Statutes, codes, and regulations
Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-021 - ARKids First-B Update Transmittal #23

016.06.05 Ark. Code R. 021

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Current through Register Vol. 49, No. 10, October, 2024
Rule 016.06.05-021 - ARKids First-B Update Transmittal #23
Section II ARKids First-B
223.100 Procedure for Extension of Benefits
A. Medical Supplies

To request a benefit extension for medically necessary medical supplies; submit form DMS-699, Request for Extension of Benefits, a completed ARKids First-B claim and additional medical records, if needed, to substantiate medical necessity to the Division of Medical Services Utilization Review Section. View or print the Division of Medical Services Utilization Review Section address.The Benefit Limit Review Committee, which includes medical personnel, will review the medical records and notify the requesting provider of the approval or denial of the request. The approved notice will contain an authorization number that must be shown on the claim.

B. Speech Therapy

If the provider determines the recipient needs more speech therapy services than those allowed in the Occupational, Physical, Speech Therapy Provider Manual, a form DMS-671, Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, must be completed and sent to the Arkansas Foundation for Medical Care. View or print AFMC contact information. View or print form DMS-671.

262.110 Medical Supplies Procedure Codes

The following medical supplies procedure codes may be billed by Medicaid-enrolled Home Health and Prosthetics providers for ARKids First participants. Type of service codes are used only when billing on paper.

A4206

A4221

A4222

A4253 U1

A4256

A4259 U2

A4265

A4310

A4311

A4312

A4313

A4314

A4315

A4316

A4320

A4322

A4326

A4327

A4328

A4330

A4338

A4340

A4344

A4346

A4348

A4351

A4352

A4354

A4355

A4356

A4357

A4358

A4359

A4361

A4362

A4364

A4367

A4369

A4371

A4397

A4398

A4399

A4400

A4402

A4404

A4405

A4406

A4450

A4452

A4455

A4558

A4561

A4562

A4623

A4624

A4625

A4626

A4628

A4629

A4772

A4927

A5051

A5052

A5053

A5054

A5055

A5061

A5062

A5063

A5071

A5072

A5073

A5081

A5082

A5093

A5102

A5105

A5112

A5113

A5114

A5119

A5121

A5122

A5126

A5131

A6154

A6234

A6241

A6242

A6248

A7520

B4086

E0776

Procedure Code

Required Modifier

Description

A6257

-

Transparent film, each (16 square inches or less)

A6258

-

Transparent film, each (more than 16, but less than 48 square inches)

A6259

-

Transparent film, each (more than 48 square inches)

A6216 A6219 A6228

"

Gauze pads medicated or non-medicated, each (16 square inches or less)

A6217 A6220 A6229 A6403

Gauze pads medicated or non-medicated, each (more than 16, but less than 48 square inches)

A6204 A6218 A6221 A6230

Gauze pads medicated or non-medicated, each (more than 48 square inches)

A6441 A6446

-

Gauze, non-elastic, per roll (1 linear yard)

A6242 A6245

-

Hydrogel dressing, each (16 square inches or less)

A6243 A6246

-

Hydrogel dressing, each (more than 16, but less than 48 square inches)

A6244 A6247

-

Hydrogel dressing, each (more than 48 square inches)

A6248

-

Hydrogel dressing, each (1 ounce)

A6234 A6237

-

Hydrocolloid dressing, each (16 square inches or less)

A6235 A6238

-

Hydrocolloid dressing, each (more than 16, but less than 48 square inches)

A6238

U1

Hydrocolloid dressing, each (more than 48 square inches)

A6196

-

Alginate dressing, each (16 square inches or less)

A6197

-

Alginate dressing, each (more than 16, but less than 48 square inches)

A6198

-

Alginate dressing, each (more than 48 square inches)

A6197

-

Alginate dressing, each (1 linear yard)

A6209 A6212

-

Foam dressing, each (16 square inches or less)

A6210 A6213

-

Foam dressing, each (more than 16, but less than 48 square inches)

A6211

-

Foam dressing, each (more than 48 square inches)

A6200 A6203

-

Composite dressing, each (16 square inches or less)

