June 2002 North Carolina Medicaid Bulletin

In This Issue……

All Providers:

CPT Code Update 2002 – Code Description Correction

Fee Schedules and Reimbursement Plans

Proposed Medical Coverage Policies

Checkwrite Schedule

Electronic Cut-Off Schedule

Federally Qualified Health Centers:

Core Service Code Conversion

Health Check Providers:

Health Check Seminar

Mecklenburg County Providers:

Managed Care Update

Physicians:

Injectable Drug List Update

Miscellaneous Supplies

Residential Child Care Facility Providers:

Accreditation Requirement and Provider Status Changes

Rural Health Clinics:

Core Service Code Conversion

Attention: All Providers

Proposed Medical Coverage Policies

In accordance with S.L. 2001-424, SB 1005, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA’s website at http://www.dhhs.state.nc.us/dma/prov.htm. To submit a comment related to a policy, refer to the instructions on the website. The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

Darlene Cagle, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

CPT Code Update 2002 – Code Description Correction

The correct description for CPT code 10022 is Fine needle aspiration; with imaging guidance. This replaces the description published in the April 2002 general Medicaid bulletin.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Mecklenburg County Providers

Managed Care Update

Mecklenburg County now offers two types of Medicaid managed care programs to recipients. Recipients may choose between HMO or Carolina ACCESS enrollment. The names of the two HMOs are United Healthcare and SouthCare. The name of the HMO is printed on its members’ Medicaid card. There are three groups of Carolina ACCESS providers available to recipients: Carolinas Medical Center-ACCESS II, Metrolina Comprehensive, and a group of independent Carolina ACCESS providers. The name, address, and telephone number of the individual Carolina ACCESS/ACCESS II provider or Metrolina is printed on the recipient’s Medicaid card. This information can also be obtained through the Automated Voice Response (AVR) system. (Refer to Special Bulletin II, July 2001 for more information.)

Providers who serve HMO enrollees must obtain referral authorization and payment from the HMO for in-plan services. Providers who serve another provider’s Carolina ACCESS enrollee must obtain referral authorization from the Carolina ACCESS primary care provider listed on the recipient’s card. The referral authorization number must be entered in block 19 of the HCFA-1500 claim form submitted to Medicaid for reimbursement. Many procedures and services covered by the Medicaid program require prior approval. The referral authorization does not replace the prior approval process required by Medicaid.

Darryl Frazier, Managed Care Section
DMA, 919-857-4022

Attention: Physicians

Miscellaneous Supplies

Effective with date of service July 1, 2002, procedure code W5120 will be end-dated and replaced with HCPCS procedure code A9900, miscellaneous supplies. Claims submitted for over-the-counter supplies that can be purchased without a physician’s prescription are noncovered and will deny. Items excluded from the N.C. Medicaid program must not be billed.

An invoice must be submitted with the claim. HCPCS procedure code A9900 is priced from the invoice. Items or supplies that are noncovered will be denied with EOB 009, "Service not covered by the Medicaid program."

EDS, 1-800-688-6696 or 919-851-8888

Attention: Physicians

Injectable Drug List Update

The following table is an updated list of FDA approved drugs currently covered by the N.C. Medicaid program when provided in a physician’s office for the FDA approved indications. This list replaces previously published lists. Fees are effective with date of service July 1, 2002. Vaccines and immune globulins are not included on this list and will be published separately.

Physicians will continue to bill on the HCFA-1500 claim form using the appropriate drug code and indicating the specified number of units administered.

(*) Designates that an invoice is required to accompany the HCFA-1500 claim form. Payment is based on the invoice price.

* Procedure Code Description Fee

J0130 Abciximab 10 mg
487.37

J1120 Acetazolamide Sodium, up to 500 mg (Diamox)
28.16

J0150 Adenosine I.V., 6 mg (Adenocard)
32.54

J0151 Adenosine, 90 mg (Adenoscan)
201.93

J0170 Adrenalin, Epinephrine, up to 1 ml ampule
1.52

J0205 Alglucerase, per 10 units (Ceredase)
35.65

J0256 Alpha 1 Proteinase Inhibitor Human A, 10 mg (Prolastin)
1.99

J9015 Aldesleukin, per single use vial (Proleukin, IL-2, Interleukin) 22 million I.U.
664.24

J0207 Amifostine 500 mg (Ethyol)
372.45

S0016 Amikacin Sulfate (250 mg)
14.67

S0072 Amikacin Sulfate (100 mg)
7.02

J0280 Aminophyllin, up to 250 mg
1.00

J1320 Amitriptyline HCL, up to 20 mg (Elavil, Enovil)
2.11

J0300 Amobarbital, up to 125 mg (Amytal)
2.10

J0285 Amphotericin B, 50 mg (Amphocin, Fungizone IV)
10.51

J0286 Amphotericin B Any Lipid Formulation, 50 mg
84.23

J0295 Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm (Unasyn)
7.13

J0290 Ampicillin, up to 500 mg (Omnipen-N, Totacillin-N)
1.42

J0350 Anistreplase, per 30 units (Eminase)
2,296.82

J7197 Antithrombin II (human) per I.U. (Throbate III)
1.00

J0395 Arbutamine HCL, 1 mg (GenESA)
173.28

J9020 Asparaginase, 10,000 units (Elspar)
56.72

J0460 Atropine Sulfate, up to 0.3 mg
.06

J2910 Aurothioglucose, up to 50 mg (Solganal)
13.84

* J3490 Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list

J0456 Azithromycin, 500 mg. (Zithromax)
22.06

J0475 Baclofen, Kit 1*20 ml. Amp. (10 mg/20ml. 500 meg/ml.)
222.02

* J3490 Baclofen, Kit 2*5 ml. Amp. (10 mg./5 ml. 2000 meg/ml.)

* J3490 Baclofen, Kit 4*5 ml. Amp. (10 mg./5ml. 2000 meg/ml.)

J0476 Baclofen, for intrathecal trial, 50 mcg (Lioresal for intrathecal trial)
75.81

J9031 BCG live (intravesical) per installation (Tice, TheraCys)
162.91

J0585 Botulinum toxin type A, per unit (Botox)
4.43

J0702 Betamethasone Acetate and Betamethasone Sodium Phosphate, per 3 mg
4.64

J0704 Betamethasone Sodium Phosphate, per 4 mg
2.15

J0520 Bethanechol Chloride, mytonachol or urecholine, up to 5 mg (Urecholine)
4.55

