Revenue Code Requirements (Medicaid ... - State of Michigan

C = Covered NC = NonCovered NA = Not Applicable A = Activation Pkg = Packaged

Units/Required (covered svcs) Y = Yes N = No HCPCS (or Rate for IP) Req Y = Yes N = No V = Valid, Not Required

REVENUE CODE TABLE

-

-

NA NA NA

-

NA NA

-

-

NC NC

-

-

NA NA

-

-

NA NA

-

-

NA NA

HCPCS REQ

NA NA NA

UNITS REQ

-

COV SVC

-

HCPCS REQ

NA NA NA

UNITS REQ

-

PDN

COV SVC

-

HCPCS REQ

NA NA C

UNITS REQ

-

HOME HEALTH Y

Y

COV SVC

-

COV SVC

HCPCS REQ

NA NA NA

HOSPICE

UNITS REQ

Y

COV SVC

-

UNITS REQ

OPPS -

INPATIENT

HCPCS REQ

RATE/HCPCS REQ

NA

UNITS REQ

COV SVC

Reserved All-Inclusive Rate ALL INCL R&B/ANC ALL INCL R&B Reserved

HCPCS REQ

002X 0020 0021 0022 0023 0024 0025-9 003X to 009X 010X 0100 0101 0102-9

TOTAL CHARGE Reserved for Internal Payer Use Health Insurance-Prospective Payment System (HIPPS) Reserved Reserved SNF PPS (RUG) HH PPS (HRG) REHAB PPS (CMG) Reserved

UNITS REQ

0001 001X

STANDARD ABBREVIATION

COV SVC

Revenue Code

Special Note

The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy. Table changes will be date specific and identified by revision date. Specific changes are noted in red.

SNF- NRSG FAC Y

NA

-

NA NA NA

-

-

NA NA NA

-

-

-

-

NA NA

-

-

NA NA

-

-

Y

CLINICS -

011X 0110 0111 0112 0113 0114 0115 0116 0117 0118 0119

Room & Board (R&B) Private(One Bed) ROOM-BOARD/PVT MED-SUR-GY/PVT OB/PVT PEDS/PVT PSYCH/PVT HOSPICE/PVT DETOX/PVT ONCOLOGY/PVT REHAB/PVT Other */PVT

NA NA NA NA NA NA NA NA NA NA

-

-

C C C C C NA C C C NC

Y Y Y Y Y Y Y Y -

Y Y Y Y Y Y Y Y -


-

-


-

-


-

-

C NA NA NA NA NA NA NA NA C

Y -

N -


-

-

012X 0120 0121 0122 0123 0124 0125 0126

Room & Board Semi Private(Two beds) ROOM-BOARD/SEMI-PVT MED-SUR-GY/SEMI-PVT OB/SEMI-PVT PEDS/SEMI-PVT PSYCH/SEMI-PVT H0SPICE/SEMI-PVT DETOX/SEMI-PVT

NA NA NA NA NA NA NA

-

-

C C C C C NA C

Y Y Y Y Y Y

Y Y Y Y Y Y

C NA NA NA NA NA NA

Y -

N -


-

-


-

-

C NA NA NA NA NA NA

Y -

N -


-

-

Rev. 2/1/18

Page 1 of 18

Special Notes T5 = Title V * = FIDS Beds



REVENUE CODE TABLE

Rev. 2/1/18


Y Y Y Y Y Y Y Y -

Y Y Y Y Y Y Y Y -


-


-

-

NC NC NC NC NC NA NC NC NC NC

-

-



-

-


Y Y Y Y Y Y Y Y -

Y Y Y Y Y Y Y Y -


COV SVC

Page 2 of 18

HCPCS REQ

-

SNF- NRSG FAC NA NA C Y N

NA NA NA

-


-

-


-

-

C NA NA NA NA NA NA NA NA NA

Y -

N -


-

-

-

-


-

-


-

-


Y -

N -


-

-

-

-


-

-


-

-


Y -

N -


-

-

UNITS REQ

PDN -

COV SVC

-

HCPCS REQ

HCPCS REQ

NA NA NA

UNITS REQ

UNITS REQ

HOME HEALTH NA NA NA -

HOSPICE -

COV SVC

COV SVC

-

NA NA NA

HCPCS REQ


INPATIENT Y Y Y Y Y Y

UNITS REQ

C C C

COV SVC

-

UNITS REQ

OPPS -

HCPCS REQ

RATE/HCPCS REQ

COV SVC

NA NA NA

UNITS REQ

HCPCS REQ

ONCOLOGY/SEMI REHAB/SEMI-PVT Other/SEMI-PVT * Room & Board (3 & 4 beds) ROOM-BOARD/3&4BED MED-SUR-GY/3&4BED 0B/3&4BED PEDS/3&4BED PSYCH/3&4BED HOSPICE/3&4BED DETOX/3&4BED ONCOLOGY/3&4BED REHAB/3&4BED Other/3&4BED Room & Board - Deluxe Private ROOM-BOARD/DLX PVT MED-SUR-GY/DLX PVT OB/DLXPVT PEDS/DLXPVT PSYCH/DLXPVT HOSPICE/DLXPVT DETOX/DLXPVT ONCOLOGY/DLXPVT REHAB//DLXPVT Other/DLXPVT ROOM & BOARD WARD ROOM-BOARD/WARD MED-SUR-GY/WARD OB/WARD PEDS/WARD PSYCH/WARD HOSPICE/WARD DETOX/WARD ONCOLOGY/WARD REHAB/WARD Other/WARD ROOM & BOARD OTHER

