016.06.05 Ark. Code R. 092

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.05-092 - Child Health Services / Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Provider Manual Update Transmittal #69; Ventilator Equipment Provider Manual Update Transmittal #55; Division of Youth Services (DYS) and Division of Children and Family Services (DCFS) Targeted Case Management Provider Manual Update Transmittal #9; Children's Services Targeted Case Management Provider Manual Update Transmittal #17; DDS Alternative Community Services (ACS) Waiver Program Provider Manual Update Transmittal #57; Prosthetics Provider Manual Update Transmittal #74

Section II

Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment

242.100 Procedure Codes

See section 212.000 for EPSDT screening terminology.

An EPSDT periodic complete medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic or interperiodic vision or hearing screen on the same day or within 7 days of an EPSDT complete medical screen by the same or different providers. The above billing combinations represent a duplication of services.

An EPSDT interperiodic full medical screen includes both hearing and vision screens. Providers must not bill an EPSDT periodic or interperiodic vision screen on the same day or within 7 days of an EPSDT interperiodic full medical screen by the same or different providers. The above billing combinations represent a duplication of services.

Claims for EPSDT medical screenings must be billed electronically or using the DMS-694 EPSDT paper claim form. View or print a DMS-694 sample claim form.

Procedure Code	Modifier 1	Modifier 2	Description
99381-99385	EP	U1	EPSDT Periodic Complete Medical Screen (New Patient)
99391-99395	EP	U2	EPSDT Periodic Complete Medical Screen (Established Patient)
99381-99385	EP	EPSDT Interperiodic Full Medical Screen (New Patient)
99391-99395	EP	EPSDT Interperiodic Full Medical Screen (Established Patient)
99391-99395	EP	UB	Partial Medical Screen/Reassessment EPSDT health and developmental history, including assessment of physical development (Established Patient)
96151	EP	Partial Medical Screen/Reassessment EPSDT health and developmental history, including assessment of mental development
99381-99385	EP	UB	Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (New Patient)
99391-99395	EP	U1	Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (Established Patient)
99431¹99432¹99435¹	EP EP EP	Initial Newborn Care/EPSDT screen in hospital
99173¹	EP	EPSDT Periodic Vision Screen
V5008	EP	EPSDT Periodic Hearing Screen
V5008	EP	U1	EPSDT Interperiodic Hearing Screen
D0120¹	CHS/EPSDT Oral Examination
D0140¹	EPSDT Interperiodic Dental Screen, with prior authorization
92012¹	EP	TS	EPSDT Interperiodic Vision Screen
99401	EP	EPSDT Health Education - Preventive Medical Counseling
36415²	Collection of venous blood by venipuncture
83655	Lead

¹ Exempt from PCP referral requirements

²Covered when specimen is referred to an independent lab

Immunizations and laboratory tests may be billed separately from comprehensive screens.

The verbal assessment of lead toxicity risk is part of the complete CHS/EPSDT screen. The cost for the administration of the risk assessment is included in the fee for the complete screen.

Laboratory/X-ray and immunizations associated with an EPSDT screen may be billed on the DMS-694 EPSDT claim form.

When billing on paper, the EPSDT screening services must be billed with a type of service code "6."

For billing on paper, immunizations must be billed with a type of service code "1."

242.150 Limitation for Laboratory Procedures Performed as Part of EPSDT

Screens

Child Health Services (EPSDT) screens do not include laboratory procedures unless the screen is performed by the recipient's primary care physician (PCP) or is conducted in accordance with a referral from the PCP.

The following tests are exempt from this limitation and may continue to be billed in conjunction with an EPSDT Screen performed in accordance with existing Medicaid policy:

81000 -	Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy
81001 -	Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy
81002 -	Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy
83020 -	Hemoglobin, electrophoresis (e.g., AZ, S, C)
83655 -	Lead
85013 -	Blood count; spun microhematocrit
85014 -	Blood count; other than spun hematocrit
85018 -	Blood count, hemoglobin
86580 -	Skin test; tuberculosis, intradermal
86585 -	Tuberculosis, tine test

Claims for laboratory tests, other than those specified above, performed in conjunction with an EPSDT screen will be denied, unless the screen is performed by the PCP or in accordance with a referral from the PCP.