J9040 Bleomycin Sulfate, 15 units (Blenoxane)
274.90

J0945 Brompheniramine Maleate, 10mg
.81

S0009 Butorphanol Tartrate, 1mg (Stadol)
6.48

J0635 Calcitriol, 1 mcg amp (Calcijex)
13.13

J0610 Calcium Gluconate, per 10 ml (Kaleinate)
1.22

J0620 Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan)
4.89

J9045 Carboplatin, 50 mg (Paraplatin)
117.42

J9050 Carmustine, 100 mg (BiCNU)
120.90

J0690 Cefazolin Sodium, 500 mg (Ancef, Kefzol, Zolicef)
1.03

J0692 Cefepime HCL, 500 mg (Maxiprene)
7.22

J0698 Cefotaxime Sodium, per gm (Claforan)
9.93

J0694 Cefoxitin Sodium, 1 gm (Mefoxin)
9.84

J0713 Ceftazidime per 500 mg (Fortaz, Tazidime)
6.42

J0715 Ceftizoxime Sodium, per 500 mg (Cefizox)
5.85

J0696 Ceftriaxone Sodium, per 250 mg (Rocephin)
13.47

J0697 Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef)
6.10

J1890 Cephalothin Sodium, up to 1 gm (Keflin)
9.75

J0710 Cephapirin Sodium, up to 1 gm (Cefadyl)
1.33

J0720 Chloramphenicol Sodium Succinate, up to 1 gm
5.99

J1990 Chlordiazepoxide HCL, up to 100 mg (Librium)
23.75

J2400 Chlorprocaine HCL 30 ml (Nesacaine, Nesacaine-MPF)
9.98

J0390 Chloroquine HCL, up to 250 mg (Aralen)
17.92

J1205 Chlorothiazide Sodium, 500 mg (Diuril Sodium)
9.50

J3230 Chlorpromazine HCL up to 50 mg (Thorazine)
2.44

J0725 Chorionic Gonadotropin, per 1,000 USP units
1.54

J0740 Cidofovir 375 mg (Vistide)
763.52

J0743 Cilastatin Sodium Imipenem, per 250 mg (Primaxin IM, Primaxin IV)
14.73

S0023 Cimetadine HCL, 300 mg (Tagamet)
4.99

J0744 Ciprofloxacin, 200 mg (Cipro)
13.00

J9062 Cisplatin, 50 mg (Platinol AQ)
200.36

J9060 Cisplatin, powder or solution, per 10 mg (Platinol, Plantinol AQ)
40.07

J9065 Cladribine, per 1 mg (Leustatin)
50.72

J0735 Clonidine Hydrochloride, 1 mg
52.40

J0745 Codeine Phosphate, per 30 mg
1.02

J0760 Colchicine, 1 mg
6.72

J0770 Colistimethate Sodium, up to 150 mg (Coly-Mycin M)
37.91

J0800 Corticotropin, up to 40 units (Acthar, ACTH)
4.51

J0835 Cosyntropin, per 0.25 mg (Cortrosyn)
14.57

J3420 Cyanocobalamin, vitamin B 12, 1000 mcg
.06

J9096 Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized)
46.42

J9093 Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized)
5.82

J9091 Cyclophosphamide, 1.0 gm (Cytoxan, Neosar)
45.26

J9070 Cyclophosphamide, 100 mg (Cytoxan, Neosar)
5.68

J9092 Cyclophosphamide, 2.0 gm (Cytoxan, Neosar)
90.51

J9080 Cyclophosphamide, 200 mg (Cytoxan, Neosar)
10.77

J9090 Cyclophosphamide, 500 mg (Cytoxan, Neosar)
22.62

J9094 Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized)
11.06

J9095 Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized)
23.20

J9097 Cyclophosphamide Lyophilized, 2gm
92.86

J9100 Cytarabine 100 mg (Cytosar-U)
5.72

J9110 Cytarbine, 500 mg (Cytosar-U)
23.49

J9130 Dacarbazine 100 mg (DTIC-Dome)
12.05

J9140 Dacarbazine 200 mg (DTIC-Dome)
21.43

J7513 Daclizumab, 25 mg (Zenapax)
377.43

J9120 Dactinomycin, .5 mg (Cosmegen)
12.57

J1645 Dalteparin, per 2500 I.U. (Fragmin)
10.17

J9150 Daunorubicin HCL, 10 mg (Cerubidine)
76.04

J9151 Daunorubicin Citrate Liposomal, 10 mg (DaunoXome)
61.37

J0895 Deferoxamine Mesylate, 500 mg (Desferal)
12.83

J9160 Denileukin Diftitox, 300mcg (Ontak)
1,044.87

J1000 Depoestradiol Cypionate, up to 5 mg
2.47

J1095 Dexamethasone Acetate 8 mg
2.19

J2597 Desmopression Acetate per 1 mcg (DDAVP)
4.54

J1100 Dexamethosone Sodium Phosphate, 1 mg (Cortastat, Dalalone)
.10

J1190 Dexrazoxane HCL, 250 mg (Zinecard)
184.80

J7110 Dextran 75, 500 ml
97.96

J7042 Dextrose 5%/Normal Saline (500 ml = 1 unit)
7.89

J7070 D5W, 1000 cc
11.36

J7060 Dextrose 5%/Water (500 ml = 1 unit)
8.84

J3360 Diazepam, up to 5 mg (Valium, Zetran)
1.12

J1730 Diazoxide, up to 300 mg (Hyperstat IV)
111.18

J0500 Dicyclomine HCL, up to 20 mg (Bentyl, Dilomine, Antispas)
9.64

J9165 Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol)
13.69

J1160 Digoxin, up to 0.5 mg (Lanoxin)
2.05

J1110 Dihydroergotamine Mesylate, up to 1 mg
13.86

J0470 Dimercaprol, per 100 mg
22.49

J1240 Dimenhydrinate, up to 50 mg
.36

J1200 Diphenhydramine HCL, up to 50 mg (Benadryl)
1.11

J1245 Dipyridamole, per 10 mg (Persantine IV)
20.80

J1212 DMSO, Dimethyl Sulfoxide, 50%, 50 ml
39.66

J1250 Dobutamine HCL, 250 mg (Dobutrex)
10.31

J9170 Docetaxel, 20 mg (Taxotere)
297.08

J1260 Dolasetron Mesylate, 10 mg (Anzemet)
15.63

J9001 Doxorubicin HCL, all lipid formulations, 10 mg,
359.42

J9000 Doxorubicin HCL, 10 mg (Adriamycin PFS, Adriamycin RDF, Rubex)
41.07

J1810 Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar)
10.95

J1790 Droperidol, up to 5 mg (Inapsine)
5.17

J1180 Dyphylline, up to 500 mg (Lufyllin, Dilor)
7.48

J0600 Edetate Calcium Disodium up to 1000 mg
38.09

J1650 Enoxaparin Sodium, 10 mg (Lovenox)
5.25

Q9920 EPO, per 1000 units, Patient HCT 20 or less
11.69

Q9921 EPO, per 1000 units, Patient HCT 21
11.69

Q9922 EPO, per 1000 units, Patient HCT 22
11.69

Q9923 EPO, per 1000 units, Patient HCT 23
11.69

Q9924 EPO, per 1000 units, Patient HCT 24
11.69

Q9925 EPO, per 1000 units, Patient HCT 25
11.69

Q9926 EPO, per 1000 units, Patient HCT 26
11.69

Q9927 EPO, per 1000 units, Patient HCT 27
11.69

Q9928 EPO, per 1000 units, Patient HCT 28
11.69

Q9929 EPO, per 1000 units, Patient HCT 29
11.69

Q9930 EPO, per 1000 units, Patient HCT 30
11.69

Q9931 EPO, per 1000 units, Patient HCT 31
11.69

Q9932 EPO, per 1000 units, Patient HCT 32
11.69

Q9933 EPO, per 1000 units, Patient HCT 33
11.69

Q9934 EPO, per 1000 units, Patient HCT 34
11.69

Q9935 EPO, per 1000 units, Patient HCT 35
11.69

Q9936 EPO, per 1000 units, Patient HCT 36
11.69

Q9937 EPO, per 1000 units, Patient HCT 37
11.69

Q9938 EPO, per 1000 units, Patient HCT 38
11.69

Q9939 EPO, per 1000 units, Patient HCT 39
11.69

Q9940 EPO, per 1000 units, Patient HCT 40
11.69

Q0136 Epoetin Alpha (for non ESRD use) per 1000 units (Epogen)
11.69

J1325 Epoprostenol 0.5 mg
17.16

J1330 Ergonovine Maleate, up to 0.2 mg
4.28

J1364 Erythromycin Lactobionate, per 500 mg (Erythrocin)
5.64

J1380 Estradiol Valerate, up to 10 mg
9.18

J1390 Estradiol Valerate, up to 20 mg
12.94

J0970 Estradiol Valerate, up to 40 mg (Delestrogen)
21.48

J1410 Estrogen Conjugated, per 25 mg (Premarin Intravenous)
52.35

J1435 Estrone, per 1 mg (Estone Aqueous, Estronol, etc.)
.18

J1436 Etidronate Disodium, per 300 mg (Didronel)
60.47

J9181 Etoposide, 10 mg (VePesid)
9.93

J9182 Etoposide, 100 mg (VePesid)
99.28

J3010 Fentanyl Citrate, 0.1 mg (2 ml) (Sublimaze)
1.23

J7190 Factor VIII (anti-hemophilic factor, human) per I.U.
.82

J7191 Factor VIII (anti-hemophilic factor, porcine) per I.U.
1.99

J7192 Factor VIII (anti-hemophilic factor, recombinant) – per I.U.
1.06

J7194 Factor IX complex, per I.U.
.29

J7193 Factor IX (Antihemophilic Factor, Purified, non-recombinant) – per I.U.
1.00

J7195 Factor IX (Antihemophilic Factor, recombinant) – per I.U.
1.07

J1440 Filgrastim , 300 mcg/1ml (Neupogen)
170.13

J1441 Filgrastim , 480 mcg/1.6ml (Neupogen)
284.38

J9200 Floxuridine, 500 mg (FUDR)
123.08

J9185 Fludarabine Phosphate, 50 mg (Fludara)
295.57

J9190 Fluorouracil, 500 mg (Adrucil)
2.47

J2680 Fluphenazine Decanoate, up to 25 mg (Prolixin Decanoate)
13.39

J1455 Foscarnet Sodium, per 1000 mg (Foscavir)
11.48

J1940 Furosemide, up to 20 mg (Lasix, Furomide M.D.)
1.18

J1460 Gamma Globulin, Intramuscular, 1 cc (Gammar)
3.24

J1470 Gamma Globulin, Intramuscular, 2 cc
6.48

J1480 Gamma Globulin, Intramuscular, 3 cc
9.72

J1490 Gamma Globulin, Intramuscular, 4 cc
12.96

J1500 Gamma Globulin, Intramuscular, 5 cc
16.20

J1510 Gamma Globulin, Intramuscular, 6 cc
19.44

J1520 Gamma Globulin, Intramuscular, 7 cc
22.68

J1530 Gamma Globulin, Intramuscular, 8 cc
25.92

J1540 Gamma Globulin, Intramuscular, 9 cc
29.16

J1550 Gamma Globulin, Intramuscular, 10 cc
32.40

J1560 Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of above codes)