UNITS REQ

0127 0128 0129 013X 0130 0131 0132 0133 0134 0135 0136 0137 0138 0139 014X 0140 0141 0142 0143 0144 0145 0146 0147 0148 0149 015X 0150 0151 0152 0153 0154 0155 0156 0157 0158 0159 016X


COV SVC

Revenue Code

Special Note


CLINICS -




REVENUE CODE TABLE

Rev. 2/1/18

C

-

-

NA

-

NA

-

-

NA

-

-

NA

NA

-

-

NC

-

-

NA NA NA NA NA

-

-

C C C C C

Y Y Y

NA

-

-

C

NA

-

-

NA NA

-

NA

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

Y Y Y

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

NA NA

-

-

NA C

Y

N

NA NA

-

-

NA NA

-

-

NA C

Y

N

NA NA

-

-

-

-

NA

-

-

C

Y

N

NA

-

-

NA

-

-

C

Y

N

NA

-

-

NA

-

-

NC

-

-

C

-

-

NA

-

-

NA

-

-

C

Y

N

NA

-

-

NA NA NA NA NA

-

-

C C C C C

Y Y Y Y Y

Y Y Y Y Y

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA

-

-

C C C C

Y Y Y Y

Y Y Y Y

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

COV SVC

Page 3 of 18

HCPCS REQ

-

UNITS REQ

NA

COV SVC

-

HCPCS REQ

HCPCS REQ

SNF- NRSG FAC C Y N

UNITS REQ

UNITS REQ

-

COV SVC

COV SVC

NA

HCPCS REQ

PDN -

HOSPICE -

UNITS REQ

NA

NA

COV SVC

HOME HEALTH NA -

INPATIENT NA -

UNITS REQ

-

HCPCS REQ

RATE/HCPCS REQ

OPPS -

UNITS REQ

NA

COV SVC

HCPCS REQ

R&B RESERVED R&B/STERILE RESERVED R&B/SELF RESERVED R&B/OTHER NURSERY NURSERY NURSERY/LEVEL I NURSERY/LEVEL II NURSERY/LEVEL III NURSERY/LEVEL IV RESERVED NURSERY/OTHER LEAVE OF ABSENCE Leave of Absence or LOA RESERVED LOA/PT CONV LOA/THERAPEUTIC RESERVED LOA/NURS HOME RESERVED LOA/OTHER * SUBACUTE CARE INTENSIVE CARE UNIT INTENSIVE CARE (ICU) ICU/SURGICAL ICU/MEDICAL ICU/PEDS ICU/PSYCH RESERVED ICU/INTERMEDIATE ICU/BURN CARE ICU/TRAUMA ICU/OTHER CORONARY CARE UNIT)

UNITS REQ

0160 0161-3 0164 0165-6 0167 0168 0169 017X 0170 0171 0172 0173 0174 0175-8 0179 018X 0180 0181 0182 0183 0184 0185 0186-8 0189 019X 020X 0200 0201 0202 0203 0204 0205 0206 0207 0208 0209 021X


COV SVC

Revenue Code

Special Note


CLINICS -




REVENUE CODE TABLE

Rev. 2/1/18

COV SVC

UNITS REQ

HCPCS REQ

NA

-

-

C

Y

NA NA NA NA NA

-

-

NC NC NC NC NC

NC

-

-

NA NA NA NA NA NA

-

NA

Pkg Pkg Pkg NC Pkg Pkg NC Pkg Pkg Pkg

HOME HEALTH NA NA NA NA NA -

NA NA NA NA NA

PDN -

-

SNF- NRSG FAC NA NA NA NA NA -

NA NA NA NA NA

CLINICS -

-

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

C C C C C NA

N N N N N -

N N N N N -

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

-

-

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

-

C C C NA NA NA NC C C NC

N N N N N -

N N N N N -


-

-


-

-


-

-


-

-

C C C NA C C NA C C C

N N N N N N N N

Y Y Y Y Y Y Y Y

Page 4 of 18

HCPCS REQ

HCPCS REQ

-

UNITS REQ

UNITS REQ

HOSPICE -

COV SVC

COV SVC

NA NA NA NA NA

INPATIENT Y Y Y Y Y Y Y Y Y Y

HCPCS REQ

HCPCS REQ

C C C C C

UNITS REQ

UNITS REQ

-

COV SVC

COV SVC

OPPS -

RATE/HCPCS REQ

COV SVC

NA NA NA NA NA

UNITS REQ

HCPCS REQ

025X 0250 0251 0252 0253 0254 0255 0256 0257 0258 0259

CORONARY CARE(CCU) CCU/MYO INFARC CCU/PULMONARY CCU/TRANSPLANT CCU/INTERMEDIATE RESERVED CCU/OTHER SPECIAL CHARGES SPECIAL CHARGE ADMIT CHARGE TECH SUPPT CHG UR CHARGE LATE DISCH/MED NEC RESERVED OTHER SPEC CHG INCREMENTAL NURSING CHARGE NURSING INCREM NUR INCR/NURSERY NUR INCR/OB NUR INCR/ICU NUR INCR/CCU NUR INCR/HOSPICE RESERVED NUR INCR/OTHER ALL INCLUSIVE ANCILLARY Pharmacy (also see 063X, an extension of 025X) PHARMACY DRUGS/GENERIC DRUGS/NONGENERIC DRUGS/TAKEHOME DRUGS/ICIDENT ODX DRUGS/ICIDENT RAD DRUGS/EXPERIMT DRUGS/NONPSCRPT IV SOLUTIONS DRUGS/OTHER

UNITS REQ

0210 0211 0212 0213 0214 0215-8 0219 22X 0220 0221 0222 0223 0224 0225-8 0229 023X 0230 0231 0232 0233 0234 0235 0236-8 0239 024X