The following screens will be affected by this policy:

Procedure Code	Modifier 1	Modifier 2	Description
99381-99385	EP	U1	EPSDT Periodic Complete Medical Screen (New Patient)
99391-99395	EP	U2	EPSDT Periodic Complete Medical Screen (Established Patient)
*99381-99385	EP	EPSDT Interperiodic Full Medical Screen (New Patient)
99391-99395	EP	EPSDT Interperiodic Full Medical Screen (Established Patient)
99391-99395	EP	UB	Partial Medical Screen/Reassessment EPSDT health and developmental history (including assessment of physical development) (Established Patient)
99381-99385	EP	UB	Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (New Patient)
99391-99395	EP	U1	Partial Medical Screen/Reassessment EPSDT unclothed physical assessment (Established Patient)
96151	EP	Partial Medical Screen EPSDT health and development history including assessment of mental development

* Procedure codes 99381 through 99385 (New Patient) with modifier EP should only be used to bill an EPSDT Interperiodic Full Medical Screen for new patients, ages 0 through 20 years of age, who have already received an EPSDT Periodic Complete Medical Screen by another PCP within the current fiscal year.

Ventilator Equipment

242.100 Ventilator Equipment and Supplies Procedure Codes 12-5-05

Procedure codes must be billed either electronically or on paper with the modifiers indicated. Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "9" for individuals of all ages.

Prior authorization requirements are shown under the heading PA.

1 Code may only be billed for a ventilator patient in his or her home. The code is not covered for a ventilator patient in a nursing facility.

2 Bill only for TOS 6.

* Prior authorization is not required when another insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Procedure Code	Modifier(s) Description	PA	Max. Units	Payment Method
A4483	Nasal prosthesis	No	N/A 1 per day (1 day = 1 unit)	Purchase
E0250¹	Hospital bed, fixed height, with any type side rails, with mattress	Yes*	N/A 1 per day (1 day = 1 unit)	Capped Rental
E0255¹	Hospital bed, variable height, hi-lo, with any type side rails, with mattress	Yes*	1 per day (1 day = 1 unit)	Capped Rental
E0260¹	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress	Yes*	1 per day (1 day = 1 unit)	Capped Rental
E0424¹	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Yes*	1 per day (1 day = 1 unit)	Rental Only
E0430¹	Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing	Yes*	1 per day (1 day = 1 unit)	Rental Only
E0435¹	Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter	Yes*	1 per day (1 day = 1 unit)	Rental Only
E0439¹	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing	Yes*	1 per day (1 day = 1 unit)	Rental Only
E0450	***(New equipment) Volume control ventilator without pressure support mode, may include pressure control mode, used with invasive interface, e.g., tracheostomy tube	Yes	1 per day (1 day = 1 unit)	Rental Only
E0450¹ UB	***(Positive pressure ventilator supplies -Includes suction catheter kits, trach kits, trach tubes, sterile water and all respiratory care supplies) Volume control ventilator, may include pressure control mode, used with invasive interface, e.g., tracheostomy tube	Yes	1 per day (1 day = 1 unit)	Purchase
E0450 UE	***(Used equipment) Volume control ventilator without pressure support mode, may include pressure control mode, used with invasive interface, e.g., tracheostomy tube	Yes	1 per day (1 day = 1 unit)	Rental Only
E0500	IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source	Yes	1 per day	Rental Only
E0570¹	Nebulizer with compressor	Yes*	1 per day (1 day = 1 unit)	Purchase Only
E0600¹	Respiratory suction pump, home model, portable or stationary, electric	No	1 per day (1 day = 1 unit)	Rental Only
E0600¹ U1	Suction pump, home model, portable (used equipment)	Yes	1 per day (1 day = 1 unit)	Rental Only
E1390	Oxygen concentrator, Yes* single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate	1 per day	Rental Only
G0237²G0238²	EP, UA EP, UA	Respiratory therapy Yes services for ventilator-dependent patients	Frequency of visits as prescribed	N/A

