Monday, Jan. 8, 2007
Jane S. McKimmon Center
1101 Gorman St.
Raleigh, NC  27606

Tuesday, Jan. 9, 2007
Coastline Convention Center
501 Nutt St.
Wilmington, NC 28401

Tuesday, Jan. 16, 2007
Matthews Community Center
100 McDowell St. E.
Matthews, NC 28105

Wednesday, Jan. 24, 2007
Crown Plaza Hotel and Resort
One Holiday Inn Drive
Asheville, NC 28806

Please Mail to:
DMA Provider Services
Attention:  NPI Form
2501 Mail Service Center
Raleigh, NC  27699-2501

Please Fax to:
(919) 715-7140

Please E-mail to:
npi.dma@ncmail.net

January

01/05/07

01/09/07

01/12/07

01/17/07

01/19/07

01/25/07

February

02/02/07

02/06/07

02/08/07

02/13/07

02/15/07

02/20/07

02/22/07

02/28/07

March

03/01/07

03/06/07

03/08/07

03/13/07

03/15/07

03/20/07

03/22/07

03/29/07

April

04/05/07

04/10/07

04/12/07

04/17/07

04/19/07

04/26/07

May

05/03/07

05/08/07

05/10/07

05/15/07

05/17/07

05/22/07

05/24/07

05/31/07

June

05/31/07

06/05/07

06/07/07

06/12/07

06/14/07

06/21/07

July

06/28/07

07/03/07

07/05/07

07/10/07

07/12/07

07/17/07

07/19/07

07/26/07

August

08/02/07

08/07/07

08/09/07

08/14/07

08/16/07

08/23/07

September

08/30/07

09/05/07

09/06/07

09/11/07

09/13/07

09/18/07

09/20/07

09/27/07

October

10/04/07

10/09/07

10/11/07

10/16/07

10/18/07

10/23/07

10/25/07

10/31/07

November

11/01/07

11/06/07

11/08/07

11/14/07

11/15/07

11/21/07

December

11/29/07

12/04/07

12/06/07

12/11/07

12/13/06

12/20/07

New Covered CPT Codes

00625

00626

15002

15003

15004

15005

15731

15830

15847

17311

17312

17313

17314

17315

19300

19301

19302

19303

19304

19305

19306

19307

22865

25109

25606

25607

25608

25609

27325

27326

28055

33202

33203

33254

33255

33256

33265

33266

33675

33676

33677

33724

33726

35302

35303

35304

35305

35306

35537

35538

35539

35540

35637

35638

35883

35884

37210

44157

44158

47719

48105

48548

49324

49325

49326

49402

49435

49436

54865

55875

56422

57296

57558

58541

58542

58543

58544

58548

58957

58958

67346

72291

72292

76776

76813

76814

76998

77001

77002

77003

77011

77012

77013

77014

77021

77022

77031

77032

77051

77052

77053

77054

77055

77056

77057

77058

77059

77072

77073

77074

77075

77076

77077

77078

77079

77080

77081

77082

77083

77084

77371

77372

77373

77435

82107

83913

86788

86789

87305

87498

87640

87641

87653

87808

88576

92025

92640

94002

94003

94004

94610

94644

94645

94777

End-Dated CPT Codes

01995

15000

15001

15831

17304

17305

17306

17307

17310

19140

19160

19162

19180

19182

19200

19220

19240

21300

25611

25620

26504

27315

27320

28030

31700

31708

31710

33200

33201

33245

33246

33253

35381

35507

35541

35546

35641

44152

44153

47716

48005

48180

49085

54152

54820

55859

56720

57820

67350

75998

76003

76005

76006

76012

76013

76020

76040

76061

76062

76065

76066

76070

76071

76075

76076

76077

76078

76082

76083

76086

76088

76090

76091

76092

76093

76094

76095

76096

76355

76360

76362

76370

76393

76394

76400

76778

76986

78704

78715

78760

91060

92573

94656

94657

95078

New CPT Codes Not Covered Pending Further Review

22526

22527

22857

22862

32998

92640

New CPT Codes Not Covered

19105

43647

43648

43881

43882

64910

64911

70554

70555

77071

83698

91111

94005

94774

94775

94776

95012

96020

96040

96904

99364

99636

15847

N/A

N/A

Prior approval is required and allowed for the following criteria:

• Medically necessary to provide additional abdominal support.