J1570 Ganciclovir Sodium, 500 mg (Cytovene)
32.20

J7310 Ganciclovir, Long-acting Implant, 4.5 mg (Vitrasert)
4,512.50

J9201 Gemcitabine HCl. 200 mg (Gemzar)
106.45

J1580 Gentamicin (Garamycin Sulfate) up to 80 mg (Gentamicin Sulfate, Jenamicin)
1.85

J1610 Glucagon Hydrochloride, per 1 mg
43.32

J1600 Gold Sodium Thiomaleate, up to 50 mg (Myochrysine)
10.66

J1620 Gonadorelin Hydrochloride, per 100 mcg (Factrel)
182.75

J9202 Goserelin Acetate Implant, per 3.6 mg (Zoladex)
424.17

J1626 Granisetron Hydrochloride, 100 mcg (Kytril)
17.61

J1631 Haloperidol Decanoate, per 50 mg (Haldol Decanoate – 50)
25.37

J1630 Haloperidol Lactate, up to 5 mg (Haldol)
6.77

J1642 Heparin Sodium, per 10 units (Heparin Lock Flush)
.05

J1644 Heparin Sodium, per 1000 units
.33

J3470 Hyaluronidase, up to 150 units (Wydase)
5.78

J0360 Hydralazine HCL, up to 20 mg (Apresoline)
16.92

J1700 Hydrocortisone Acetate, up to 25 mg
.32

J1710 Hydrocortisone Sodium Phosphate, up to 50 mg
5.04

J1720 Hydrocortisone Sodium Succinate, up to 100 mg
1.72

J1170 Hydromorphone, up to 4 mg (Dilaudid)
.96

J3410 Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50)
.67

J7320 Hylan G-F 20, 16 mg, for intra-arterial injection (Synvisc)
212.09

J1980 Hyoscyamine Sulfate, up to 0.25 mg (Levsin)
7.51

J7130 Hypertonic Saline Solution, 50 or 100 mEq, 20 cc vial)
.45

J1742 Ibutilide Fumarate 1 mg. (Corvert)
228.61

J9211 Idarubicin Hydrochloride, 5 mg (Idamycin)
411.18

J9208 Ifosfamide, 1 gm (Ifex)
153.28

J1785 Imiglucerase, per unit (Cerezyme)
3.56

J1561 Immune Globulin, Intravenous, 500 mg (Panglobulin)
36.10

J1745 Infliximab, 10 mg (Remicade)
62.42

J1820 Insulin, up to 100 units (Regular, NPH, Lente, or Ultralente))
2.40

J9213 Interferon, Alfa-2A, Recombinant, 3 million units (Roferon-A)
33.14

J9214 Interferon, Alfa-2B, Recombinant, 1 million units (Intron A)
12.82

J9215 Interferon, Alfa-N3, (human leukocyte derived) 250,000 IU (Alferon N)
7.47

J9212 Interferon, Alfacon-1, Recombinant, 1 mcg (Infergen)
3.90

J9216 Interferon, Gamma 1-B, 3 million units (Actimmune)
271.36

J9206 Irinotecan, 20 mg (Camptosar)
133.66

J1750 Iron Dextran, 50 mg (Infed)
17.01

J1840 Kanamycin Sulfate, up to 500 mg (Kantrex, Klebcil)
2.03

J1850 Kanamycin Sulfate, up to 75 mg (Kantrex, Klebcil)
2.94

J1885 Ketorolac Tromethamine, per 15 mg (Toradol)
5.46

J1910 Kutapressin, up to 2 ml
12.62

J0640 Leucovorin Calcium, per 50 mg (Wellcovorin)
16.64

J9217 Leuprolide Acetate, 7.5 mg (Lupron, for Depot Suspension)
580.98

J1950 Leuprolide Acetate, 3.5 mg (Lupron, for Depot Suspension)
483.05

J9218 Leuprolide Acetate, per 1 mg (Lupron)
24.84

J1955 Levocarnitine, per 1 gm (Carnitor)
32.49

J1956 Levofloxacin, 250 mg (Levaquin)
17.87

J1960 Levorphanol tartrate, up to 2 mg (Levo-Dromoran)
3.57

J2000 Lidocaine HCL, 50 cc (Xylocaine)
1.38

J2010 Lincomycin HCL, up to 300 mg (Lincocin)
1.30

J2060 Lorazepam, 2 mg (Ativan)
1.30

* J3490 Leuprolide Acetate, 11.25 mg (Lupron Depot Pediatric)
(Send in claim with invoice for manual pricing)

* J3490 Leuprolide Acetate, 15 mg (Lupron Depot Pediatric)
(Send in claim with invoice for manual pricing)

* J3490 Leuprolide Acetate, 7.5 mg (Lupron Depot Pediatric)
(Send in claim with invoice for manual pricing)

J3475 Magnesium Sulfate, 500 mg.
.21

J2150 Mannitol, 25% in 50 ml
2.87

J9230 Mechlorethamine Hydrochloride (Nitrogen Mustard), 10 mg
10.88

J1055 Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera)
43.29

J1050 Medroxyprogesterone Acetate, 100 mg (Depo-Provera)
9.45

J9245 Melphalan Hydrochloride, 50 mg, (Alkeran)
395.93

J2180 Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection)
3.73

J2175 Meperidine Hydrochloride, per 100 mg (Demerol HCL)
.57

J0670 Mepivacaine, per 10 ml (Carbocaine)
1.80

J9209 Mesna, 200 mg (Mesnex)
34.66

J0380 Metaraminol Bitartrate, 10 mg (Aramine)
1.15

J1230 Methadone HCL, up to 10 mg (Dolophine)
.71

J2800 Methocarbamol, up to 10 ml (Robaxin)
6.09

J9250 Methotrexate Sodium, 5 mg
.46

J9260 Methotrexate Sodium, 50 mg
5.36

J0210 Methyldopate HCL, up to 250 mg (Aldomet)
8.53

J2210 Methylergonovine Maleate, up to 0.2 mg (Methergine)
3.37

J1020 Methylprednisolone Acetate, 20 mg (Depo Medrol)
2.26

J1030 Methylprednisolone Acetate, 40 mg
4.09

J1040 Methylprednisolone Acetate, 80 mg
8.18

J2930 Methylprednisolone Sodium Succinate, up to 125 mg (Solu-Medrol, A-methaPred)
2.95

J2920 Methylprednisolone Sodium Succinate, up to 40 mg (Solu-Medrol, A-Metha Pred)
1.82

J2765 Metoclopramide HCL, up to 10 mg (Reglan)
1.81

J2250 Midazolam HCL, per 1 mg (Versed)
.64

J2260 Milrinone Lactate, 5 mg per 5 ml (Primacor)
40.47

J9290 Mitomycin, 20 mg (Mutamycin)
392.23

J9291 Mitomycin, 40 mg (Mutamycin)
825.79

J9280 Mitomycin, 5 mg (Mutamycin)
118.30

J9293 Mitoxantrone HCL, per 5 mg (Novantrone)
252.87

J2275 Morphine Sulfate (preservative-free sterile solution), per 10 mg (Astramorph PF, Duramorph)
7.32

