2015 PA Codification Document
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- Katherine Holmes
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1 NOTE: To search this document, use [Ctrl + F keys]; enter text or number in search navigation pane at left. TABLE OF CONTENTS Specialty/Service Page Codification Document Change/Update Tracking 2 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services; 3 Cosmetic, Plastic & Reconstructive Procedures (in ANY setting) 3 Dental General Anesthesia 4 Dialysis 4 Durable Medical Equipment (DME) 5 Experimental / Investigational 6 Genetic Counseling & Testing 7 Habilitative Therapy 7 Home Health Care 8 Hospice & Palliative Care 8 Imaging 9 In-Patient (IP) Admissions 10 Neuropsychological and Psychological Testing 10 Non-Par Providers/Facilities 10 Occupational Therapy 10 Office-Based Procedures (Do Not Require Auth) 11 Out-Patient (OP) Hospital/Ambulatory Surgery Center (ASC) Procedures 12 Pain Management 16 Physical Therapy 16 Pregnancy & Delivery 16 Prosthetics & Orthotics 17 Radiation Therapy & Radiosurgery 18 Rehabilitation OP Services 19 Sleep Studies 19 Speech Therapy 19 Specialty Pharmacy Drugs (Injectable) 20 Transplant Services 21 Transportation (Non-Emergent Air/Ground) 21 Unlisted/Miscellaneous & Temporary (T) Codes 22 Wound Therapy (including Wound Vacs & Hyperbaric Wound Therapy) 24 Medicare Exceptions CPT Codes Requiring Authorization.docx Page 1
2 Codification Document Change/Update Tracking: Received Date Effective Date Specialty/Service Change/Update Description Exceptions 10/15/ /01/2015 All Reformatted original excel codification document into word. None CPT Codes Requiring Authorization.docx Page 2
3 Behavioral Health, Mental Health, Alcohol & Chemical Dependency Services Inpatient, Residential Treatment, Partial Hospitalization, Day Treatment Electroconvulsive Therapy (ECT) Applied Behavioral Analysis (ABA) for treatment of Autism Spectrum Disorder (ASD) MEDICAID ONLY MKT PLACE ONLY H0012 H0031 H0012 H H0016 H0032 H0016 H H0017 H0046 H0017 H H H H H H2013 Q3014 H2013 Q3014 H2015 S5111 H2015 S5111 H2016 H2014 H2016 H2014 H2017 H2019 H2017 H2019 H2018 H2020 H2018 H2020 Cosmetic, Plastic & Reconstructive Procedures PA required in any setting J CPT Codes Requiring Authorization.docx Page 3
4 Dental General Anesthesia MEDICAID ONLY MKT PLACE ONLY N/A Dialysis Annual (One Time) Notification Only G J J Q CPT Codes Requiring Authorization.docx Page 4