COV SVC

Revenue Code

Special Note





REVENUE CODE TABLE

OPPS 026X 0260 0261 0262 0263 0264 0265-8 0269 027X 0270 0271 0272 0273 0274 0275 0276 0277 0278 0279 028X 0280 0281-8 0289 029X 030X 0300 0301 0302 0303 0304 0305 0306 0307 0308 0309

IV THERAPY IV THERAPY IV THER/INFSN PUMP IV THER/PHARM SVC IV THER/DRUG/SUPPLY/DEL IV THER/SUPPLIES RESERVED IV THERAPY/OTHER MED/SURG Supplies & Devices (also see 062X , an extension of 027X) MED-SUR SUPPLIES NON-STER SUPPLY STERILE SUPPLY TAKEHOME SUPPLY PROSTH/ORTH DEV PACE MAKER INTRA OC LENS 02/TAKEHOME SUPPLY/IMPLANTS SUPPLY/OTHER ONCOLOGY ONCOLOGY RESERVED ONCOLOGY/OTHER Durable Medical Equipment (DME) (other than renal) LABORATORY LAB CHEMISTRY TESTS IMMUNOLOGY TESTS RENAL-HOME NON-RTNE DIALYSIS HEMATOLOGY TESTS BACT & MICRO TESTS UROLOGY TESTS RESERVED OTHER LAB TESTS

Rev. 2/1/18

INPATIENT

HOSPICE

HOME HEALTH

PDN

SNF- NRSG FAC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

RATE/HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS

Pkg Pkg Pkg Pkg Pkg

-

-

C C NA NA NA

N N -

N N -

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

C C C C C

N N N N N

Y Y Y Y Y

Pkg

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

Y

Pkg Pkg Pkg Pkg C Pkg Pkg NC Pkg Pkg

Y -

Y -

C C C NC C C C NA C C

N N N N N N N N

N N N N N N N N


-

-

C C C NC NC NC NC NC NC NC

Y Y Y -

Y Y Y -


-

-


-

-

-

-

C C C C C C C NA C C

N N N N Y N N N N

N N N N N N N N Y

Pkg

-

-

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

N

Pkg

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

N

C C C C C C C C

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

C C C C C C C C

N N N N N N N N

N N N N N N N N

NA NA NA NA NA NA NA NA

-

-


-

-


-

-


-

-

C C C C C C C C

N Y Y Y Y Y Y Y

N Y Y Y Y Y Y Y

C

Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

Page 5 of 18




REVENUE CODE TABLE

OPPS 031X 0310 0311 0312 0313 0314 0315-8 0319 032X 0320 0321 0322 0323 0324 0325-8 0329 033X 0330 0331 0332 0333 0334 0335 0336-8 0339 034X 0340 0341 0342 0343 0344 0345-8 0349 035X 0350

LABORATORY PATHOLOGY PATHOLOGY LAB CYTOLOGY TESTS HYSTOLOGY TESTS RESERVED BIOPSY TESTS RESERVED PATH LAB OTHER RADIOLOGY - DIAGNOSTIC DX X-RAY DX X-RAY/ANGlO DX X-RAY/ARTHO DX X-RAY/ARTER DX X-RAY/CHEST RESERVED DX X-RAY/OTHER Radiology -Therapeutic and/or Chemotherapy Administration RADIOLOGY THERAPY RAD-CHEMO-INJECT RAD-CHEMO-ORAL RAD-RADIATION RESERVED RAD-CHEMO-IV RESERVED RADIOLOGY/OTHER NUCLEAR MEDICINE (NUC MED) NUCLEAR MEDICINE NUC MED/DX NUC MED/RX NUC MED/DX RADIOPHARM NUC MED/RX RADIOPHARM RESERVED NUC MED/OTHER COMPUTED TOMOGRAPH (CT) SCAN CT SCAN