Division of Youth Services (DYS) and Division of Children and Family Services (DCFS) Targeted Case Management

262.200 DYS Procedure Codes

Procedure Code

Required Modifier

Description

262.300 DCFS Procedure Codes

Procedure Code	Required Modifier	Required Modifier	Description
T1017	U3	UA	DCFS targeted case management

CS Targeted Case Management

262.100 Children's Services Targeted Case Management Procedure Code 12-5-05

Providers of Children's Services targeted case management (TCM) must bill for services provided using the procedure code shown in the list below. Providers must use this code and the indicated modifiers when billing either electronically or on paper for Children's Services TCM services. Additionally, when billing on paper, the procedure code must be billed with a type of service code "9."

Procedure Code	Modifier 1	Modifier 2	Type of Service	Description	Benefit Limit
T1017	U2	UA	9	Targeted case management, each 15 minutes (Children's Services targeted case management)	One (1) unit per client per day.

DDS Alternative Community Services (ACS) Waiver

272.100 DDS ACS Waiver Procedure Codes

The following procedure codes and any associated modifier(s) must be billed for DDS ACS Waiver Services. Prior authorization is required for all services.

Procedure Code	M1	M2 P A	Description	Unit of Service	POS for Paper Claims	POS for Electronic Claims
A0080	Y	ACS Non-Medical Transportation	1 Year	0	99
H2016	Y	ACS Supportive Living (Individual)	1 Year	4, 0	12, 99
H2016	UB	Y	ACS Supportive Living (Group)	1 Year	4, 0	12, 99
H2023¹	Y	Supported Employment	15 Minutes	0	99
S5151	Y	ACS Respite Care	1 Year	4, 0	12, 99
T2020	Y	Community Experiences	1 Year	4, 0	12, 99
T2020	UA	Y	Community Experiences	1 Year	4, 0	12, 99
T2022	Y	Case Management Services	1 Month	4, 0	12, 99
T2024	Y	ACS Waiver Coordination	1 Year	4, 0	12, 99
T2025²	Y	Consultation Services	1 Hour	4, 0	12, 99
T2028³	Y	ACS Specialized Medical Supplies	1 Year	4, 0	12, 99
T2034	Y	Crisis Center	1 Year	0, 4	99, 12
T2034⁴	U1	UA Y	ACS Crisis Intervention Services	1 Hour	0, 4	99, 12

1 Individuals are limited to a maximum of 32 units (8 hours) of supported employment services per date of service.

A breakdown of the supported employment units of service includes:

One unit = 15 minutes to 21 minutes Two units = 22 minutes to 37 minutes Three units = 38 minutes to 52 minutes Four units = 53 minutes to 67 minutes

2 Beneficiaries may receive twenty-five (25) hours of ACS consultation services per waiver-eligible year.

3 Reimbursement cannot exceed $300 per month.

4 Crisis intervention services may require a maximum of 24 hours of service during any one day.

The following list contains the procedure codes used for ACS physical adaptations. Physical adaptations have a benefit limit of $7500 per year.

Procedure Code	M1	M2 P A	Description	POS for Paper Claims	POS for Electronic Claims
K0108	Y	***(ACS environmental modifications) Other accessories	4	12
S5160	Y	***(Adaptive equipment, personal emergency response system [PERS], installation and testing) Emergency response system; installation and testing	4	12
S5161	Y	***(Adaptive equipment, personal emergency response system [PERS], service fee, per month, excludes installation and testing) Emergency response system; service fee, per month (excludes installation and testing)	4	12
S5162	Y	***(Adaptive equipment, personal emergency response system [PERS], purchase only) Emergency response system; purchase only	4	12
S5165	U1	Y	***(ACS adaptive equipment) Home modifications, per service	4	12

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Refer to section 272.200 for definitions of the place of service codes listed above.