5 Durable Medical Equipment (DME) MEDICAID ONLY A4639 E0328 E0657 E1004 E2227 E2378 K0010 K0839 K0900 E0481 V5244 A7025 E0329 E0667 E1005 E2228 E2397 K0011 K0840 Q0479 S1034 V5245 A8000 E0371 E0668 E1006 E2291 E2500 K0012 K0841 Q0480 S1035 V5246 A8001 E0372 E0670 E1007 E2292 E2502 K0014 K0842 Q0481 S1036 V5247 A8002 E0373 E0671 E1008 E2293 E2504 K0108 K0843 Q0482 S1037 V5248 A8003 E0445 E0672 E1010 E2294 E2506 K0455 K0848 Q0483 V5030 V5249 A8004 E0450 E0673 E1014 E2295 E2508 K0606 K0849 Q0484 V5050 V5250 E0184 E0460 E0675 E1020 E2310 E2510 K0609 K0850 Q0485 V5060 V5251 E0186 E0461 E0691 E1029 E2311 E2511 K0730 K0851 Q0486 V5100 V5252 E0193 E0462 E0692 E1030 E2312 E2605 K0800 K0852 Q0487 V5120 V5253 E0194 E0463 E0693 E1035 E2313 E2606 K0801 K0853 Q0489 V5130 V5254 E0196 E0464 E0694 E1036 E2321 E2607 K0802 K0854 Q0490 V5140 V5255 E0197 E0470 E0731 E1161 E2322 E2608 K0806 K0855 Q0491 V5170 V5256 E0198 E0471 E0740 E1225 E2325 E2609 K0807 K0856 Q0493 V5180 V5257 E0217 E0472 E0747 E1226 E2326 E2611 K0808 K0857 Q0495 V5210 V5258 E0225 E0480 E0748 E1227 E2327 E2612 K0813 K0858 Q0496 V5220 V5259 E0239 E0482 E0749 E1230 E2328 E2613 K0814 K0859 Q0497 V5242 V5260 E0255 E0483 E0760 E1232 E2329 E2614 K0815 K0860 Q0498 V5243 V5261 E0256 E0565 E0762 E1233 E2330 E2615 K0816 K0861 Q0501 E0260 E0601 E0764 E1234 E2340 E2616 K0820 K0862 Q0502 E0261 E0610 E0782 E1235 E2341 E2617 K0821 K0863 Q0503 E0265 E0615 E0783 E1236 E2342 E2620 K0822 K0864 Q0504 E0266 E0617 E0784 E1237 E2343 E2621 K0823 K0868 Q0506 E0277 E0618 E0785 E1238 E2351 E2622 K0824 K0869 S8540 E0292 E0619 E0786 E1296 E2361 E2623 K0825 K0870 S8423 E0293 E0620 E0849 E1298 E2366 E2624 K0826 K0871 S8425 E0294 E0627 E0855 E1310 E2367 E2625 K0827 K0877 S8426 E0295 E0628 E0947 E1399 E2368 E2626 K0828 K0878 V2530 E0296 E0629 E0948 E1700 E2369 E2627 K0829 K0879 V2531 E0297 E0636 E0983 E2100 E2370 E2628 K0830 K0880 E0300 E0640 E0984 E2120 E2373 E2629 K0831 K0884 E0301 E0650 E0986 E2201 E2374 E2630 K0835 K0885 E0302 E0651 E0988 E2202 E2375 E2631 K0836 K0886 E0303 E0652 E1002 E2203 E2376 K0008 K0837 K0890 E0304 E0656 E1003 E2204 E2377 K0009 K0838 K CPT Codes Requiring Authorization.docx Page 5
6 Experimental/Investigational MEDICAID ONLY 0019T 0181T 0233T 0290T 0334T T 0332T 0042T 0182T 0234T 0291T 0335T T 0333T 0051T 0184T 0235T 0292T 0336T T 0334T 0052T 0188T 0236T 0293T 0337T T 0189T 0237T 0294T 0338T T 0190T 0238T 0295T 0339T T 0191T 0239T 0296T 0340T T 0195T 0240T 0297T 0342T T 0196T 0241T 0298T 0343T T 0197T 0243T 0299T 0344T T 0198T 0244T 0300T 0345T T 0199T 0245T 0301T 0347T T 0200T 0246T 0302T 0348T T 0201T 0247T 0303T 0349T T 0202T 0248T 0304T 0350T T 0205T 0249T 0305T 0351T T 0206T 0253T 0306T 0352T T 0207T 0254T 0307T 0353T T 0208T 0255T 0308T 0354T T 0209T 0262T 0309T 0355T T 0210T 0263T 0310T 0356T T 0211T 0264T 0311T 0357T T 0212T 0265T 0312T 0358T T 0213T 0266T 0313T 0359T T 0214T 0267T 0314T 0360T T 0215T 0268T 0315T 0361T T 0216T 0269T 0316T 0362T T 0217T 0270T 0317T 0363T T 0218T 0271T 0319T 0364T T 0219T 0272T 0320T 0365T J T 0220T 0273T 0321T 0366T J T 0221T 0274T 0322T 0367T L T 0222T 0275T 0323T 0368T L T 0223T 0278T 0324T 0369T L T 0224T 0281T 0325T 0370T L T 0225T 0282T 0326T 0371T L T 0226T 0283T 0327T 0372T L T 0227T 0284T 0328T 0373T L T 0228T 0285T 0329T 0374T L T 0229T 0286T 0330T L T 0230T 0287T 0331T L T 0231T 0288T 0332T L T 0232T 0289T 0333T 2015 CPT Codes Requiring Authorization.docx Page 6