A6201 A6204

-

Composite dressing, each (more than 16, but less than 48 square inches)

A6202 A6205

-

Composite dressing, each (more than 48 square inches)

A4253

-

Blood glucose test or reagent strips for home blood glucose monitor, per 25 strips

A4353

-

Urinary intermittent catheter with insertion tray

A4394

-

Ostomy deodorant, all types, per ounce

A4365

-

Adhesive remover wipes, 50 per box

A4368

-

Ostomy filters, any type, each

A6449 A6452

-

Gauze elastic, all types, per roll (linear yard)

A4483

-

Tracheostomy vent-heat moisture device

B4100

-

Thick-It per 8 oz. can

L8239*

-

Stocking (Jobst)

*NOTE: L8239 must be prior authorized. Form DMS-699 may be used for the request for prior authorization. View or print form DMS-699 and instructions for completion.

The costs of B4100 and L8239 are not subject to the $125 medical supplies monthly benefit limit.

The following procedure code must be utilized when billing for Pedia-Pop. Reimbursement for this product is provider's cost plus ten percent. Pedia-Pop is only for oral consumption, and only in frozen form.

Z2487 Pedia-Pop 1 unit = 1 box Maximum = 2 units per date of service

NOTE: Pedia-Pop must be billed on paper.

262.120 Durable Medical Equipment (DME) Procedure Codes

The following DME HCPCS procedure codes may be billed by Medicaid-enrolled prosthetics providers for ARKids First-B participants. These procedure codes may be billed with type of service (paper only) code "H", "U" (used equipment) or'T (initial rental).

HCPCS code

Type of service (paper only)

