sftwre prgrm for pc/pda

K0546 Sgd accessory

K0547 Accessory speech generating device

K0549 Hospital bed, heavy duty, extra wide

K0550 Hospital bed, heavy duty, extra wide

K0556 Addition to lower extremity

K0557 Addition to lower extremity

K0558 Add to lower extremity, below knee

K0559 Add to lower extremity, below


K0560 Metacarpal phalangeal joint replace

K0581 Ostomy pouch, closed, w/bar-rier

K0582 Ostomy pouch, closed

K0583 Ostomy pouch, closed

K0584 Ostomy pouch, closed, each



K0587 Ostomy pouch, drainable, each




K0591 Ostomy pouch, urinary



K0594 Ostomy pouch, urinary, each


K0596 Ostomy pouch, urinary, each


L1885 Knee upright w/resistance

L2102 Afo tibial fx cast plstr mol

L2104 Afo tib fx cast synthetic mo

L2122 Kafo fem fx cast plaster mol

L2124 Kafo fem fx cast synthetic mol

Q0086 Physical therapy evaluation

Q2010 Glatiramer acetate, per dose

Q9920 Epoetin with hct <= 20

Q9921 Epoetin with hct = 21



















2004 HCPCS Short Definition Changes TableThe short definition of the following codes have changed. The new descriptions are listed below.



Q9940 Epoetin with hct >= 40

S0009 Injection, butorphanol tartrate, 1mg

S0124 Inj urofollitropin 75 iu

S0130 Inj c gonadotropin 5000 iu

S0135 Injection, pegfilgrastim, 6mg

S8181 Trach tube holder

S8433 Skin support/breast prosth

S8945 Pt phonophoresis 30 mins

S9546 Home inf blood prod nurs ser

S9802 Specialty drug admin/nsg srv

S9803 Each additional hour

S9806 RN services, infusion of IV therap

V2116 Nonaspheric lens bifocal

V2117 Aspheric lens bifocal

V2216 Lens lenticular nonaspheric

V2217 Lens lenticular aspheric bif

V2316 Lens lenticular nonaspheric

V2317 Lens lenticular aspheric tri

V2740 Rose tint plastic


00220 Anesth, intrcrn nerve

00320 Anesth, neck organ, 1 & over

00528 Anesth, chest partition view

00942 Anesth, surg on vag/urethral

01214 Anesth, hip arthroplasty

01402 Anesth, knee arthroplasty

01464 Anesth, ankle/ft arthroscopy

01622 Anes dx shoulder arthroscopy

01732 Anesth, dx elbow arthroscopy

01916 Anesth, dx arteriography

01995 Regional anesthesia limb

01996 Hosp manage cont drug admin

16036 Escharotomy; add’l incision

20552 Inj trigger point, 1/2 muscle

44799 Unlisted procedure intestine

44799 Unlisted procedure intestine


45381 Colonoscopy, submucous inj

45386 Colonoscopy dilate stricture

50548 Laparo remove w/ureter

63043 Laminotomy, add’l cervical

63044 Laminotomy, add’l lumbar

76362 Ct guide for tissue ablation

76872 Us, transrectal

84155 Assay of protein, serum

84160 Assay of protein, any source

84165 Electrophoreisis of proteins

87075 Cultr bacteria, except blood

87272 Cryptosporidium ag, if

87328 Cryptosporidium ag, eia

89055 Leukocyte assessment, fecal

89250 Cultr oocyte/embryo <4 days

89251 Cultr oocyte/embryo <4 days

89258 Cryopreservation; embryo(s)

A4538 Reusable diaper from dpr svc

A4632 Infuse pump replcemnt battery

A9517 Th i131 so iodide cap millic

C1716 Brachytx source, gold 198

C1718 Brachytx source, iodine 125

C1719 Brachytx sour, non-hdr ir-192

C1720 Brachytx sour, palladium 103

C1775 Fdg, per dose (4-40 mci/ML)

E0952 Toe loop/holder, each

E1226 W/ch access anti-rollback

J0880 Darbepoetin alfa injection

L0480 Tlso rigid plastic custom fa

L4386 Non-pneumatic walking splint

L5848 Knee-shin sys hydraul stance

L6620 Flexion/extension wrist unit

L8658 Interphalangeal joint spacer

P9017 Plasma 1 donor frz w/in 8 hr

S9123 Nursing care in home rn

V2103 Spherocylindr 4.00d/12-2.00d

V2200 Lens spher bifoc plano 4.00d

V2202 Lens sphere bifocal 7.12-20.

V2203 Lens sphcyl bifocal 4.00d/.1

V2204 Lens sphcy bifocal 4.00d/2.1

V2205 Lens sphcy bifocal 4.00d/4.2

V2206 Lens sphcy bifocal 4.00d/ove

V2207 Lens sphcy bifocal 4.25-7d/.

V2208 Lens sphcy bifocal 4.25-7/2.

V2209 Lens sphcy bifocal 4.25-7/4.



2004 HCPCS Long Definition Changes IndexThe codes below have been identified as having long description changes. However, due to AMA and ADA copyright requirements, these long description changes cannot be published.

V2210 Lens sphcy bifocal 4.25-7/ov

V2211 Lens sphcy bifo 7.25-12/.25-

V2212 Lens sphcyl bifo 7.25-12/2.2

V2213 Lens sphcyl bifo 7.25-12/4.2

V2214 Lens sphcyl bifocal over 12.

V2301 Lens sphere trifocal 4.12-7.

V2302 Lens sphere trifocal 7.12-20

V2303 Lens sphcy trifocal 4.0/.12-

V2304 Lens sphcy trifocal 4.0/2.25

V2305 Lens sphcy trifocal 4.0/4.25

V2306 Lens sphcyl trifocal 4.00/>6

V2307 Lens sphcy trifocal 4.25-7/.

V2308 Lens sphc trifocal 4.25-7/2.

V2309 Lens sphc trifocal 4.25-7/4.

V2310 Lens sphc trifocal 4.25-7/>6

V2311 Lens sphc trifo 7.25-12/.25-

V2312 Lens sphc trifo 7.25-12/2.25

V2313 Lens sphc trifo 7.25-12/4.25

V2314 Lens sphcyl trifocal over 12

00528 11100 20240 20550 20551

26356 26357 31622 31625 31628

31629 33310 36400 36410 38208

38209 43242 43259 43752 58340

61538 61539 61543 63173 64680

67916 67917 67923 67924 70250

70260 72270 75860 75953 76362

76394 76831 76872 76873 78800

78802 79100 79400 83716 84155

84160 87040 87045 87046 87070

87272 87328 88312 88342 88358

89055 89250 89251 89258 90657

90658 90693 90703 90704 90705

90706 90707 90708 90718 90727

90733 95967 97537 99024 99050

99293 99295 99296 99512 A4207

A4326 A4538 A4623 A6025 C1716

C1718 C1719 C1720 E0141 E0143

E0144 E0147 E0149 E0950 E0951

Procedure Code Short Description E0952 E0958 E0959 E0961 E0966

E0967 E0972 E0973 E0974 E0978

E0990 E0992 E0995 E1225 E1226

E1390 G0247 G0249 K0455 L0480

L1950 L2405 L4350 L4360 L4386

L5646 L5648 L5848 L5984 L6620

L6675 L6676 L8658 M0100 M0301

P9017 S9123


Notes:


Notes:


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Documents

Texas Medicaid - Welcome to TMHP · Texas Medicaid Bulletin, No. 180 2004 HCPCS Special Bulletin4 Effective for dates of service on or after July 1, 2004, the following procedure