7 Genetic Counseling & Testing MEDICAID ONLY M S M S M S M S S3800 S S3840 S S S S S S * * Including Oncotype DX) Habilitative Therapy MEDICARE / MEDICAID (Healthy Michigan benefit only) & MKT PLACE MEDICAID (Healthy Michigan benefit) ONLY MKT PLACE ONLY S9128 S9152 S9128 S S9129 S G G G CPT Codes Requiring Authorization.docx Page 7
8 Home Health Care/Home Infusion MEDICAID ONLY MEDICARE ONLY MKT PLACE ONLY G0151 G0155 G0159 G0162 S X 043X S G0152 G0156 G0160 G X 044X G0153 G0157 G0161 G X 055X G0154 G X 027X 057X 029X 060X 042X 062X Hospice & Palliative Care Notification Only MEDICAID ONLY MKT PLACE ONLY 081X S0271 T2044 S0271 T X T2042 T2045 T2042 T T2043 T2046 T2043 T CPT Codes Requiring Authorization.docx Page 8
9 Imaging, Advanced & Specialty Imaging MEDICARE ONLY C S8042 C C C C C C C C C C C C C C C C C C C C C C C G CPT Codes Requiring Authorization.docx Page 9
10 In-Patient Admissions Note: All LOBs require Authorization Neuropsychological & Psychological Testing MEDICARE / MEDICAID & MKT PLACE Non-Par Providers/Facilities MEDICARE / MEDICAID Emergency Department services Professional fees associated with ER visit, approved Ambulatory Surgery Center (ASC) or inpatient stay Women s Health, Family Planning and Obstetrical Services Federally Qualified Health Center (FQHC) / Rural Health Center (RHC) / Tribal Health Center (THC) Child and Adolescent Health Center Services Local Health Department (LHD) services Other services based on state requirements MKT PLACE Emergency Department services Professional fees associated with ER visit, approved Ambulatory Surgery Center (ASC) or inpatient stay Occupational Therapy MEDICAID ONLY MKT PLACE ONLY S9129 S G G G CPT Codes Requiring Authorization.docx Page 10
11 Office Based Procedures DO NOT REQUIRE AUTHORIZATION 2015 CPT Codes Requiring Authorization.docx Page 11
12 Out-Patient (OP) Hospital/Ambulatory Surgery Center F F F F F F F F F F F F F F F CPT Codes Requiring Authorization.docx Page 12
13 CPT Codes Requiring Authorization.docx Page 13
14 CPT Codes Requiring Authorization.docx Page 14
15 CPT Codes Requiring Authorization.docx Page 15
16 Pain Management Procedures Except trigger point injections [Acupuncture is not a Medicare covered benefit] MEDICAID ONLY MKT PLACE ONLY G Physical Therapy After initial evaluation plus six (6) visits for outpatient and home settings MEDICAID ONLY S G G G0329 Pregnancy and Delivery Notification Only (All inpatient admissions require authorization) CPT Codes Requiring Authorization.docx Page 16