Prosthetics

233.000 Orthotic and Prosthetic Reimbursement for Repairs 12-5-05

Providers must bill for the repair of orthotic appliances and prosthetic devices utilizing the procedure codes listed in the table below. One unit of service equals 15 minutes. A maximum of 20 units of service is allowed per date of service. Any applicable pages from the manufacturer's catalog and the manufacturer's invoice for parts must be attached to all repair claims.

National Code	Required Modifier	Description
L4205	-	Repair of orthotic appliances and prosthetic devices (non-EPSDT)
L4210	-
L7510	-
L7520	-
L4205	EP	Repair of orthotic appliances and prosthetic devices (EPSDT)
L4210	EP
L7510	EP, UB
L7520	-

Reimbursement for orthotic appliances and prosthetic devices requiring manual pricing will be calculated using the manufacturer's invoice price plus 10%. The manufacturer invoice must be attached to all repair claims.

E. Providers may be reimbursed for capped rental and rental-only items if the equipment is used fewer than 30 consecutive days from the first day of rental. This ensure the provider of adequate reimbursement for equipment used fewer than 30 days.

F. A rent-to-purchase item is an item for which Arkansas Medicaid reimburses a provider for the Medicaid-established purchase price of the item. After reimbursement has reached the maximum allowed, the equipment will become the property of the Medicaid beneficiary. Reimbursement is only approved for new equipment.

G. Initial rental transactions are those for which equipment is used in a beneficiary's home for fewer than 30 consecutive days. Initial rental transactions must not be used by the provider to bill a month in advance. Arkansas Medicaid will only pay after services are rendered. An example of an initial rental transaction is that of a hospital bed delivered on July 2 and removed from the home after 10 days.

H. Manually priced items are those for which Arkansas Medicaid pays the manufacturer's invoice price plus 10 percent. The provider must attach the invoice with their claim for services rendered.

I. A used item is any item that has been rented for 90 days or longer by anyone prior to the current Medicaid "rental only" or capped rental" transaction. The provider must maintain documentation that certifies a used item is reconditioned and in good working order and has no defect in workmanship or material.

J. Repair of a "rental only" item is covered in the rental fee. Repair of "purchased" items is covered separately. Total (cumulative) repair costs must not exceed 50% of the item's total purchase cost.

242.110 Respiratory and Diabetic Equipment, All Ages 12-5-05

When billed either electronically or on paper, procedure codes found in this section must be billed with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS "H" for individuals age 21 and over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, the information is indicated with a "Y" in the column; if not, an "N" is shown.

* Prior authorization is not required when another insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Respiratory and Diabetic Equipment, All Ages (section 242.110)

Procedure Code	M1	M2	TOS	Description	PA	Payment Method
A4230	NU	H	Infusion set for external insulin pump, nonneedle cannula type (each)	Y*	Purchase

Providers will be reimbursed for a minimum of 30 days of rental when the equipment is used less than 30 days. Initial rental codes should only be billed when equipment is used less than 30 days during the first month of rental.

Arkansas Medicaid will only reimburse for one initial minimum 30 days of rental per state fiscal year period per beneficiary per procedure code. The provider will not be reimbursed for the same procedure code utilizing another modifier and type of service for the same time period.

242.112 Home Blood Glucose Monitor and Supplies - Pregnant Women Only, All Ages

Procedure codes found in this section must be billed either electronically or on paper with modifier NU for individuals of all ages. When a second modifier is listed, that modifier must be used in conjunction with the NU modifier.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "H" for individuals of all ages. Modifiers in the section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization is indicated by the heading PA.

Procedure Code	M1	M2	TOS	Description	PA	Payment Method
E0607	NU	U1	H	Home Blood Glucose Monitor	N	Purchase
A4253	NU	U1	H	Blood glucose test or reagent strips for home glucose monitor, per 50 strips	N	Purchase
A4259	NU	U2	H	Lancets, per box of 100	N	Purchase

242.120 Medical Supplies, All Ages 12-5-05

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "H" for individuals of all ages.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

1 These supplies must be prior authorized. Form DMS-679 may be used for the request for prior authorization. View or print form DMS-679 and instructions for completion. Please note: Compression burn garments are manually priced.