J2270 Morphine Sulfate, up to 10 mg
1.35

J2271 Morphine Sulfate (100 mg)
9.26

J2310 Nalaxone HCL, per 1 mg (Narcan)
3.99

J2300 Nalbuphine Hydrochloride, 10 mg
1.37

J2321 Nandrolone Decanoate, up to 100 mg
6.00

J2322 Nandrolone Decanoate, up to 200 mg
12.01

J2320 Nandrolone Decanoate, up to 50 mg
4.94

J2710 Neostigmine Methylsulfate, up to 0.5 mg (Prostigmin)
.67

J7030 Normal Saline Solution, 1000 cc, infusion
11.31

J7050 Normal Saline Solution, 250 cc, infusion
10.81

J7040 Normal Saline Solution, Sterile (500 ml=1 unit), infusion
10.29

S0079 Octreotide Acetate, 100 mcg (Sandostatin)
15.75

J2352 Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 30 mg
1,385.54

* J3490 Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 20 mg

* J3490 Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 10 mg

J2405 Ondansetron Hydrochloride, per 1 mg (Zofran)
5.79

J2355 Oprelvekin, 5 mg (Newmega)
233.52

J2360 Orphenadrine Citrate, up to 60 mg (Norflex, etc.)
1.44

J2700 Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin)
.62

J2410 Oxymorphone HCL, up to 1 mg (Numorphan)
2.66

J2460 Oxytetracycline HCL, up to 50 mg (Terramycin IM)
.90

J2590 Oxytocin, up to 10 units (Pitocin, Syntocinon)
.72

J9265 Paclitaxel, 30 mg (Taxol)
155.88

J2430 Pamidronate Disodium, per 30 mg (Aredia)
252.58

J2440 Papaverine HCL, up to 60 mg
3.38

* J9266 Pegaspargase Single Dose vial, (5 ml) (Oncaspar)

J0540 Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units (Bicillin C-R)
13.67

J0550 Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units (Bicillin C-R)
27.37

J0530 Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units (Bicillin C-R)
8.36

J0570 Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen)
18.79

J0580 Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen)
42.18

J0560 Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen)
11.89

J2540 Penicillin G Potassium, up to 600,000 units (Pfizerpen)
.28

J2510 Penicillin G Procaine, Aqueous, up to 600,000 units (Wycillin, etc.)
6.39

J2545 Pentamidine Isethionate, inhalation solution, per 300 mg (Pentam 300, NebuPent, PentacaRinat)
89.12

S0080 Pentamidine Isethionate, IV, IM, per 300 mg
88.88

J3070 Pentazocine HCL, up to 30 mg (Talwin)
4.08

J2515 Pentobarbital Sodium (Nembutal Sodium Solution), per 50 mg
.50

J9268 Pentostatin, per 10 mg (Nipent)
1,571.43

J2543 Piperacillin Sodium/Tazobactam Sodium 1gm/0.125 gm (1.125gm) (Zosyn)
4.64

J3310 Perphenazine, up to 5 mg (Trilafon)
6.45

J2560 Phenobarbital Sodium, up to 120 mg
1.54

J2760 Phentolamine Mesylate, up to 5 mg (Regitine)
30.96

J2370 Phenylephrine HCL, up to 1 ml (NeoSynephrine)
1.22

J1165 Phenytoin Sodium, per 50 mg (Dilantin)
.09

J9270 Plicamycin, 2.5 mg (Mithracin)
89.11

J9600 Porfimer Sodium, 75 mg (Photofin)
2,473.49

J3480 Potassium Chloride, per 2 mEq.
.16

J2730 Pralidoxime Chloride, up to 1 gm (Protopam Chloride)
97.81

J2650 Prednisolone Acetate, up to 1 ml
.32

J2690 Procainamide HCL, up to 1 gm (Pronestyl)
10.48

J0780 Prochlorperazine Edisylate 10 mg (Compazine, Cotranzine, Compa-Z, Ultrazine-10)
2.48

J2950 Promazine HCL, up to 25 mg (Sparine, Prozine-50)
.44

J2550 Promethazine HCL, up to 50 mg (Phenergan, Phenazine)
2.71

J1800 Propranolol HCL, up to 1 mg (Inderal)
11.04

J2720 Protamine Sulfate, per 10 mg
.73

J2725 Protirelin, per 250 mcg (Relefact TRH, Thypinone)
23.18

J2780 Rantidine HCL, 25 mg (Zantac)
1.37

J7120 Ringers Lactate Infusion, up to 1000 cc
12.70

J9310 Rituximab (Rituxan) 100 mg (Rituxan)
431.82

J2820 Sargramostim (GM-CSF), 50 mcg (Leukine, Prokine)
27.61

* J3490 Sodium Bicarbonate 7.5% up to 50 ml

J2912 Sodium Chloride, 0.9% per 2 ml
.09

J7316 Sodium Hyaluronate, 5 mg. for intra-articular injection (Biolon, Provisc, Vitrax, Hyalgan)
26.49

J3320 Spectinomycin Dihydrochloride, up to 2 gm (Trobicin)
25.46

J7051 Sterile Saline or Water (up to 5 cc)
.18

J2995 Streptokinase, per 250,000 IU (Streptase)
114.90

J3000 Streptomycin, up to 1 gm (Streptomycin Sulfate)
6.02

J9320 Streptozocin, 1 gm (Zanosar)
111.76

J0330 Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin)
.10

J9170 Docetaxel, 20 mg (Taxotere)
297.08

J3105 Terbutaline Sulfate, up to 1 mg (Brethine, Bricanyl Subcutaneous)
2.02

J1060 Testosterone Cypionate and Estradiol Cypionate, up to 1 ml
3.52

J1080 Testosterone Estradiol Cypionate, 1 cc, 200 mg
7.12

J1070 Testosterone Estradiol Cypionate, up to 100 mg
4.10

J0900 Testosterone Enanthate and Estradiol Valerate up to 1 cc (Deladumone, etc.)
1.56

J3120 Testosterone Enanthate, up to 100 mg (Evarone, Delatestryl, etc.)
6.47

J3130 Testosterone Enanthate, up to 200 mg, (Evarone, Delatestryl, Andro L.A. 200, etc.)
12.94

J3150 Testosterone Propionate, up to 100 mg (Testex)
.89

J3140 Testosterone Suspension, up to 50 mg (Andronaq 50, Testosterone Aqueous, etc.)
.92

* J0120 Tetracycline, up to 250 mg (Achromycin, Panmycin, Sumycin)

J3280 Thiethylperazine Maleate, up to 10 mg (Norzine, Torecan)
4.37

J9340 Thiotepa, 15 mg (Thioplex)
111.12

J3240 Thyrotropin Alfa, 0.9 mg (Thyrogen)
538.34

J3260 Tobramycin Sulfate, up to 80 mg (Nebcin)
4.98

J9350 Topotecan, 4 mg (Hycamtin)
660.26

J3265 Torsemide, 10 mg/ml (Demadex)
2.10

J2670 Tolazoline HCL, up to 25 mg (Priscoline HCL)
3.72

J9355 Trastuzumab, 10 mg (Herceptin)
50.19

J3301 Triamcinolone Acetonide, per 10 mg (Kenalog-10, Kenalog-40, Tri-Kort, etc.)
1.44

J3302 Triamcinolone Diacetate, per 5 mg (Aristocort Intralesional, Aristocort Forte, Amcort, etc.)
.19

J3303 Triamcinolone Hexacetonide, per 5 mg (Aristospan Intralesional, Aristospan Intra-articular)
2.47

J3400 Triflupromazine HCL, up to 20 mg (Vesprin)
8.24

J3250 Trimethobenzamide HCL, up to 200 mg (Tigan, Ticon, Tiject-20, Arrestin)
.90