15731

N/A

N/A

Prior approval is required and allowed for the following criteria:

• Medically necessary to improve/restore/correct significant deformity resulting from trauma or cancer .
• Not for cosmetic reasons.

22865

N/A

N/A

Prior approval is required and allowed for the following criteria:

• Medical necessity based on complications directly related to the artificial disc.

33675 33676 33677

N/A

Allowed with one of the following primary diagnoses: 

745.5, 747.0

N/A

37210

N/A

Allowed with one of the following primary diagnoses: 

218.0, 218.1, 218.2, 218.9

N/A

57296

N/A

N/A

Prior approval is required and allowed for the following criteria:

• Medical documentation substantiates that the congenital anomaly and/or ambiguous genitalia was present prior to the age of two.
• Medical documentation substantiates that the development of pronounced secondary sex characteristics occurred during puberty.
• Medical documentation substantiates that certain conditions are due to pelvic malignancies, such as repair of vaginal vault prolapse, treatment of female genitourinary disease, and/or treatment of malignant cancers.

67346

• For a single muscle biopsy, one eye, bill 67346 for one unit.
• For a single muscle biopsy, both eyes, bill 67346 with modifier 50 for one unit.
• For two biopsies, left eye, bill 67346, modifier LT, two units.
• For two biopsies, right eye, bill 67346, modifier RT, two units.

72291

72292

Must be billed as a professional component with modifier 26.

N/A

N/A

77371 77372 77373 77435

Refer to April 2005 Medicaid Bulletin for instructions on billing a radiation treatment delivery code.

Allowed with one of the following diagnoses:

191.0 through 191.9, 192.1, 192.2, 192.3, 194.3, 198.3, 198.4, 225.0, 225.1, 225.2, 225.3, 225.4, 225.8, 225.9, 227.3, 237.0, 237.5, 237.6, 237.70 through 237.72, 239.6, 239.7, 350.1, 377.51 through 377.54, 742.9, 747.81, 747.82, 747.89

N/A

92025

• The description includes “unilateral or bilateral,” therefore limited to one unit.
• Not covered for routine follow-up scans.
• Routine scans of an uninvolved eye are not covered.
• Repeat testing is indicated only if a change of vision is reported in connection with the allowable diagnosis code(s).

Allowed with one of the following diagnoses:

V42.5, 370.00 through 370.07, 371.00, 371.23, 371.50 through 371.58, 371.60 through 371.62, 372.40 through 372.45, 372.52, 996.51

N/A

New CPT Codes Covered for ASCs (effective with date of service Jan. 1, 2007)

15002

2

15003

1

15004

2

15005

1

15731

3

15847

3

19300

4

19301

3

19302

7

19303

4

19304

4

25606

3

25607

5

25608

5

25609

5

27325

2

27326

2

49402

2

54865

1

55875

9

56442

1

57558

3

67346

2

CPT Codes End-Dated for ASCs (effective with date of service Dec. 31, 2006)

15000

15001

19140

19160

19162

19180

19182

25611

25620

26504

27315

27320

49085

54800

56720

57820

Health Check Screening with Immunization(s)

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP and 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP and 90472EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90465EP or 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) are not required.

Cannot bill 90471EP or 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) are not required.

Health Check Screening with Immunization(s)

Cannot bill 90465EP.

Report vaccine CPT code(s).

Immunization diagnosis code(s) not required.

Cannot bill 90471EP.

Report vaccine CPT code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90465EP.

For two or more vaccines, bill 90465EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two or more vaccines, bill 90471EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

Health Check Screening with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

Core Visit with Immunization(s)

N/A

N/A

Health Check Screening with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90467EP.

Report vaccine CPT code.

Immunization diagnosis code is not required.

Cannot bill 90473EP.

Report vaccine CPT code.

Immunization diagnosis code is not required.

Health Check Screening with Immunization(s)

Cannot bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A.

Immunization diagnosis code is not required.

Cannot bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code not required.