Rev. 2/1/18

INPATIENT

HOSPICE

HOME HEALTH

PDN

SNF- NRSG FAC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

RATE/HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS

C C C

Y Y Y

Y Y Y

C C C

N N N

N N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

Y Y Y

Y Y Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C C C C C

N N N N N

N N N N N

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C C C C

Y Y Y Y

Y Y Y Y

C C C C

N N N N

N N N N

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

C C C C

Y Y Y Y

Y Y Y Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C C C Pkg Pkg

Y Y Y -

Y Y Y -

C C C C C

N N N N N

N N N N N

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C

Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

Page 6 of 18




REVENUE CODE TABLE

Rev. 2/1/18

Y

Y

NC

-

-

NA

-

C C C

Y Y -

Y Y Y

C C C

N N N

N N N

NA NA NA

NC

-

-

C

N

N

C

Y

Y

NC

-

Pkg Pkg Pkg

-

-

C C C

NC

-

-

Pkg

-

C C C C C C C C

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

-

-

-

-

-

-

-

-

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

N N N

Y Y Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

Y

N N N

N N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

N N N

N N N

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

N

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

C C C C C C C C

Y Y Y N N N N N

N N N N N N N N


-

-


-

-


-

-


-

-

C C C C C C C C

N Y Y Y N N N N

Y Y Y Y Y Y Y Y

C

Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

Y

Pkg C Pkg

Y -

Y -

C C C

N N N

N N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

N Y Y

Y Y Y

Pkg

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

Y

COV SVC

Page 7 of 18

HCPCS REQ

C C

UNITS REQ

SNF- NRSG FAC NA NA -

COV SVC

C

HCPCS REQ

HCPCS REQ

-

UNITS REQ

UNITS REQ

PDN -

HOSPICE -

COV SVC

COV SVC

NA NA

NA NA

HCPCS REQ

HOME HEALTH NA NA -

INPATIENT N N N N

UNITS REQ

C C

COV SVC

Y Y

UNITS REQ

OPPS Y Y

HCPCS REQ

RATE/HCPCS REQ

COV SVC

C C

UNITS REQ

HCPCS REQ

CT SCAN/HEAD CT SCAN/BODY RESERVED CT SCAN/OTHER OPERATING ROOM SERVICES OR SERYICES OR/MINOR OR/ORGAN TRANS RESERVED OR/KIDNEY TRANS RESERVED OR/OTHER ANESTHESIA ANESTHESIA ANESTH/INCIDENT RAD ANESTH/INCDNT OTHR DX RESERVED ANESTH/ACUPUNC RESERVED ANESTH/OTHER BLOOD & BLOOD COMPONENTS BLOOD & BLOOD COMP BLOOD/PKD RED BLOOD/WHOLE BLOOD/PLASMA BLOOD/PLATELETS BLOOD/LEUKOCYTES BLOOD/COMPONENTS BLOOD/DERIVATIVES RESERVED BLOOD/OTHER BLOOD STORAGE & PROCESSING BLOOD/ADMIN/STOR BLOOD/ADMIN BLOOD/STORAGE RESERVED BLOOD/ADMIN/STOR/OTHER

UNITS REQ

0351 0352 0353-8 0359 036X 0360 0361 0362 0363-6 0367 0368 0369 037X 0370 0371 0372 0373 0374 0375-8 0379 038X 0380 0381 0382 0383 0384 0385 0386 0387 0388 0389 039X 0390 0391 0392 0393-8 0399


COV SVC

Revenue Code

Special Note


CLINICS Y Y Y Y




REVENUE CODE TABLE

OPPS 040X 0400 0401 0402 0403 0404 0405-8 0409 041X 0410 0411 0412 0413 0414-8 0419 042X 0420 0421 0422 0423 0424 0425-8 0429 043X 0430 0431 0432 0433 0434 0435-8 0439 044X 0440 0440 0441 0441 0442

OTHER IMAGING SERVICES IMAGING SERVICE DIAG MAMMOGRAPHY ULTRASOUND SCRN MAMMOGRAPHY PET SCAN RESERVED OTHER IMAG SVS RESPIRATORY SERVICES RESPIRATORY SVC RESERVED INHALATION SVC HYPERBARIC O2 RESERVED OTHER RESPIR SVCS PHYSICAL THERAPY PHYSICAL THERP PHYS THERP/VISIT PHYS THERP/HOUR PHYS THERP/GROUP PHYS THERP/EVAL RESERVED OTHER PHYS THERP OCCUPATIONAL THERAPY OCCUPATIONAL THER OCCUP THERP/VISIT OCCUP THERP/HOUR OCCUP THERP/GROUP OCCUP THERP/EVAL RESERVED OCCUP THER/OTHER SPEECH-LANGUAGE PATHOLOGY SPEECH THERAPY T5 SPEECH THERAPY SPEECH THERP/VISIT T5 SPEECH THERP/VISIT SPEECH THERP/HOUR

Rev. 2/1/18

INPATIENT

HOSPICE

HOME HEALTH

PDN

SNF- NRSG FAC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

RATE/HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C C C C C

N N N N N

N N N N N

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C

Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

C

Y

N

C

Y

Y

C C

Y Y

Y Y

C C

N N

N N

NA NA

-

-

NA NA

-

-

NA NA

-

-

NA NA

-

-

C C

Y Y

Y Y

C

Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C C C C C

N N N N N

N N N N N

NA NA NA NA NA

-

-

C C C NC C

Y Y Y Y

Y Y Y Y

NA NA NA NA NA

-

-

C NA NA NA C

Y Y

Y Y

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C

Y

Y

NC

-

-

NA

-

-

NC

-

-

NA

-

-

C

Y

Y

C

Y

Y

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C C C C C

N N N N N

N N N N N

NA NA NA NA NA

-

-

C C C NC C

Y Y Y Y

Y Y Y Y

NA NA NA NA NA

-

-

C NA NA NA C

Y Y

Y Y

C C C C C

Y Y Y Y Y

Y Y Y Y Y

C

Y

Y

NC

-

-

NA

-

-

NC

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

-

C

Y

Y

C

Y

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

Y Y -

-

Y

Y Y -

NA

C

NC C NC C NC

NA

-

-

NA

-

-

C

Y

Y

Page 8 of 18




REVENUE CODE TABLE

OPPS 0442 0443 0444 0444 0445-8 0449 045X 0450 0451 0452 0453-5 0456 0457-8 0459 046X 0460 0461-8 0469 047X 0470 0471 0472 0473-8 0479 048X 0480 0481 0482 0483 0484-8 0489 049X 050X 051X 0510 0511 0512

T5 SPEECH THERP/HOUR SPEECH THERP/GROUP SPEECH THERP/EVAL T5 SPEECH THERP/EVAL RESERVED OTHER SPEECH THERP EMERGENCY ROOM EMERG ROOM ER/EMATALA ER/BEYOND EMTALA RESERVED ER/URGENT RESERVED OTHER EMERG ROOM PULMONARY FUNCTION PULMONARY FUNC RESERVED OTHER PULMONARY FUNC AUDIOLOGY AUDIOLOGY AUDIOLOGY/DX AUDIOLOGY/RX RESERVED OTHER AUDIOL CARDIOLOGY CARDIOLOGY CARDIAC CATH LAB STRESS TEST ECHOCARDIOLOGY RESERVED OTHER CARDIOL AMBULATORY SURGICAL CARE OUTPATIENT SERVICES CLINIC CLINIC CHRONIC PAIN CLINIC DENTAL CLINIC