J3305 Trimetrexate Glucoronate, per 25 mg (Neutrexin)
112.81

J3350 Urea, up to 40 gm (Ureaphil)
80.02

J3365 Urokinase, 250,000 I.U. Vial (Abbokinase)
442.86

J3364 Urokinase, 5000 I.U. vial (Abbokinase Open-Cath)
53.78

J9357 Valrubicin, intravesical, 200 mg (Valstar)
500.35

J3370 Vancomycin HCL, 500 mg (Varcocin, Vancoled)
4.94

J9360 Vinblastine Sulfate, 1 mg (Velban)
3.90

J9370 Vincristine Sulfate, 1 mg (Oncovin,)
30.47

J9375 Vincristine Sulfate, 2 mg (Oncovin)
49.54

J9380 Vincristine Sulfate, 5 mg (Oncovin,)
146.84

J9390 Vinorelbine Tartrate, per 10 mg (Navelbine)
94.32

J3430 Vitamin K, Phytonadione 1 mg/0.5ml
2.21

J2500 Zemplar (Paricalcitol) 5 mcg
23.84

*	Procedure Code	Description	Fee
	J0130	Abciximab 10 mg	487.37
	J1120	Acetazolamide Sodium, up to 500 mg (Diamox)	28.16
	J0150	Adenosine I.V., 6 mg (Adenocard)	32.54
	J0151	Adenosine, 90 mg (Adenoscan)	201.93
	J0170	Adrenalin, Epinephrine, up to 1 ml ampule	1.52
	J0205	Alglucerase, per 10 units (Ceredase)	35.65
	J0256	Alpha 1 Proteinase Inhibitor Human A, 10 mg (Prolastin)	1.99
	J9015	Aldesleukin, per single use vial (Proleukin, IL-2, Interleukin) 22 million I.U.	664.24
	J0207	Amifostine 500 mg (Ethyol)	372.45
	S0016	Amikacin Sulfate (250 mg)	14.67
	S0072	Amikacin Sulfate (100 mg)	7.02
	J0280	Aminophyllin, up to 250 mg	1.00
	J1320	Amitriptyline HCL, up to 20 mg (Elavil, Enovil)	2.11
	J0300	Amobarbital, up to 125 mg (Amytal)	2.10
	J0285	Amphotericin B, 50 mg (Amphocin, Fungizone IV)	10.51
	J0286	Amphotericin B Any Lipid Formulation, 50 mg	84.23
	J0295	Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm (Unasyn)	7.13
	J0290	Ampicillin, up to 500 mg (Omnipen-N, Totacillin-N)	1.42
	J0350	Anistreplase, per 30 units (Eminase)	2,296.82
	J7197	Antithrombin II (human) per I.U. (Throbate III)	1.00
	J0395	Arbutamine HCL, 1 mg (GenESA)	173.28
	J9020	Asparaginase, 10,000 units (Elspar)	56.72
	J0460	Atropine Sulfate, up to 0.3 mg	.06
	J2910	Aurothioglucose, up to 50 mg (Solganal)	13.84
*	J3490	Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list
	J0456	Azithromycin, 500 mg. (Zithromax)	22.06
	J0475	Baclofen, Kit 1*20 ml. Amp. (10 mg/20ml. 500 meg/ml.)	222.02
*	J3490	Baclofen, Kit 2*5 ml. Amp. (10 mg./5 ml. 2000 meg/ml.)
*	J3490	Baclofen, Kit 4*5 ml. Amp. (10 mg./5ml. 2000 meg/ml.)
	J0476	Baclofen, for intrathecal trial, 50 mcg (Lioresal for intrathecal trial)	75.81
	J9031	BCG live (intravesical) per installation (Tice, TheraCys)	162.91
	J0585	Botulinum toxin type A, per unit (Botox)	4.43
	J0702	Betamethasone Acetate and Betamethasone Sodium Phosphate, per 3 mg	4.64
	J0704	Betamethasone Sodium Phosphate, per 4 mg	2.15
	J0520	Bethanechol Chloride, mytonachol or urecholine, up to 5 mg (Urecholine)	4.55
	J9040	Bleomycin Sulfate, 15 units (Blenoxane)	274.90
	J0945	Brompheniramine Maleate, 10mg	.81
	S0009	Butorphanol Tartrate, 1mg (Stadol)	6.48
	J0635	Calcitriol, 1 mcg amp (Calcijex)	13.13
	J0610	Calcium Gluconate, per 10 ml (Kaleinate)	1.22
	J0620	Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan)	4.89
	J9045	Carboplatin, 50 mg (Paraplatin)	117.42
	J9050	Carmustine, 100 mg (BiCNU)	120.90
	J0690	Cefazolin Sodium, 500 mg (Ancef, Kefzol, Zolicef)	1.03
	J0692	Cefepime HCL, 500 mg (Maxiprene)	7.22
	J0698	Cefotaxime Sodium, per gm (Claforan)	9.93
	J0694	Cefoxitin Sodium, 1 gm (Mefoxin)	9.84
	J0713	Ceftazidime per 500 mg (Fortaz, Tazidime)	6.42
	J0715	Ceftizoxime Sodium, per 500 mg (Cefizox)	5.85
	J0696	Ceftriaxone Sodium, per 250 mg (Rocephin)	13.47
	J0697	Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef)	6.10
	J1890	Cephalothin Sodium, up to 1 gm (Keflin)	9.75
	J0710	Cephapirin Sodium, up to 1 gm (Cefadyl)	1.33
	J0720	Chloramphenicol Sodium Succinate, up to 1 gm	5.99
	J1990	Chlordiazepoxide HCL, up to 100 mg (Librium)	23.75
	J2400	Chlorprocaine HCL 30 ml (Nesacaine, Nesacaine-MPF)	9.98
	J0390	Chloroquine HCL, up to 250 mg (Aralen)	17.92
	J1205	Chlorothiazide Sodium, 500 mg (Diuril Sodium)	9.50
	J3230	Chlorpromazine HCL up to 50 mg (Thorazine)	2.44
	J0725	Chorionic Gonadotropin, per 1,000 USP units	1.54
	J0740	Cidofovir 375 mg (Vistide)	763.52
	J0743	Cilastatin Sodium Imipenem, per 250 mg (Primaxin IM, Primaxin IV)	14.73
	S0023	Cimetadine HCL, 300 mg (Tagamet)	4.99
	J0744	Ciprofloxacin, 200 mg (Cipro)	13.00
	J9062	Cisplatin, 50 mg (Platinol AQ)	200.36
	J9060	Cisplatin, powder or solution, per 10 mg (Platinol, Plantinol AQ)	40.07
	J9065	Cladribine, per 1 mg (Leustatin)	50.72
	J0735	Clonidine Hydrochloride, 1 mg	52.40
	J0745	Codeine Phosphate, per 30 mg	1.02
	J0760	Colchicine, 1 mg	6.72
	J0770	Colistimethate Sodium, up to 150 mg (Coly-Mycin M)	37.91
	J0800	Corticotropin, up to 40 units (Acthar, ACTH)	4.51
	J0835	Cosyntropin, per 0.25 mg (Cortrosyn)	14.57
	J3420	Cyanocobalamin, vitamin B 12, 1000 mcg	.06
	J9096	Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized)	46.42
	J9093	Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized)	5.82
	J9091	Cyclophosphamide, 1.0 gm (Cytoxan, Neosar)	45.26
	J9070	Cyclophosphamide, 100 mg (Cytoxan, Neosar)	5.68
	J9092	Cyclophosphamide, 2.0 gm (Cytoxan, Neosar)	90.51
	J9080	Cyclophosphamide, 200 mg (Cytoxan, Neosar)	10.77
	J9090	Cyclophosphamide, 500 mg (Cytoxan, Neosar)	22.62
	J9094	Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized)	11.06
	J9095	Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized)	23.20
	J9097	Cyclophosphamide Lyophilized, 2gm	92.86
	J9100	Cytarabine 100 mg (Cytosar-U)	5.72
	J9110	Cytarbine, 500 mg (Cytosar-U)	23.49
	J9130	Dacarbazine 100 mg (DTIC-Dome)	12.05
	J9140	Dacarbazine 200 mg (DTIC-Dome)	21.43
	J7513	Daclizumab, 25 mg (Zenapax)	377.43
	J9120	Dactinomycin, .5 mg (Cosmegen)	12.57
	J1645	Dalteparin, per 2500 I.U. (Fragmin)	10.17
	J9150	Daunorubicin HCL, 10 mg (Cerubidine)	76.04
	J9151	Daunorubicin Citrate Liposomal, 10 mg (DaunoXome)	61.37
	J0895	Deferoxamine Mesylate, 500 mg (Desferal)	12.83
	J9160	Denileukin Diftitox, 300mcg (Ontak)	1,044.87
	J1000	Depoestradiol Cypionate, up to 5 mg	2.47
	J1095	Dexamethasone Acetate 8 mg	2.19
	J2597	Desmopression Acetate per 1 mcg (DDAVP)	4.54
	J1100	Dexamethosone Sodium Phosphate, 1 mg (Cortastat, Dalalone)	.10
	J1190	Dexrazoxane HCL, 250 mg (Zinecard)	184.80
	J7110	Dextran 75, 500 ml	97.96
	J7042	Dextrose 5%/Normal Saline (500 ml = 1 unit)	7.89
	J7070	D5W, 1000 cc	11.36
	J7060	Dextrose 5%/Water (500 ml = 1 unit)	8.84
	J3360	Diazepam, up to 5 mg (Valium, Zetran)	1.12
	J1730	Diazoxide, up to 300 mg (Hyperstat IV)	111.18
	J0500	Dicyclomine HCL, up to 20 mg (Bentyl, Dilomine, Antispas)	9.64
	J9165	Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol)	13.69
	J1160	Digoxin, up to 0.5 mg (Lanoxin)	2.05
	J1110	Dihydroergotamine Mesylate, up to 1 mg	13.86
	J0470	Dimercaprol, per 100 mg	22.49
	J1240	Dimenhydrinate, up to 50 mg	.36
	J1200	Diphenhydramine HCL, up to 50 mg (Benadryl)	1.11
	J1245	Dipyridamole, per 10 mg (Persantine IV)	20.80
	J1212	DMSO, Dimethyl Sulfoxide, 50%, 50 ml	39.66
	J1250	Dobutamine HCL, 250 mg (Dobutrex)	10.31
	J9170	Docetaxel, 20 mg (Taxotere)	297.08
	J1260	Dolasetron Mesylate, 10 mg (Anzemet)	15.63
	J9001	Doxorubicin HCL, all lipid formulations, 10 mg,	359.42
	J9000	Doxorubicin HCL, 10 mg (Adriamycin PFS, Adriamycin RDF, Rubex)	41.07
	J1810	Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar)	10.95
	J1790	Droperidol, up to 5 mg (Inapsine)	5.17