Capped rental, purchase or rental only

A4635

H, U

Purchase only

A4636

H, U

Purchase only

A4637

H, U

Purchase only

E0100

H

Purchase only

E0105

H, U

Purchase only

E0110

H, U

Purchase only

E0111

H, U

Purchase only

E0112

H, U

Purchase only

E0113

H, U

Purchase only

E0114

H, U

Purchase only

E0116

H, U

Purchase only

E0130

H, U

Purchase only

E0135

H, U

Purchase only

E0140

H, U

Purchase only

E0143

H, U

Purchase only

E0147

H, U

Purchase only

E0153

H, U

Purchase only

E0154

H, U

Purchase only

E0155

H, U

Purchase only

E0157

H, U

Purchase only

E0158

H, U

Purchase only

E0161

H, U

Purchase only

E0163

H, U

Purchase only

E0164

H, U

Purchase only

E0166

H, I, U

Purchase only

E0167

H, U

Purchase only

E0175

H, U

Purchase only

E0178U1

H, U

Purchase only

E0180

H, U

Purchase only

E0181

H, I

Capped rental

E0182

H, U

Purchase only

E0184

H, U

Purchase only

E0185

H, U

Purchase only

E0189

H, U

Purchase only

E0190

H

Purchase only

E0191

H, U

Purchase only

E0192

H, U

Capped rental

E0196

H

Purchase only

E0197

H, U

Purchase only

E0200

H, I, U

Capped rental

E0202

H

Rental only

E0205

H, I, U

Capped rental

E0217

H, I, U

Capped rental

E0225

H, I, U

Capped rental

E0235

H, U

Purchase only

E0236

H, I, U

Capped rental

E0238

H, U

Purchase only

E0239

H, I, U

Capped rental

E0249

H, U

Purchase only

E0250

H, I

Capped rental

E0255

H, I, U

Capped rental

E0260

H, I, U

Capped rental

E0271

H, I, U

Capped rental

E0272

H, I

Capped rental

E0273

H, U

Purchase only

E0275

H, U

Purchase only

E0276

H, U

Purchase only

E0280

H, U

Purchase only

E0325

H, U

Purchase only

E0326

H, U

Purchase only

E0424

H, I

Rental only

E0430

H, I

Rental only

E0435

H, I

Rental only

E0439

H, I

Rental only

E0443

H

Purchase only

E0444

H

Purchase only

E0480

H, I, U

Capped rental

E0560

H, U

Purchase only

E0565

H, I, U

Capped rental

E0570

H, U

Purchase only

E0575

H, U

Capped rental

E0585

H, I, U

Capped rental

E0600

H, U

Rental only

E0605

H, U

Purchase only

E0606

H, I, U

Capped rental

E0607 U1

H, U

Purchase only

E0630

H, I, U

Capped rental

E0650

H, I, U

Capped rental

E0667

H, I

Capped rental

E0668

H, I

Capped rental

E0691

H, I

Rental only

E0692

H, I

Rental only

E0693

H, I

Rental only

E0694

H, I

Rental only

E0720

H, I, U

Capped rental

E0730

H, I, U

Capped rental

E0740

H, U

Purchase only

E0745

H, I, U

Capped rental

E0747

H, I, U

Rental only

E0840

H, U

Purchase only

E0850

H, U

Purchase only

E0860

H

Purchase only

E0870

H, U

Purchase only

E0880

H, U

Purchase only

E0890

H, U

Purchase only

E0900

H, U

Purchase only

E0910

H, I, U

Capped rental

E0920

H, I, U

Capped rental

E0930

H, I, U

Capped rental

E0935

H, I, U

Capped rental

E0940

H, I, U

Capped rental

E0941

H, I, U

Capped rental

E0942

H, U

Purchase only

E0944

H, U

Purchase only

E0945

H, U

Purchase only

E0946

H, U

Purchase only

E0947

H, U

Purchase only

E0948

H, U

Purchase only

E1130

H, I, U

Capped rental

E1140

H

Capped rental

E1150

H

Capped rental

E1160

H

Capped rental

E1224

H, I, U

Capped rental

E1390

H, I

Rental only

E1391

H, I

Rental only

Procedure Code

Required Modifier

Type of Service Code (paper only)

Description

Capped rental, purchase or rental only

E1340

NU

H

Durable medical equipment repairs/parts only repairs will not be approved for more than the allowed purchase price of new equipment. (The manufacturer's invoice must be attached to the repair claim for all parts.)

Manually priced

Bill on paper

H

Unlisted durable medical equipment, $500.00 and over. (The manufacturer's invoice must be attached to the claim form.)

Manually priced

E1340

EP, U2

H

Repair enteral nutrition infusion pump

Manually priced

E0779 E0779

RR

H I

Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home

Rental only

A7034 A7034

RR

H I

CPAP (continuous positive airway pressure) device, nasal (includes necessary accessory items) Note: Complete medical data pertinent to the request must be submitted with a prior authorization request.

Rental only

S8105

-

H, I

Pulse oximeter (including 4 disposable probes)

Rental only

E1340

EP, U3

6

Unlisted repairs/wheelchairs

Manually priced

E0483 E0483

UB RR

H

F

Bronchial drainage system

Rental only

E0483

-

H

Pulmonary vest (The manufacturer's invoice must be attached to the claim form.)

Purchase only

E1340

U4

H

Maintenance for capped rental items

N/A

E1340

NU, U1

H

Labor only (a maximum of twenty (20) units per date of service is allowed) (20 units = 5 hours of labor)

Manually priced

E1340

6

Labor only (a maximum of twenty (20) units per date of service is allowed) (20 units = 5 hours of labor)

Manually priced

A4670

-

H

Electronic blood pressure monitor and cuff

Rental only

A4230

-

H

Soft set, 25 per box (non-needle infusion set)

Purchase only

A4213

-

H

Syringes/reservoir, 30 per box

Purchase only

Bill on paper

-

H

Power kit/batteries

Purchase only

A6021 A6022 A6023 A6024

H

Polyskin dressing

Purchase only

A4627

UB

H

Spacer bag or reservoir, without mask, for use with metered dose inhaler

Purchase only

A4627

H

Spacer bag or reservoir, with mask, for use with metered inhaler

Purchase only

92507

-

Individual Speech Session

92508

-

Group Speech Session

92507

UB

Individual Speech Therapy by Speech Language Pathology Assistant

92508

-

Group Speech Therapy by Speech Language Pathology Assistant

92506

-

-

016.06.05 Ark. Code R. 021

6/3/2005