Rev. 2/1/18

INPATIENT

HOSPICE

HOME HEALTH C Y Y NC NC C Y Y

C C

Y Y

Y Y

C C

N N

N N

NA NA

-

-

C

Y

Y

NC

-

-

NA

-

-

NC

-

C C C

Y Y Y

Y Y Y

C NA NA

N -

N -

NA NA NA

-

-

NA NA NA

C

Y

Y

NA

-

-

NA

-

-

NC

-

-

NC

-

-

NA

-

C

Y

Y

C

N

N

NA

C

Y

Y

NC

-

-

C C C

Y Y Y

Y Y Y

C C C

N N N

C

Y

Y

NC

C C C C

Y Y Y Y

Y Y Y Y

C

Y

C C NC

Y Y -

PDN

SNF- NRSG FAC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

RATE/HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS

NA NA

-

-

C C

Y Y

Y Y

C C

Y Y

Y Y

-

NA

-

-

C

Y

Y

C

Y

Y

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

N N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

Y Y Y

Y Y Y

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C C C C

N N N N

N N N N

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

C C C C

Y Y Y Y

Y Y Y Y

Y

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

Y Y -

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

Page 9 of 18




REVENUE CODE TABLE

Rev. 2/1/18

COV SVC

UNITS REQ

HCPCS REQ

HCPCS REQ

HCPCS REQ

-


NA NA NA NA NA

PDN -

-


NA NA NA NA NA

CLINICS -

-

C

Y

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-


-

-


-

-


-

-


-

-


-

-


-

-

C C C C C C C NA C C

Y Y Y Y N N Y N Y

Y Y Y Y N N Y N Y

C NC NC NC NC C C NC NC NC

Y Y Y -

Y Y Y -


-

-


-

-


-

-


-

-


-

-


Y -

Y -

NC NC NC

-

-

NA NA NA

-

-

NA C NA

Y -

Y -

C C C

Y Y Y

Y Y Y

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NC

-

-

NA

-

-

NA

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

UNITS REQ

UNITS REQ

HOSPICE -

COV SVC

COV SVC

NA NA NA NA NA

Page 10 of 18

HCPCS REQ

HCPCS REQ

INPATIENT NA NA NA NA NA -

UNITS REQ

UNITS REQ

Y Y Y Y

COV SVC

COV SVC

RATE/HCPCS REQ

OPPS Y Y Y Y

UNITS REQ

NC C C C C

COV SVC

HCPCS REQ

PSYCHIATRIC CLINIC (PT 21 ONLY) OB-GYN CLINIC PEDIATRIC CLINIC URGENT CARE CLINIC FAMILY CLINIC RESERVED OTHER CLINIC FREE-STANDING CLINIC FREEST AND CLINIC FS-RURAL/CLINIC FS-RURAL/HOME FS-FAMILY PRACT FR/STD FAMILY CLINIC RHC/FQHC/SNF/NONCOVERED FR/STD URGENT CLINIC RHC/FQHC/HOME/VIS NURSE RHC/FQHC/OTHER SITE OTHER FS-CLINIC OSTEOPATHIC SERVICES AMBULANCE AMBULANCE AMBUL/SUPPLY AMBUL/MED TRANS AMBUL/HEART MOB AMBUL/OXYGEN AIR AMBULANCE AMBUL/NEONAT AMBUL/PHARMAS AMBUL/EKG TRANS AMBUL/OTHER SKILLED NURSING SKILLED NURSING SKILLED NURS/VISIT SKILLED NURS/HOUR RESERVED SKILLED NURS/OTHER

UNITS REQ

0513 0514 0515 0516 0517 0518 0519 052X 0520 0521 0522 0523 0524 0525 0526 0527 0528 0529 053X 054X 0540 0541 0542 0543 0544 0545 0546 0547 0548 0549 055X 0550 0551 0552 0553-8 0559


COV SVC

Revenue Code

Special Note





REVENUE CODE TABLE

OPPS 056X 0560 0561 0562 0563-8 0569 057X 0570 0571 0572 0573-8 0579 058X 0580 0581 0582 0583 0584-8 0589 059X 060X 061X 0610 0611 0612 0613 0614 0615 0616 0617

HOME HEALTH (HH) - MEDICAL SOCIAL SERVICES MEDICAL SOCIAL SERVICES-GENERAL CLASSIFICATION MEDICAL SOCIAL SERVICES-VISIT CHARGE MEDICAL SOCIAL SERVICES-HOURLY CHARGE RESERVED MEDICAL SOCIAL SERVICES-OTHER MED. SOCIAL SERVICE HOME HEALTH (HH) AIDE HH AIDE HH AIDE-VISIT HH AIDE-HOUR RESERVED HH AIDE-OTHER HOME HEALTH (HH) - OTHER VISITS HH-OTH VIS HH-OTH VIS/VISIT HH-OTH VIS/HOUR HH-OTH VIS/ASSESS RESERVED HH-OTH VIS/OTHER HOME HEALTH (HH) UNITS OF SERVICE HOME HEALTH (HH) - OXYGEN MAGNETIC RESONANCE TECHNOLOGY (MRT) MRT MRI/BRAIN MRI/SPINE RESERVED MRI/OTHER MRA/HEAD & NECK MRA/LOWER EXTRM RESERVED