	J1180	Dyphylline, up to 500 mg (Lufyllin, Dilor)	7.48
	J0600	Edetate Calcium Disodium up to 1000 mg	38.09
	J1650	Enoxaparin Sodium, 10 mg (Lovenox)	5.25
	Q9920	EPO, per 1000 units, Patient HCT 20 or less	11.69
	Q9921	EPO, per 1000 units, Patient HCT 21	11.69
	Q9922	EPO, per 1000 units, Patient HCT 22	11.69
	Q9923	EPO, per 1000 units, Patient HCT 23	11.69
	Q9924	EPO, per 1000 units, Patient HCT 24	11.69
	Q9925	EPO, per 1000 units, Patient HCT 25	11.69
	Q9926	EPO, per 1000 units, Patient HCT 26	11.69
	Q9927	EPO, per 1000 units, Patient HCT 27	11.69
	Q9928	EPO, per 1000 units, Patient HCT 28	11.69
	Q9929	EPO, per 1000 units, Patient HCT 29	11.69
	Q9930	EPO, per 1000 units, Patient HCT 30	11.69
	Q9931	EPO, per 1000 units, Patient HCT 31	11.69
	Q9932	EPO, per 1000 units, Patient HCT 32	11.69
	Q9933	EPO, per 1000 units, Patient HCT 33	11.69
	Q9934	EPO, per 1000 units, Patient HCT 34	11.69
	Q9935	EPO, per 1000 units, Patient HCT 35	11.69
	Q9936	EPO, per 1000 units, Patient HCT 36	11.69
	Q9937	EPO, per 1000 units, Patient HCT 37	11.69
	Q9938	EPO, per 1000 units, Patient HCT 38	11.69
	Q9939	EPO, per 1000 units, Patient HCT 39	11.69
	Q9940	EPO, per 1000 units, Patient HCT 40	11.69
	Q0136	Epoetin Alpha (for non ESRD use) per 1000 units (Epogen)	11.69
	J1325	Epoprostenol 0.5 mg	17.16
	J1330	Ergonovine Maleate, up to 0.2 mg	4.28
	J1364	Erythromycin Lactobionate, per 500 mg (Erythrocin)	5.64
	J1380	Estradiol Valerate, up to 10 mg	9.18
	J1390	Estradiol Valerate, up to 20 mg	12.94
	J0970	Estradiol Valerate, up to 40 mg (Delestrogen)	21.48
	J1410	Estrogen Conjugated, per 25 mg (Premarin Intravenous)	52.35
	J1435	Estrone, per 1 mg (Estone Aqueous, Estronol, etc.)	.18
	J1436	Etidronate Disodium, per 300 mg (Didronel)	60.47
	J9181	Etoposide, 10 mg (VePesid)	9.93
	J9182	Etoposide, 100 mg (VePesid)	99.28
	J3010	Fentanyl Citrate, 0.1 mg (2 ml) (Sublimaze)	1.23
	J7190	Factor VIII (anti-hemophilic factor, human) per I.U.	.82
	J7191	Factor VIII (anti-hemophilic factor, porcine) per I.U.	1.99
	J7192	Factor VIII (anti-hemophilic factor, recombinant) – per I.U.	1.06
	J7194	Factor IX complex, per I.U.	.29
	J7193	Factor IX (Antihemophilic Factor, Purified, non-recombinant) – per I.U.	1.00
	J7195	Factor IX (Antihemophilic Factor, recombinant) – per I.U.	1.07
	J1440	Filgrastim , 300 mcg/1ml (Neupogen)	170.13
	J1441	Filgrastim , 480 mcg/1.6ml (Neupogen)	284.38
	J9200	Floxuridine, 500 mg (FUDR)	123.08
	J9185	Fludarabine Phosphate, 50 mg (Fludara)	295.57
	J9190	Fluorouracil, 500 mg (Adrucil)	2.47
	J2680	Fluphenazine Decanoate, up to 25 mg (Prolixin Decanoate)	13.39
	J1455	Foscarnet Sodium, per 1000 mg (Foscavir)	11.48
	J1940	Furosemide, up to 20 mg (Lasix, Furomide M.D.)	1.18
	J1460	Gamma Globulin, Intramuscular, 1 cc (Gammar)	3.24
	J1470	Gamma Globulin, Intramuscular, 2 cc	6.48
	J1480	Gamma Globulin, Intramuscular, 3 cc	9.72
	J1490	Gamma Globulin, Intramuscular, 4 cc	12.96
	J1500	Gamma Globulin, Intramuscular, 5 cc	16.20
	J1510	Gamma Globulin, Intramuscular, 6 cc	19.44
	J1520	Gamma Globulin, Intramuscular, 7 cc	22.68
	J1530	Gamma Globulin, Intramuscular, 8 cc	25.92
	J1540	Gamma Globulin, Intramuscular, 9 cc	29.16
	J1550	Gamma Globulin, Intramuscular, 10 cc	32.40
	J1560	Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of above codes)
	J1570	Ganciclovir Sodium, 500 mg (Cytovene)	32.20
	J7310	Ganciclovir, Long-acting Implant, 4.5 mg (Vitrasert)	4,512.50
	J9201	Gemcitabine HCl. 200 mg (Gemzar)	106.45
	J1580	Gentamicin (Garamycin Sulfate) up to 80 mg (Gentamicin Sulfate, Jenamicin)	1.85
	J1610	Glucagon Hydrochloride, per 1 mg	43.32
	J1600	Gold Sodium Thiomaleate, up to 50 mg (Myochrysine)	10.66
	J1620	Gonadorelin Hydrochloride, per 100 mcg (Factrel)	182.75
	J9202	Goserelin Acetate Implant, per 3.6 mg (Zoladex)	424.17
	J1626	Granisetron Hydrochloride, 100 mcg (Kytril)	17.61
	J1631	Haloperidol Decanoate, per 50 mg (Haldol Decanoate – 50)	25.37
	J1630	Haloperidol Lactate, up to 5 mg (Haldol)	6.77
	J1642	Heparin Sodium, per 10 units (Heparin Lock Flush)	.05
	J1644	Heparin Sodium, per 1000 units	.33
	J3470	Hyaluronidase, up to 150 units (Wydase)	5.78
	J0360	Hydralazine HCL, up to 20 mg (Apresoline)	16.92
	J1700	Hydrocortisone Acetate, up to 25 mg	.32
	J1710	Hydrocortisone Sodium Phosphate, up to 50 mg	5.04
	J1720	Hydrocortisone Sodium Succinate, up to 100 mg	1.72
	J1170	Hydromorphone, up to 4 mg (Dilaudid)	.96
	J3410	Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50)	.67
	J7320	Hylan G-F 20, 16 mg, for intra-arterial injection (Synvisc)	212.09
	J1980	Hyoscyamine Sulfate, up to 0.25 mg (Levsin)	7.51
	J7130	Hypertonic Saline Solution, 50 or 100 mEq, 20 cc vial)	.45
	J1742	Ibutilide Fumarate 1 mg. (Corvert)	228.61
	J9211	Idarubicin Hydrochloride, 5 mg (Idamycin)	411.18
	J9208	Ifosfamide, 1 gm (Ifex)	153.28
	J1785	Imiglucerase, per unit (Cerezyme)	3.56
	J1561	Immune Globulin, Intravenous, 500 mg (Panglobulin)	36.10
	J1745	Infliximab, 10 mg (Remicade)	62.42
	J1820	Insulin, up to 100 units (Regular, NPH, Lente, or Ultralente))	2.40
	J9213	Interferon, Alfa-2A, Recombinant, 3 million units (Roferon-A)	33.14
	J9214	Interferon, Alfa-2B, Recombinant, 1 million units (Intron A)	12.82
	J9215	Interferon, Alfa-N3, (human leukocyte derived) 250,000 IU (Alferon N)	7.47
	J9212	Interferon, Alfacon-1, Recombinant, 1 mcg (Infergen)	3.90
	J9216	Interferon, Gamma 1-B, 3 million units (Actimmune)	271.36
	J9206	Irinotecan, 20 mg (Camptosar)	133.66
	J1750	Iron Dextran, 50 mg (Infed)	17.01
	J1840	Kanamycin Sulfate, up to 500 mg (Kantrex, Klebcil)	2.03
	J1850	Kanamycin Sulfate, up to 75 mg (Kantrex, Klebcil)	2.94
	J1885	Ketorolac Tromethamine, per 15 mg (Toradol)	5.46
	J1910	Kutapressin, up to 2 ml	12.62
	J0640	Leucovorin Calcium, per 50 mg (Wellcovorin)	16.64
	J9217	Leuprolide Acetate, 7.5 mg (Lupron, for Depot Suspension)	580.98
	J1950	Leuprolide Acetate, 3.5 mg (Lupron, for Depot Suspension)	483.05
	J9218	Leuprolide Acetate, per 1 mg (Lupron)	24.84
	J1955	Levocarnitine, per 1 gm (Carnitor)	32.49
	J1956	Levofloxacin, 250 mg (Levaquin)	17.87
	J1960	Levorphanol tartrate, up to 2 mg (Levo-Dromoran)	3.57
	J2000	Lidocaine HCL, 50 cc (Xylocaine)	1.38
	J2010	Lincomycin HCL, up to 300 mg (Lincocin)	1.30
	J2060	Lorazepam, 2 mg (Ativan)	1.30
*	J3490	Leuprolide Acetate, 11.25 mg (Lupron Depot Pediatric) (Send in claim with invoice for manual pricing)
*	J3490	Leuprolide Acetate, 15 mg (Lupron Depot Pediatric) (Send in claim with invoice for manual pricing)
*	J3490	Leuprolide Acetate, 7.5 mg (Lupron Depot Pediatric) (Send in claim with invoice for manual pricing)
	J3475	Magnesium Sulfate, 500 mg.	.21
	J2150	Mannitol, 25% in 50 ml	2.87
	J9230	Mechlorethamine Hydrochloride (Nitrogen Mustard), 10 mg	10.88
	J1055	Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera)	43.29
	J1050	Medroxyprogesterone Acetate, 100 mg (Depo-Provera)	9.45
	J9245	Melphalan Hydrochloride, 50 mg, (Alkeran)	395.93
	J2180	Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection)	3.73
	J2175	Meperidine Hydrochloride, per 100 mg (Demerol HCL)	.57
	J0670	Mepivacaine, per 10 ml (Carbocaine)	1.80
	J9209	Mesna, 200 mg (Mesnex)	34.66
	J0380	Metaraminol Bitartrate, 10 mg (Aramine)	1.15
	J1230	Methadone HCL, up to 10 mg (Dolophine)	.71
	J2800	Methocarbamol, up to 10 ml (Robaxin)	6.09
	J9250	Methotrexate Sodium, 5 mg	.46
	J9260	Methotrexate Sodium, 50 mg	5.36