Core Visit With Immunization(s)

N/A

N/A

Health Check Screening with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine code(s)

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit With Immunization(s)

N/A

N/A

Health Check Screening with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report vaccine CPT codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report vaccine CPT codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90465EP, 90466EP or 90468EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) are not required.

Cannot bill 90471EP, 90472EP or 90474EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) are not required.

Health Check Screening with Immunization(s)

Cannot bill 90465EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Cannot bill 90471EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

Immunization(s) Only

Bill 90471 administration code

Bill vaccine CPT code.

Report diagnosis code as appropriate.

Bill 90471 and 90472

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill E/M code with modifier 25 appended in addition to 90471 if a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with modifier 25 appended in addition to 90471 and 90472 if a separately identifiable service was performed.

Bill CPT vaccine codes.

Immunization(s) Only

Bill under the C suffix .

Bill 90471 administration code.                                      

Report the vaccine CPT code if vaccine was provided at no charge from the state of North Carolina.    

OR

Bill the vaccine CPT code if vaccine was purchased.

Report diagnosis code as appropriate.

Bill under the C suffix.

Bill 90471 and 90472 administration codes.

Report the vaccine CPT codes if vaccines were provided at no charge from the state of North Carolina.

OR

Bill the CPT vaccine codes if the vaccines were purchased.

Report diagnosis codes as appropriate.

Core Visit with Immunization(s)

Immunization administration fees cannot be billed with core visits.

Immunization administration fees cannot be billed with core visits.

Immunization(s) Only

Bill 90471 administration code.

Bill vaccine CPT code.

Report diagnosis code as appropriate.

Bill 90471 and 90472.

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill E/M code with modifier 25 appended in addition to the administration code if a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with modifier 25 appended in addition to 90471 and 90472 if a separately identifiable service was performed.                                                                           

Bill vaccine CPT codes.

J9212

Injection, sodium chloride, 0.9%

Per 2 ml

J1562

Immune globulin, subcutaneous

100 mg

$13.50

J3473

Hyaluronidase, recombinant

1 USP unit

$0.40

J7317

Sodium hyaluronate

20–25 mg

J7319

Hyaluronan (sodium hyaluronate) or derivative, intra-articular injection

Per injection

$130.50

J7320

Hylan G-F 20, for intra-articular injection

16 mg

J3490

Etonogestrel contraceptive implant system (Implanon)

S0180

Etonogestrel contraceptive implant system, including implants and supplies (Implanon)*

each

$588.38

J3490

Ibandronate sodium (Boniva)

3 mg

J1740

Ibandronate sodium (Boniva)

1 mg

$138.85

J3590

Abatacept (Orencia)

250 mg

J0129

Abatacept (Orencia )

10 mg

$18.70

N/A

A9527

Iodine I-125, sodium iodide solution, therapeutic

Per mCi

Per Invoice

A9549

Technetium TC-99M arcitumomab, diagnostic per study dose

Up to 25 mCi

A9568

Technetium TC-99M arcitumomab, diagnostic per study dose

Up to 45 mCi

Per Invoice

E0164

E0166

E0180

E2320

K0090

K0091

K0092

K0093

K0094

K0095

K0096

K0097

K0098

W4704

W4705

W4706

K0010

K0011

E0163

Commode chair, mobile or stationary, with fixed arms

E0165

Commode chair, mobile or stationary, with detachable arms

E0167

Pail or pan for use with commode chair, replacement only

E0181

Powered pressure-reducing mattress overlay/pad, alternating, with pump, includes heavy duty

E0182

Pump for alternating pressure pad, for replacement only

E0720

Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation

E0730

Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, multiple nerve stimulation

E0967

Manual wheelchair accessory, hand rim with projections, any type, each

E2209

Arm trough, with or without hand support, each

E2373*

Power wheelchair accessory, hand or chin control interface, mini-proportional, compact, or short throw remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware

4 yrs/ 2yrs 00 thru 20

E2374*

Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

4 yrs/ 2yrs 00 thru 20

E2375*

Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only

4 yrs/ 2yrs 00 thru 20

E2376*

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

4 yrs/ 2yrs 00 thru 20

E2377*

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue

4 yrs/ 2yrs 00 thru 20

E2381

Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

1 year

E2382

Power wheelchair accessory, tube for pneumatic drive tire, any size replacement only, each