Rev. 2/1/18

INPATIENT

HOSPICE

HOME HEALTH

PDN

SNF- NRSG FAC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

RATE/HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NC

-

-

NA

-

-

C

Y

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NC NC NC

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

Y Y Y

Y Y Y

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NC

-

-

NA

-

-

NA

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

NC NC NC NC

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NC NC NC NC

-

-

NA NA C NA

Y -

Y -

NA NA NA NA

-

-

NA NA NA NA

-

-

NC

-

-

NA

-

-

NA

-

-

NC

-

-

NA

-

-

NA

-

-

NA

-

-

C C C

Y Y Y

Y Y Y

C C C

N N N

N N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

Y Y Y

Y Y Y

C C C

Y Y Y

Y Y Y

NA C C

N N

N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

Y Y Y

Y Y Y

Page 11 of 18




REVENUE CODE TABLE

067X 068X

Rev. 2/1/18

-

NA NA NA NA

-

-

NA NA NA NA

-

Pkg Pkg NC C C C NC

Y Y Y -

Y Y Y -


-

-


NC NC NC

-

-

NA NA NA

-

-

NC NC NC NC NC

-

-

NA NA NA NA NA

-

-

C C

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

C C C C

Y Y Y Y

Y Y Y Y

-

-


-

-


-

-


-

-

C C NA C C C NA

Y Y Y Y Y -

Y Y Y Y Y -

NC C C

Y Y

N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C C C

Y Y Y Y Y

N N Y N N

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

COV SVC

Page 12 of 18

HCPCS REQ


UNITS REQ

-

COV SVC

-

HCPCS REQ

PDN -

UNITS REQ

NA NA

COV SVC

HCPCS REQ

Pkg Pkg Pkg NC

HCPCS REQ

HOME HEALTH NA NA -

HOSPICE -

UNITS REQ

NA NA

COV SVC

INPATIENT NA NA -

UNITS REQ

Y Y

HCPCS REQ

RATE/HCPCS REQ

OPPS Y Y

UNITS REQ

C C

COV SVC

UNITS REQ

0630 0631 0632 0633 0634 0635 0636 0637 0638-9 064X 065X 0650 0651 0652 0653-4 0655 0656 0657 0658 0659 066X

COV SVC

0620 0621 0622 0623 0624 0625-9 063X

HCPCS REQ

062X

MRA/OTHER MRT/OTHER Medical/Surgical Supplies (Extension of 027X) RESERVED (use 0270 for General Classification) MED SURG SUPL-INCDT RAD MED SURG SUPL-INCDT ODX SURG DRESSINGS FDA INVEST DEVICE RESERVED PHARMACY - Extension of 025X RESERVED (Use 0250 for General Classification) DRUG/SINGLE DRUG/MULTIPLE DRUG/RESTRICT DRUG/EPO<10,000 Units DRUG/EPO>=10,000 Units DRUG/DETAIL CODE DRUG/SELF ADMIN RESERVED HOME IV THERAPY SERVICES HOSPICE SERVICES HOSPICE HOSPICE/RTN HOME HOSPICE/CTNS HOME RESERVED HOSPICE/IP RESPITE HOSPICE/IP NON RESPITE HOSPICE/PHYSICIAN HOSPICE/R&B NURSE FAC HOSPICE/OTHER * RESPITE CARE (HHA ONLY) OUTPATIENT SPECIAL RESIDENCE CHARGES TRAUMA RESPONSE

UNITS REQ

0618 0619


COV SVC

Revenue Code

Special Note


CLINICS Y Y Y Y




REVENUE CODE TABLE

076X

Rev. 2/1/18

COV SVC

UNITS REQ

HCPCS REQ

-

-

C

N

Pkg

-

-

C

Pkg Pkg C NC C

Y Y

Y Y

C

Y

C C Pkg


PDN -

-

SNF- NRSG FAC NA NA NA NA NA NA NA -


CLINICS -

-

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C C C C C

N N N N N

N N N N N

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

Y Y -

Y Y -

C C C

N N N

N N N

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C C

Y Y Y

Y Y Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

C

Y

Y

C

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

Page 13 of 18

HCPCS REQ

HCPCS REQ

HOME HEALTH NA NA NA NA NA NA NA -

UNITS REQ

UNITS REQ

-

COV SVC

COV SVC

Pkg

HCPCS REQ

HCPCS REQ

HOSPICE -

UNITS REQ

UNITS REQ


INPATIENT NA C A C A C A C A C A -

COV SVC

COV SVC

-

RATE/HCPCS REQ

OPPS -

UNITS REQ

NA Pkg Pkg Pkg Pkg Pkg

COV SVC

HCPCS REQ

069X 0700X 0700 0701-9 071X 0710 0711-9 072X 0720 0721 0722 0723 0724 0725-8 0729 073X 0730 0731 0732 0733-8 0739 074X 0740 0741-9 075X 0750 0751-9

NOT USED TRAUMA LEVEL I TRAUMA LEVEL II TRAUMA LEVEL III TRAUMA LEVEL IV RESERVED TRAUMA OTHER PRE-HOSPICE/PALLIATIVE CARE SERVICES CAST ROOM CAST ROOM RESERVED RECOVERY ROOM RECOVERY ROOM RESERVED LABOR ROOM/DELIVERY DELIVERY ROOM/LABOR LABOR DELIVERY ROOM CIRCUMCISION BIRTHING CNTR RESERVED OTHER/DELIV-LABOR ELECTROCARDIOGRAM (EKG/ECG) EKG/ECG HOLTER MONT TELEMETRY RESERVED OTHER EKG/ECG ELECTROENCEPHALOGRAM (EEG) EEG RESERVED GASTRO-INTESTINAL (GI) SERVICES GASTRO-INTSTL SVCS RESERVED SPECIALTY ROOM TREATMENT/OBSERVATION ROOM