	J0210	Methyldopate HCL, up to 250 mg (Aldomet)	8.53
	J2210	Methylergonovine Maleate, up to 0.2 mg (Methergine)	3.37
	J1020	Methylprednisolone Acetate, 20 mg (Depo Medrol)	2.26
	J1030	Methylprednisolone Acetate, 40 mg	4.09
	J1040	Methylprednisolone Acetate, 80 mg	8.18
	J2930	Methylprednisolone Sodium Succinate, up to 125 mg (Solu-Medrol, A-methaPred)	2.95
	J2920	Methylprednisolone Sodium Succinate, up to 40 mg (Solu-Medrol, A-Metha Pred)	1.82
	J2765	Metoclopramide HCL, up to 10 mg (Reglan)	1.81
	J2250	Midazolam HCL, per 1 mg (Versed)	.64
	J2260	Milrinone Lactate, 5 mg per 5 ml (Primacor)	40.47
	J9290	Mitomycin, 20 mg (Mutamycin)	392.23
	J9291	Mitomycin, 40 mg (Mutamycin)	825.79
	J9280	Mitomycin, 5 mg (Mutamycin)	118.30
	J9293	Mitoxantrone HCL, per 5 mg (Novantrone)	252.87
	J2275	Morphine Sulfate (preservative-free sterile solution), per 10 mg (Astramorph PF, Duramorph)	7.32
	J2270	Morphine Sulfate, up to 10 mg	1.35
	J2271	Morphine Sulfate (100 mg)	9.26
	J2310	Nalaxone HCL, per 1 mg (Narcan)	3.99
	J2300	Nalbuphine Hydrochloride, 10 mg	1.37
	J2321	Nandrolone Decanoate, up to 100 mg	6.00
	J2322	Nandrolone Decanoate, up to 200 mg	12.01
	J2320	Nandrolone Decanoate, up to 50 mg	4.94
	J2710	Neostigmine Methylsulfate, up to 0.5 mg (Prostigmin)	.67
	J7030	Normal Saline Solution, 1000 cc, infusion	11.31
	J7050	Normal Saline Solution, 250 cc, infusion	10.81
	J7040	Normal Saline Solution, Sterile (500 ml=1 unit), infusion	10.29
	S0079	Octreotide Acetate, 100 mcg (Sandostatin)	15.75
	J2352	Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 30 mg	1,385.54
*	J3490	Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 20 mg
*	J3490	Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 10 mg
	J2405	Ondansetron Hydrochloride, per 1 mg (Zofran)	5.79
	J2355	Oprelvekin, 5 mg (Newmega)	233.52
	J2360	Orphenadrine Citrate, up to 60 mg (Norflex, etc.)	1.44
	J2700	Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin)	.62
	J2410	Oxymorphone HCL, up to 1 mg (Numorphan)	2.66
	J2460	Oxytetracycline HCL, up to 50 mg (Terramycin IM)	.90
	J2590	Oxytocin, up to 10 units (Pitocin, Syntocinon)	.72
	J9265	Paclitaxel, 30 mg (Taxol)	155.88
	J2430	Pamidronate Disodium, per 30 mg (Aredia)	252.58
	J2440	Papaverine HCL, up to 60 mg	3.38
*	J9266	Pegaspargase Single Dose vial, (5 ml) (Oncaspar)
	J0540	Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units (Bicillin C-R)	13.67
	J0550	Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units (Bicillin C-R)	27.37
	J0530	Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units (Bicillin C-R)	8.36
	J0570	Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen)	18.79
	J0580	Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen)	42.18
	J0560	Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen)	11.89
	J2540	Penicillin G Potassium, up to 600,000 units (Pfizerpen)	.28
	J2510	Penicillin G Procaine, Aqueous, up to 600,000 units (Wycillin, etc.)	6.39
	J2545	Pentamidine Isethionate, inhalation solution, per 300 mg (Pentam 300, NebuPent, PentacaRinat)	89.12
	S0080	Pentamidine Isethionate, IV, IM, per 300 mg	88.88
	J3070	Pentazocine HCL, up to 30 mg (Talwin)	4.08
	J2515	Pentobarbital Sodium (Nembutal Sodium Solution), per 50 mg	.50
	J9268	Pentostatin, per 10 mg (Nipent)	1,571.43
	J2543	Piperacillin Sodium/Tazobactam Sodium 1gm/0.125 gm (1.125gm) (Zosyn)	4.64
	J3310	Perphenazine, up to 5 mg (Trilafon)	6.45
	J2560	Phenobarbital Sodium, up to 120 mg	1.54
	J2760	Phentolamine Mesylate, up to 5 mg (Regitine)	30.96
	J2370	Phenylephrine HCL, up to 1 ml (NeoSynephrine)	1.22
	J1165	Phenytoin Sodium, per 50 mg (Dilantin)	.09
	J9270	Plicamycin, 2.5 mg (Mithracin)	89.11
	J9600	Porfimer Sodium, 75 mg (Photofin)	2,473.49
	J3480	Potassium Chloride, per 2 mEq.	.16
	J2730	Pralidoxime Chloride, up to 1 gm (Protopam Chloride)	97.81
	J2650	Prednisolone Acetate, up to 1 ml	.32
	J2690	Procainamide HCL, up to 1 gm (Pronestyl)	10.48
	J0780	Prochlorperazine Edisylate 10 mg (Compazine, Cotranzine, Compa-Z, Ultrazine-10)	2.48
	J2950	Promazine HCL, up to 25 mg (Sparine, Prozine-50)	.44
	J2550	Promethazine HCL, up to 50 mg (Phenergan, Phenazine)	2.71
	J1800	Propranolol HCL, up to 1 mg (Inderal)	11.04
	J2720	Protamine Sulfate, per 10 mg	.73
	J2725	Protirelin, per 250 mcg (Relefact TRH, Thypinone)	23.18
	J2780	Rantidine HCL, 25 mg (Zantac)	1.37
	J7120	Ringers Lactate Infusion, up to 1000 cc	12.70
	J9310	Rituximab (Rituxan) 100 mg (Rituxan)	431.82
	J2820	Sargramostim (GM-CSF), 50 mcg (Leukine, Prokine)	27.61
*	J3490	Sodium Bicarbonate 7.5% up to 50 ml
	J2912	Sodium Chloride, 0.9% per 2 ml	.09
	J7316	Sodium Hyaluronate, 5 mg. for intra-articular injection (Biolon, Provisc, Vitrax, Hyalgan)	26.49
	J3320	Spectinomycin Dihydrochloride, up to 2 gm (Trobicin)	25.46
	J7051	Sterile Saline or Water (up to 5 cc)	.18
	J2995	Streptokinase, per 250,000 IU (Streptase)	114.90
	J3000	Streptomycin, up to 1 gm (Streptomycin Sulfate)	6.02
	J9320	Streptozocin, 1 gm (Zanosar)	111.76
	J0330	Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin)	.10
	J9170	Docetaxel, 20 mg (Taxotere)	297.08
	J3105	Terbutaline Sulfate, up to 1 mg (Brethine, Bricanyl Subcutaneous)	2.02
	J1060	Testosterone Cypionate and Estradiol Cypionate, up to 1 ml	3.52
	J1080	Testosterone Estradiol Cypionate, 1 cc, 200 mg	7.12
	J1070	Testosterone Estradiol Cypionate, up to 100 mg	4.10
	J0900	Testosterone Enanthate and Estradiol Valerate up to 1 cc (Deladumone, etc.)	1.56
	J3120	Testosterone Enanthate, up to 100 mg (Evarone, Delatestryl, etc.)	6.47
	J3130	Testosterone Enanthate, up to 200 mg, (Evarone, Delatestryl, Andro L.A. 200, etc.)	12.94
	J3150	Testosterone Propionate, up to 100 mg (Testex)	.89
	J3140	Testosterone Suspension, up to 50 mg (Andronaq 50, Testosterone Aqueous, etc.)	.92
*	J0120	Tetracycline, up to 250 mg (Achromycin, Panmycin, Sumycin)
	J3280	Thiethylperazine Maleate, up to 10 mg (Norzine, Torecan)	4.37
	J9340	Thiotepa, 15 mg (Thioplex)	111.12
	J3240	Thyrotropin Alfa, 0.9 mg (Thyrogen)	538.34
	J3260	Tobramycin Sulfate, up to 80 mg (Nebcin)	4.98
	J9350	Topotecan, 4 mg (Hycamtin)	660.26
	J3265	Torsemide, 10 mg/ml (Demadex)	2.10
	J2670	Tolazoline HCL, up to 25 mg (Priscoline HCL)	3.72
	J9355	Trastuzumab, 10 mg (Herceptin)	50.19
	J3301	Triamcinolone Acetonide, per 10 mg (Kenalog-10, Kenalog-40, Tri-Kort, etc.)	1.44
	J3302	Triamcinolone Diacetate, per 5 mg (Aristocort Intralesional, Aristocort Forte, Amcort, etc.)	.19
	J3303	Triamcinolone Hexacetonide, per 5 mg (Aristospan Intralesional, Aristospan Intra-articular)	2.47
	J3400	Triflupromazine HCL, up to 20 mg (Vesprin)	8.24
	J3250	Trimethobenzamide HCL, up to 200 mg (Tigan, Ticon, Tiject-20, Arrestin)	.90
	J3305	Trimetrexate Glucoronate, per 25 mg (Neutrexin)	112.81
	J3350	Urea, up to 40 gm (Ureaphil)	80.02
	J3365	Urokinase, 250,000 I.U. Vial (Abbokinase)	442.86
	J3364	Urokinase, 5000 I.U. vial (Abbokinase Open-Cath)	53.78
	J9357	Valrubicin, intravesical, 200 mg (Valstar)	500.35
	J3370	Vancomycin HCL, 500 mg (Varcocin, Vancoled)	4.94
	J9360	Vinblastine Sulfate, 1 mg (Velban)	3.90
	J9370	Vincristine Sulfate, 1 mg (Oncovin,)	30.47
	J9375	Vincristine Sulfate, 2 mg (Oncovin)	49.54
	J9380	Vincristine Sulfate, 5 mg (Oncovin,)	146.84
	J9390	Vinorelbine Tartrate, per 10 mg (Navelbine)	94.32
	J3430	Vitamin K, Phytonadione 1 mg/0.5ml	2.21
	J2500	Zemplar (Paricalcitol) 5 mcg	23.84