1 year

E2383

Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

1 year

E2384

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

1 year

E2385

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

1 year

E2386

Power wheelchair accessory, foam-filled drive wheel tire, any size, replacement only, each

1 year

E2387

Power wheelchair accessory, foam-filled caster tire, any size, replacement only, each

1 year

E2388

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

1 year

E2389

Power wheelchair accessory, foam caster tire, any size, replacement only, each

1 year

E2390

Power wheelchair accessory, solid (rubber/plastic}drive wheel tire, any size, replacement only, each

1 year

E2391

Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

1 year

E2392

Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

1 year

E2393

Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each

1 year

E2394

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

1 year

E2395

Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

1 year

E2396

Power wheelchair accessory, caster fork, any size, replacement only, each

1 year

K0733*

Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

1 year

K0813*

Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds

4 years

K0814*

Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0815*

Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds

4 years

K0816*

Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0820*

Power wheelchair, group 2, standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0821*

Power wheelchair, group 2 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds

4 years

K0822*

Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0823*

Power wheelchair, group 2 standard, captains seat, patient weight capacity up to and including 300 pounds

4 years

K0824*

Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0825*

Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0826*

Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0827*

Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds

4 years

K0828*

Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more

4 years

K0829*

Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601 pounds or more

4 years

K0830*

Power wheelchair, group 2, seat elevator, sling/solid seat/back, patient capacity up to and including 300 pounds

4 years

K0831*

Power wheelchair, group 2, seat elevator, captains chair, patient capacity up to and including 300 pounds

4 years

K0835*

Power wheelchair, group 2 standard, single power option, sling/solid seat back, patient weight capacity up to and including 300 pounds

4 years

K0836*

Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0837*

Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0838*

Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0839*

Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0840*

Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more

4 years

K0841*

Power wheelchair, group 2 standard, multiple power options, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0842*

Power wheelchair, group 2 standard, multiple power options, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0843*

Power wheelchair, group 2 heavy duty, multiple power options, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0848*

Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0849*

Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0850*

Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0851*

Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0852*

Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0853*

Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds

4 years

K0854*

Power wheelchair, group 3 extra heavy duty, sling/back seat/back, patient weight capacity 601 pounds or more

4 years

K0855*

Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more

4 years

K0856*

Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0857*

Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0858*

Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0859*

Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0860*

Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0861*

Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0862*

Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0863*

Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0864*

Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more

4 years

K0868*

Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0869*

Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0870*

Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0871*

Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0877*

Power wheelchair, group 4 standard, single power option, sling/solid seat back, patient weight capacity up to and including 300 pounds

4 years

K0878*

Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0879*

Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0880*

Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds

4 years

K0884*

Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0885*

Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0886*

Power wheelchair, group 4 heavy duty, multiple, power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0890*

Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

4 years

K0891*

Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

4 years

K0898*

Power wheelchair, not otherwise classified

4 years

*A8000

Helmet, protective, soft, prefabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8001

Helmet, protective, hard, prefabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8002

Helmet, protective, soft, custom fabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8003

Helmet, protective, hard, custom fabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8004

Soft interface for helmet, replacement only

6 months

*L1001

Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment

6 months

*L3806

Wrist-hand-finger orthosis, includes one or more non-torsion joint(s), elastic bands, turnbuckles, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

6 months: ages 00-20

3 years: ages 21-115

*L3808

Wrist-hand-finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment

6 months: ages 00-20

3 years: ages 21-115

*L3915

Wrist-hand orthosis, includes one or more non-torsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment

6 months: ages 00-20

3 years: ages 21-115

*L5993

Addition to lower extremity prosthesis, heavy-duty feature, foot only (for patient weight greater than 300 lbs.)

1 year: ages 00-20

3 years: ages 21-115

*L5994

Addition to lower extremity prosthesis, heavy-duty feature, knee only (for patient weight greater than 300 lbs.)