17 Prosthetics & Orthotics E0457 L0700 L2036 L3001 L4100 L5630 L5724 L5990 L6697 L7362 L8692 E1800 L0710 L2037 L3002 L4130 L5631 L5726 L6000 L6698 L7364 E1801 L1000 L2038 L3003 L4205 L5632 L5728 L6010 L6703 L7366 E1802 L1005 L2050 L3010 L4210 L5634 L5780 L6020 L6704 L7367 E1805 L1110 L2060 L3020 L4360 L5636 L5781 L6025 L6706 L7368 E1806 L1200 L2080 L3030 L4396 L5637 L5782 L6050 L6707 L7400 E1818 L1210 L2090 L3031 L4631 L5638 L5785 L6055 L6708 L7401 E1825 L1220 L2106 L3330 L5000 L5639 L5790 L6100 L6709 L7402 E1840 L1230 L2108 L3671 L5010 L5640 L5795 L6110 L6711 L7403 E1841 L1300 L2126 L3674 L5020 L5642 L5810 L6120 L6712 L7404 L0112 L1310 L2128 L3702 L5050 L5643 L5811 L6130 L6713 L7505 L0113 L1640 L2132 L3720 L5060 L5644 L5812 L6200 L6714 L7900 L0170 L1650 L2134 L3730 L5100 L5645 L5814 L6250 L6715 L8040 L0174 L1652 L2136 L3740 L5105 L5646 L5816 L6350 L6721 L8041 L0180 L1680 L2232 L3760 L5150 L5647 L5818 L6360 L6722 L8042 L0190 L1685 L2250 L3763 L5160 L5648 L5822 L6370 L6805 L8043 L0200 L1686 L2280 L3764 L5200 L5649 L5824 L6400 L6880 L8044 L0454 L1690 L2300 L3765 L5210 L5650 L5826 L6580 L6881 L8045 L0455 L1700 L2310 L3766 L5220 L5651 L5828 L6582 L6882 L8046 L0456 L1710 L2320 L3806 L5230 L5652 L5830 L6584 L6883 L8047 L0457 L1720 L2330 L3807 L5250 L5653 L5840 L6586 L6884 L8400 L0458 L1730 L2335 L3808 L5270 L5654 L5845 L6588 L6885 L8410 L0460 L1755 L2340 L3900 L5280 L5655 L5848 L6590 L6895 L8420 L0462 L1832 L2350 L3901 L5301 L5656 L5855 L6611 L6900 L8430 L0464 L1834 L2370 L3904 L5312 L5658 L5856 L6620 L6905 L8470 L0467 L1840 L2380 L3905 L5321 L5661 L5857 L6621 L6910 L8480 L0466 L1843 L2385 L3906 L5331 L5665 L5858 L6623 L6915 L8500 L0468 L1844 L2387 L3913 L5341 L5666 L5859 L6624 L6920 L8510 L0469 L1845 L2390 L3915 L5500 L5670 L5910 L6625 L6925 L8603 L0470 L1846 L2395 L3919 L5505 L5671 L5920 L6628 L6930 L8604 L0472 L1847 L2492 L3921 L5510 L5672 L5930 L6630 L6935 L8605 L0480 L1850 L2500 L3933 L5520 L5673 L5940 L6637 L6940 L8606 L0482 L1860 L2510 L3935 L5530 L5676 L5950 L6638 L6945 L8614 L0484 L1900 l2520 L3960 L5535 L5677 L5960 L6640 L6950 L8615 L0486 L1904 L2525 L3961 L5540 L5679 L5961 L6642 L6955 L8619 L0488 L1907 L2526 L3962 L5560 L5680 L5962 L6645 L6960 L8627 L0490 L1910 L2530 L3967 L5570 L5681 L5964 L6646 L6965 L8628 L0491 L1920 L2540 L3971 L5580 L5682 L5968 L6647 L6970 L8681 L0492 L1930 L2550 L3973 L5585 L5683 L5970 L6648 L6975 L8689 L0622 L1932 L2570 L3975 L5590 L5688 L5971 L6650 L7007 L8690 L0627 L1940 L2580 L3976 L5595 L5695 L5972 L6677 L7008 L8691 L0631 L1945 L2600 L3977 L5600 L5700 L5973 L6680 L7009 L8693 L0633 L1950 L2610 L3978 L5610 L5701 L5974 L6682 L7040 S1040 L0635 L1951 L2620 L4000 L5611 L5703 L5975 L6684 L7045 V2623 L0636 L1960 L2622 L4010 L5613 L5704 L5976 L6686 L7170 V2625 L0637 L1970 L2624 L4020 L5614 L5705 L5978 L6687 L7180 MEDICAID ONLY 2015 CPT Codes Requiring Authorization.docx Page 17