UNITS REQ

0680 0681 0682 0683 0684 0685-8 0689


COV SVC

Revenue Code

Special Note





REVENUE CODE TABLE

082X 0820

Rev. 2/1/18

Y

NA

-

-

NA

-

C C

Y Y

Y Y

C C

N N

N N

NA NA

C

Y

Y

C

-

-

C

Y

Y

C

N

NA NA NA NA NA

-

-

NA C C C C

NA

-

-

Y Y

-

NA

-

-

NA

-

-

NA

-

-

C

N

N

-

-

NA NA

-

-

NA NA

-

-

NA NA

-

-

C C

N N

Y Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

N

N

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C

N

Y

Y Y Y Y

N N N N

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA NA NA NA NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

Y Y

NA C C NA C C

N N -

N N Y Y

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

-

-

C

-

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

Y

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

COV SVC

Page 14 of 18

HCPCS REQ

Y

UNITS REQ

C C C

COV SVC

C

HCPCS REQ

SNF- NRSG FAC NA NA NA -

UNITS REQ

-

COV SVC

PDN -

HOSPICE -

HCPCS REQ

NA NA NA

NA NA NA

UNITS REQ

HOME HEALTH NA NA NA -

INPATIENT N N N N N N

COV SVC

C C C

UNITS REQ

Y Y -

HCPCS REQ

RATE/HCPCS REQ

OPPS Y Y -

UNITS REQ

C C Pkg

ACQUISITION OF BODY COMPONENTS ORGAN ACQUISIT NA LIVING DONOR NA CADAVER DONOR NA UNKNOWN DONOR NA UNSUCCESSFUL SEARCH C STEM CELLS-ALLOGENIC C RESERVED OTHER DONOR Pkg HEMODIALYSIS - OUTPATIENT or HOME HEMO/OP OR HOME C

HCPCS REQ

081X 0810 0811 0812 0813 0814 0815 0816-8 0819

UNITS REQ

EXTRA-CORPOREAL SHOCK WAVE THERAPY (FORMERLY LITHOTRIPSY) ESWT RESERVED INPATIENT RENAL DIALYSIS RENAL DIALYSIS DIALY/INPATIENT DIALY/IP/PER DIALY/IPCAPD DlALY/lP/CCPD RESERVED DIALY/IP/OTHER

COV SVC

079X 0790 0791-9 080X 0800 0801 0802 0803 0804 0805-8 0809

COV SVC

SPECIALTY SVC TREATMENT RM OBSERVATION RESERVED OTHER TREAT/OBSERV RM PREVENTIVE CARE SERVICES PREVENT CARE SVCS VACCINE ADMIN RESERVED TELEMEDICINE TELEMEDICINE RESERVED

HCPCS REQ

0760 0761 0762 0763-8 0769 077X 0770 0771 0772-9 078X 0780 0781-9

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS N N N Y N N




REVENUE CODE TABLE

Rev. 2/1/18

COV SVC

UNITS REQ

HCPCS REQ

HOME HEALTH NA NA NA NA NA NA -

NA NA NA NA NA NA

PDN -

-

SNF- NRSG FAC NA NA NA NA NA NA -

NA NA NA NA NA NA

CLINICS -

-

Pkg

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C C NC NC NC C

Y Y Y

Y Y Y

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

C

Y

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C C NC NC NC C

Y Y Y

Y Y Y

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

NA NA NA NA NA NA

-

-

C

Y

Y

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

NA

-

-

C C NC NC NC C C

Y Y Y Y

Y Y Y Y


-

-


-

-


-

-


-

-


-

-


-

-

Page 15 of 18

HCPCS REQ

HCPCS REQ

-

UNITS REQ

UNITS REQ

HOSPICE -

COV SVC

COV SVC

NA NA NA NA NA NA

-

HCPCS REQ

INPATIENT NA NA NA NA NA NA -

UNITS REQ

-

COV SVC

HCPCS REQ

RATE/HCPCS REQ

OPPS -

UNITS REQ

Pkg NC NC NC Pkg Pkg

COV SVC

UNITS REQ

085X 0850 0851 0852 0853 0854 0855 0859

COV SVC

084X 0840 0841 0842 0843 0844 0845 0846-8 0849

HCPCS REQ

083X 0830 0831 0832 0833 0834 0835 0836-8 0839

HEMO/COMPOSITE HEMO/HOME/SUPPL HEMO/HOME/EQUIP HEMO/HOME/100% HEMO/HOME/SUPSERV HEMO/SHORT RESERVED HEMO-OTHER op PERITONEAL DIALYSIS - OUTPATIENT or HOME PERlTONEAL/OP OR HOME PERTNL/COMPOSITE PERTNL/HOME/SUPPL PERTINL/HOME/EQUIP PERTINL/HOME/100% PERTNL/HOME/SUPSERV RESERVED PERTNL/HOME/OTHER Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home CAPD/OP OR HOME CAPD/COMPOSITE CAPD/HOME/SUPPL CAPD/HOME/EQUIP CAPD/HOME/100% CAPD/HOME/SUPSERV RESERVED CAPD/HOME/OTHER Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home CCPD/OP OR HOME CCPD/COMPOSITE CCPD/HOME/SUPPL CCPD/HOME/EQUIP CCPD/HOME/100% CCPD/HOME/SUPSERV CCPD/HOME/OTHER