1 year: ages 00-20

3 years: ages 21-115

*L6624

Upper extremity addition, flexion/extension and rotation wrist unit

6 months: ages 00-20

3 years: ages 21-115

*L6639

Upper extremity addition, heavy-duty feature, any elbow

6 months: ages 00-20

3 years: ages 21-115

*L6703

Terminal device, passive hand/mitt, any material, any size

1 year: ages 00-20

3 years: ages 21-115

*L6704

Terminal device, sport/recreational/work attachment, any material, any size

1 year: ages 00-20

3 years: ages 21-115

*L6706

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined

1 year: ages 00-20

3 years: ages 21-115

*L6707

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined

1 year: ages 00-20

3 years: ages 21-115

*L6708

Terminal device, hand, mechanical, voluntary opening, any material, any size

1 year: ages 00-20

3 years: ages 21-115

*L6709

Terminal device, hand, mechanical, voluntary closing, any material, any size

1 year: ages 00-20

3 years: ages 21-115

L0631

Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L5848

Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability

L5995

Addition to lower extremity prosthesis, heavy-duty feature, other than foot or knee (for patient weight greater than 300 lbs.)

L6805

Addition to terminal device, modifier wrist unit

L6810

Addition to terminal device, precision pinch device

L6884

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

L0100

L0110

L3902

L3914

L6700

L6705

L6710

L6715

L6720

L6725

L6730

L6735

L6740

L6745

L6750

L6755

L6765

L6770

L6775

L6780

L6790

L6795

L6800

L6806

L6807

L6808

L6809

L6825

L6830

L6835

L6840

L6845

L6850

L6855

L6860

L6865

L6867

L6868

L6870

L6872

L6873

L6875

L6880

March   2

Winston-Salem

March   6

Fayetteville

March 16

Raleigh–Durham

March 23

Greenville

March 30

Asheville

D0273

Bitewings – three films

*      allowed one (1) time per 12 calendar month period

*      not allowed on the same date of service as D0270, D0272 or D0274

*      not allowed within the same 12 calendar month period as D0210

$24.46

D1206

Topical fluoride varnish; therapeutic application for moderate to high-caries-risk patients

*      limited to recipients under age 21

*      allowed one time per recipient per six calendar month period for the same provider

$15.44

D2970

Temporary crown (fractured tooth)

*      limited to recipients under age 21

$126.91

D7311

Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

*      must be at least three edentulous units in a quadrant to qualify for payment for alveoloplasty

*      requires a quadrant indicator in the area of oral cavity or tooth number field

*$82.00

D7321

Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

*      requires prior approval

*      must be at least three edentulous units in a quadrant to qualify for payment for alveoloplasty

*      requires a quadrant indicator in the area of oral cavity or tooth number field

$131.61

D1201

Topical application of fluoride (including prophylaxis) - child

D1205

Topical application of fluoride (including prophylaxis) - adult

D7310

Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces per quadrant

D7320

Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces per quadrant

D7944

Osteotomy – segmented or subapical

D7950

Osseous, osteoperiosteal or cartilage graft of the mandible or maxilla – autogenous or nonautogenous, by report

D9610

Therapeutic parenteral drug, single administration

*      allowed for a single administration of antibiotics, steroids, anti-inflammatory drugs or other therapeutic medications.

*      not allowed for the administration of sedatives, anesthetic or reversal agents.

*      identify the drug, dosage, and rationale in the recipient’s dental record and on the claim form if filed as a paper claim

D0150

Comprehensive oral evaluation – new or established patient

D0120

Periodic oral evaluation – established patient

D1203

Topical application of fluoride (including prophylaxis) – child

D1330

Oral hygiene instructions

D0145

Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

*      replacing procedure codes D0150, D0120, and D1330

*      must be billed in conjunction with D1206

*      limited to recipients under age 3

*      allowed once every 90 days

*      limited to six times prior to the recipient’s third birthday

$38.07

D1206

Topical fluoride varnish; therapeutic application for moderate to high-caries-risk patients

*      replacing procedure code D1203

*      must be billed in conjunction with D0145

*      limited to recipients under age 3

*      allowed once every 90 days

*      limited to six times prior to the recipient’s third birthday

$15.44

January

01/05/07

01/09/07

01/12/07

01/17/07

01/19/07

01/25/07

February

02/02/07

02/06/07

02/08/07

02/13/07

02/15/07

02/20/07

02/22/07

02/28/07

March

03/01/07

03/06/07

03/08/07

03/13/07

03/15/07

03/20/07

03/22/07

03/29/07