18 L0638 L1971 L2627 L4030 L5616 L5706 L5979 L6688 L7181 L0639 L1980 L2628 L4040 L5617 L5707 L5980 L6689 L7185 L0640 L1990 L2630 L4045 L5618 L5710 L5981 L6690 L7186 L0641 L2000 L2640 L4050 L5620 L5711 L5982 L6691 L7190 L0642 L2005 L2750 L4055 L5622 L5712 L5984 L6692 L7191 L0643 L2010 L2755 L4060 L5624 L5714 L5985 L6693 L7260 L0649 L2020 L2768 L4070 L5626 L5716 L5986 L6694 L7261 L0650 L2030 L2800 L4080 L5628 L5718 L5987 L6695 L7360 L0651 L2034 L3000 L4090 L5629 L5722 L5988 L6696 L7360 MEDICAID ONLY Radiation Therapy & Radio Surgery Intraoperative Radiation Therapy (IORT) Intensity Modulated Radiation Therapy (IMRT) Proton Beam and Neutron Beam Radiotherapy Intra-Hepatic Microspheres (e.g., TheraSphere, MDS Nordion Inc., SIR-Spheres, Sirtex Medical Inc.) Drug-Eluting Beads Trans-Arterial Chemoembolization Stereotactic radiosurgery with a Cyber knife, Gamma Knife, or Linear Accelerator (LINAC) T S CPT Codes Requiring Authorization.docx Page 18
19 Rehabilitation OP Services Cardiac and Pulmonary Comprehensive Outpatient Rehab Facility (CORF services for Medicare only [Bill type 75X]) G0422 G G0424 Sleep Studies G G G0400 Speech Therapy After initial evaluation plus six (6) visits for outpatient and home settings (ST services rendered in a home setting is a Medicare benefit only). MEDICAID ONLY MKT PLACE ONLY S9128 S9152 S9128 S CPT Codes Requiring Authorization.docx Page 19
20 Specialty Pharmacy Drugs (Injectable): J0881 J1826 J3488 J7506 J J0885 J1830 J3489 J7507 J9354 C9022 J0890 J1930 J3490 J7508 J9371 C9025 J0895 J19306 J3590 J7510 J9400 C9026 J0897 J1931 J7178 J7513 J9600 C9132 J1290 J1950 J7180 J7515 Q0515 C9133 J1300 J2170 J7183 J7516 Q2028 C9134 J1324 J2278 J7185 J7517 Q2043 C9135 J1325 J2315 J7186 J7525 Q2050 C9399 J1438 J2323 J7187 J7527 Q3027 C9441 J1442 J2353 J7189 J7639 Q3028 C9497 J1446 J2354 J7190 J7682 Q4074 J0129 J1458 J2355 J7191 J7686 Q4101 J0135 J1459 J2357 J7192 J8499 Q4139 J0151 J1460 J2426 J7193 J8530 Q4145 J0178 J1556 J2440 J7194 J8562 Q4149 J0180 J1557 J2503 J7195 J8999 Q9970 J0207 J1559 J2505 J7196 J9019 Q9973 J0215 J1560 J2507 J7197 J9042 S0145 J0220 J1561 J2597 J7198 J9047 S0148 J0221 J1562 J2778 J7199 J9202 J0256 J1566 J2793 J7301 J9212 J0257 J1568 J2820 J7302 J9213 J0401 J1569 J2940 J7309 J9214 J0480 J1571 J2941 J7310 J9216 J0485 J1572 J3030 J7311 J9217 J0490 J1573 J3060 J7312 J9218 J0585 J1595 J3110 J7316 J9219 J0586 J1599 J3140 J7321 J9225 J0587 J1602 J3150 J7323 J9226 J0588 J1645 J3240 J7324 J9245 J0597 J1650 J3262 J7325 J9262 J0638 J1652 J3285 J7326 J9293 J0717 J1675 J3315 J7330 J9302 J0740 J1743 J3357 J7500 J9306 J0775 J1744 J3385 J7502 J9307 J0800 J1745 J3396 J7504 J9310 J0850 J1786 J3487 J7505 J CPT Codes Requiring Authorization.docx Page 20