UNITS REQ

0821 0822 0823 0824 0825 0826 0827-8 0829


COV SVC

Revenue Code

Special Note





REVENUE CODE TABLE

OPPS 086X 0860 0861 0862-9 087X 088X 089X

090X 0900 0901 0902 0903 0904 0905 0906 0907 0908-9

091X 0910 0911 0912 0913 0914 0915 0916 0917 0918 0919 092X 0920 0921 0922 0923

Magnetoencephalography (MEG) General Classification Pkg MEG Pkg RESERVED RESERVED MISCELLANEOUS DIALYSIS RESERVED BEHAVIORAL HEALTH TREATMENT/SERVICES (also see 091x, an extension of 090x) BH/TREATMENTS C BH/ELECTRO SHOCK C BH/MILIEU THERAPY C BH/PLAY THERAPY C BH/ACTIVITY THERAPY NC BH/INTENS OP/PSYCH NC BH/INTENS OP/CHEM DEP NC BH/COMMUNITY NC RESERVED BEHAVIORAL HEALTH TREATMENTS/SERVICES - EXTENSION OF 090X RESERVED BH/REHAB C BH/PARTIAL HOSP NC BH/PARTIAL INTENSV NC BH/INDIV RX C BH/GROUP RX C BH/FAMILY RX C BH/BIOFEED NC BH/TESTING C BH/OTHER C OTHER DIAGNOSTIC SERVICES OTHER DX SVCS C PERI VASCUL LAB C EMG C PAP SMEAR C

Rev. 2/1/18

INPATIENT

HOSPICE

HOME HEALTH

PDN

SNF- NRSG FAC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ

COV SVC

RATE/HCPCS REQ

UNITS REQ

COV SVC

HCPCS REQ

UNITS REQ


COV SVC

Revenue Code

Special Note


CLINICS

-

-

C C

N N

N N

NA NA

-

-

NA NA

-

-

NA NA

-

-

NA NA

-

-

NA NA

-

-

Y Y Y Y -

Y Y Y Y -

C C NC NC NA NA NA NA

N N -

N N -


-

-


-

-


-

-


-

-

C C C C C C C C

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y Y Y

C NA NA C C C NC C NA

N N N N N -

N N N N N -

NA NA NA NA NA NA NA NA NA

-

-


-

-


-

-


-

-

C NA NA C C C NA C C

Y Y Y Y Y Y

Y Y Y Y Y Y

Y Y Y Y

Y Y Y Y

C C C C

N N N N

N N N N

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

C C C C

N Y Y Y

N Y Y Y

Page 16 of 18




REVENUE CODE TABLE

098X 0980 0981 0982 0983 0984

Rev. 2/1/18

Y

NA

-

-

NA

-

Pkg NC Pkg Pkg NC NC NC NC Pkg C

Y

Y

C C NA C NA NA NA NC NA NA

N N N -

N N N -


NA NA NA

-

-

NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

-

NA

-

-

NA

-

-

NA

-

-

C

Y

Y

-

-


-

-


-

-


-

-

C C C C C C C C C C

N Y Y Y Y Y Y Y Y Y

N Y Y Y Y Y Y Y Y Y

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

NA NA NA

-

-

C C NA

Y Y -

Y Y -

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

NA NA NA NA

-

-

COV SVC

Page 17 of 18

HCPCS REQ

C C

UNITS REQ


COV SVC

Y

HCPCS REQ

-

UNITS REQ

PDN -

COV SVC

C

HCPCS REQ

NA NA

HOSPICE -

UNITS REQ

HOME HEALTH NA NA -

NA NA

COV SVC

C C

UNITS REQ

Y Y

HCPCS REQ

RATE/HCPCS REQ

OPPS Y Y

UNITS REQ

HCPCS REQ

097X

UNITS REQ

096x

C C

INPATIENT N N N N

COV SVC

0950 0951 0952 0953 0954-9

COV SVC

095X

HCPCS REQ

094X 0940 0941 0942 0943 0944 0945 0946 0947 0948 0949

ALLERGY TEST PREG TEST RESERVED OTHER DX SVCS MEDICAL REHAB DAY PROGRAM Other Therapeutic Services (also see 095X, ext of 094X) OTHER RX SVCS RECREATION RX EDUC/TRAINING CARDIAC REHAB DRUG REHAB ALCOHOL REHAB CMPLX MED EQUIP-ROUT CMPLX MED EQUIP-ANC PULMONARY REHAB OTHER Other Therapeutic Services (extension of 094X) RESERVED (use 0940 for General Classification) ATHLETIC TRAINING KINESIOTHERAPY CHEMDEP RESERVED PROFESSIONAL FEES (also see 097x and 098x) PROFESSIONAL FEES (extension of 096X) PROFESSIONAL FEES (extension of 096X & 097X) RESERVED (use 0960 for General Classification) PRO FEE/ER PRO FEE/OUTPT PRO FEE/CLINIC PRO FEE/SOC SVC

UNITS REQ

0924 0925 0926-8 0929 093X


COV SVC

Revenue Code

Special Note


CLINICS Y Y Y Y




REVENUE CODE TABLE

100x 101X to 209X 210x 211X to 309x 310x 311x to 999x

UNITS REQ

HCPCS REQ


COV SVC

-

HCPCS REQ

PDN -

UNITS REQ

HCPCS REQ

NA NA NA NA NA

COV SVC

UNITS REQ


COV SVC

-

HCPCS REQ

HOSPICE -

UNITS REQ

HCPCS REQ

NA NA NA NA NA

COV SVC

UNITS REQ

INPATIENT NA NA NA NA NC -

COV SVC

-

RATE/HCPCS REQ

OPPS -

UNITS REQ

NA NA NC NC NC

COV SVC

HCPCS REQ

PRO FEE/EKG PRO FEE/EEG PRO FEE/HOS VIS PRO FEE/CONSULT PRO FEE/PVT NURSE PATIENT CONVENIENCE ITEMS BEHAVIORAL HEALTH ACCOMMODATIONS

UNITS REQ

0985 0986 0987 0988 0989 099X


COV SVC

Revenue Code

Special Note


NA NA NA NA NA

CLINICS -

-

RESERVED ALTERNATIVE THERAPY SERVICES RESERVED ADULT CARE RESERVED

Rev. 2/1/18

Page 18 of 18


Revenue Code Requirements (Medicaid ... - State of Michigan

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