Revised April 18, 2002

EDS, 1-800-688-6696 or 919-851-8888

Attention: Health Check Providers

Health Check Seminar

Health Check seminars for all providers except health departments are scheduled for August 2002. The July general Medicaid bulletin will have the registration form and a list of site locations for the seminars. Attendance at these seminars is very important because Health Check billing requirements will change on October 1, 2002. Due to the magnitude of the changes in Health Check billing, these seminars will only focus on the new Health Check billing requirements and will not include any basic Medicaid billing instructions.

A separate teleconference sponsored by the Division of Public Health is scheduled for health department providers. The July general Medicaid bulletin will include registration information for the teleconference.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

Fee Schedules and Reimbursement Plans

Fee Schedule Request Form

There is no charge for fee schedules or reimbursement plans requested from the Division of Medical Assistance (DMA). DMA stipulates that the information provided is to be used only for internal analysis. Providers are expected to bill their usual and customary rate. All requests for fee schedules and reimbursement plans must be made on the Fee Schedule Request form and mailed to:

Division of Medical Assistance
Financial Operations - Fee Schedules
2509 Mail Service Center
Raleigh, N. C. 27699-2509

Or fax your request to DMA’s Financial Operations section at 919-715-0896.

NOTE: PHONE REQUESTS ARE NOT ACCEPTED

Attention: Residential Child Care Facility Providers

Accreditation Requirement and Provider Status Changes

Effective February 1, 2002, the Division of Medical Assistance no longer requires a compliance verification credential from the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. Licensure through the Division of Facility Services (DFS) for a Residential Child Care Facility (Levels II through IV) satisfies the accreditation requirement for enrollment with the N.C. Medicaid program.

Providers who are currently enrolled as a Residential Child Care Facility but choose to change the number of beds available in the facility must apply for a new license from DFS and submit a copy of the new license to the address listed below. Failure to maintain appropriate licensure reflecting the number of beds available in the facility may result in a denied claim.

Division of Medical Assistance
Provider Services
2506 Mail Service Center
Raleigh, NC 27699-2506

Providers must report all other changes in status (address and telephone number changes, name changes, change of ownership, etc.) to the N.C. Medicaid program using the Notification of Change in Provider Status form. The form is available from the DMA website at http://www.dhhs.state.nc.us/dma.

Joe Ann McCullough, Provider Services
DMA, 919-857-4017

Attention: Rural Health Clinics and Federally Qualified Health Centers

Core Service Code Conversion

Effective with date of service June 30, 2002, state-created codes Y2058 and Y2089 will be end-dated to comply with the implementation of national procedure codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Effective with date of service July 1, 2002, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) providers must bill procedure code T1015 – Clinic visit/encounter, all inclusive –for all core services. An RHC/FQHC core service visit must be billed using the provider’s six-digit provider number with alpha suffix "A."

End-dated Code New Code

Y2058 – RHC Core Service T1015 – Clinic visit/encounter, all inclusive

Y2059 – FQHC Core Service T1015 – Clinic visit/encounter, all inclusive

End-dated Code	New Code
Y2058 – RHC Core Service	T1015 – Clinic visit/encounter, all inclusive
Y2059 – FQHC Core Service	T1015 – Clinic visit/encounter, all inclusive

EDS, 1-800-688-6696 or 919-851-8888

Checkwrite Schedule

June 11, 2002

July 16, 2002

August 13, 2002

June 18, 2002

July 23, 2002

August 20, 2002

June 27, 2002

July 31, 2002

August 29, 2002

Electronic Cut-Off Schedule

June 7, 2002

July 12, 2002

August 9, 2002

June 14, 2002

July 19, 2002

August 16, 2002

June 21, 2002

July 26, 2002

August 23, 2002

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

______________________		_______________________
Nina M. Yeager, Director		Ricky Pope
Division of Medical Assitance		Executive Director
Department of Health and Human Services		EDS

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June 21, 2002	July 26, 2002	August 23, 2002