21 Transplant Services: Corneal Transplants do not require authorization MEDICAID ONLY MKT PLACE ONLY S S S2053 S2140 S2053 S S2054 S2142 S2054 S S2055 S2150 S2055 S S2060 S2152 S2060 S S2061 S Transportation Services PA required for non-emergent ambulance (air or ground) MEDICAID ONLY MKT PLACE ONLY A0426 A0428 A0430 A0431 S9960 S9961 S9960 S CPT Codes Requiring Authorization.docx Page 21
22 Unlisted/Miscellaneous/ T Codes: Molina requires standard codes when requesting authorization. Should an unlisted or miscellaneous code be used, medical necessity documentation and rationale must be prior authorized. MEDICAID MKT PLACE ONLY ONLY 0019T 0181T 0233T 0290T 0334T D0502 D6999 D0502 D T 0182T 0234T 0291T 0335T D0999 D7999 D0999 D T 0184T 0235T 0292T 0336T D2999 D8999 D2999 D T 0188T 0236T 0293T 0337T D3999 D9630 D3999 D T 0189T 0237T 0294T 0338T D4999 D9999 D4999 D T 0190T 0238T 0295T 0339T D5899 J8499 D5899 J T 0191T 0239T 0296T 0340T D5999 T5999 D5999 T T 0195T 0240T 0297T 0342T D6199 D T 0196T 0241T 0298T 0343T 0071T 0197T 0243T 0299T 0344T 0072T 0198T 0244T 0300T 0345T 0073T 0199T 0245T 0301T 0347T 0075T 0200T 0246T 0302T 0348T 0076T 0201T 0247T 0303T 0349T 0085T 0202T 0248T 0304T 0350T 0092T 0205T 0249T 0305T 0351T 0095T 0206T 0253T 0306T 0352T 0098T 0207T 0254T 0307T 0353T 0099T 0208T 0255T 0308T 0354T 0100T 0209T 0262T 0309T 0355T 0101T 0210T 0263T 0310T 0356T 0102T 0211T 0264T 0311T 0357T 0103T 0212T 0265T 0312T 0358T 0106T 0213T 0266T 0313T 0359T 0107T 0214T 0267T 0314T 0360T 0108T 0215T 0268T 0315T 0361T 0109T 0216T 0269T 0316T 0362T 0110T 0217T 0270T 0317T 0363T 0111T 0218T 0271T 0319T 0364T 0123T 0219T 0272T 0320T 0365T 0126T 0220T 0273T 0321T 0366T 0159T 0221T 0274T 0322T 0367T 0163T 0222T 0275T 0323T 0368T 0164T 0223T 0278T 0324T 0369T 0165T 0224T 0281T 0325T 0370T 0169T 0225T 0282T 0326T 0371T 0171T 0226T 0283T 0327T 0372T 0172T 0227T 0284T 0328T 0373T 0174T 0228T 0285T 0329T 0374T 0175T 0229T 0286T 0330T V CPT Codes Requiring Authorization.docx Page 22
23 0178T 0230T 0287T 0331T V T 0231T 0288T 0332T V T 0232T 0289T 0333T V A A A A B E E E E J J J J J K K L L L L L L L L L L Q Q Q MEDICAID ONLY MKT PLACE ONLY 2015 CPT Codes Requiring Authorization.docx Page 23
24 Wound Therapy, including Wound Vacs & Hyperbaric Wound Therapy G E2402 G G0456 Medicare Exceptions Non Covered Codes MEDICARE ONLY 0006M Q2052 S1037 S3841 S M S0144 S2066 S3853 S L5420 S1034 S2067 S3855 S L5430 S1035 S2068 S3861 S L5790 S1036 S3800 S CPT Codes Requiring Authorization.docx Page 24
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