Medical Supplies, All Ages (section 242.120)

Procedure Code	M1	M2	TOS Description
A4206	NU	H Syringe with needle, sterile, 1 cc, ea
A4207	NU	Syringe with needle, sterile, 2 cc, ea

242.180 Orthotic Appliances, All Ages 12-5-05

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When prior authorization is not applicable (for U21) that information is shown with an "N/A" in the column.

When codes are payable for all ages, "All" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Orthotic Appliances, All Ages (section 242.180)

Procedure Code	M1 M2	TOS	Description	All U21 21+	PA 21+	Payment Method
A5500	NU	H	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe	21+	Y	Purchase
A5501	NU	H	For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient's foot (custom molded shoe), per shoe	21+	Y	Purchase
A5503	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	21+	Y	Purchase
A5504	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe	21+	Y	Purchase
A5505	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe	21+	Y	Purchase

Orthotic Appliances, All Ages (section 242.180)

Procedure Code	M1	M2	TOS	Description	All U21 21+	PA 21+	Payment Method
L7499	NU EP	H 6	*(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.**) Upper extremity prosthesis, not otherwise specified	All	Y	Manually Priced Manually Priced
L7510	NU EP	UB	H 6	Repair of prosthetic device, hourly rate	All	Y	Manually Priced Purchase
L7520	NU EP	H 6	Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L8499	NU EP	H 6	*(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.**) Unlisted procedure for miscellaneous prosthetic services	All	Y	Manually Priced Purchase

242.190 Prosthetic Devices, All Ages 12-5-05

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for individuals age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for beneficiaries age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When codes are payable for all ages, "All" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

* Replacement only

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Prosthetic Devices, All Ages (section 242.190)

Procedure Code

TOS

Description

All

U21

21+

PA Payment 21+ Method

L8600

NU EP

H 6

Implantable breast prosthesis, silicone or equal

All

N Manually Priced

242.191 Specialized Wheelchairs and Wheelchair Seating Systems 12-5-05

for Individuals Age Two Through Adult

Additionally, when billed on paper, procedure codes found in this section must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. The type of service code is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

Other coding information found in the chart:

1 The purchase of this wheelchair component for individuals age 21 and older is limited to one per five-year period.

2 The purchase of this wheelchair component for individuals under age 21 is limited to one per two-year period.

* The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period.

** Bill only for TOS code "6."

# This procedure code is payable for individuals ages 2 through 20, using TOS code "6." Prior authorization is required through Utilization Review.

**** Items listed require prior authorization (PA) when used in combination with other items listed and the total combined value exceeds the $1,000.00 Medicaid maximum allowable reimbursement limit.

* Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.

Note: W/C or w/c indicates wheelchair.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

242.192 Specialized Rehabilitative Equipment, All Ages 12-5-05

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and over. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under 21 years of age or TOS code "H" for individuals age 21 or over.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

** Indicates that providers may bill only for individuals under age 21.

* Prior authorization is not required when another insurance pays at least 50% of the

Medicaid maximum allowable reimbursement amount.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Specialized Rehabilitative Equipment, All Ages (section 242.192)

Procedure Code	M1	M2	TOS	Description	PA	Payment Method
E0149	NU EP	H 6	*******(4 Wheel Reverse Walker) Walker, heavy duty, wheeled, rigid or folding, any type	N	Purchase
E0163	EP	6	***(Potty Chair - Sm) Commode chair, stationary, with fixed arms	Y	Purchase
E0166	EP	U1	6	***(Potty Chair - Lg) Commode chair, mobile, with detachable arms	Y	Purchase
E0168	NU	U1	H	***(Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each	Y*	Purchase
E0168	EP	6	***(Rehab Shower/Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each	Y*	Purchase
E0168	NU	H	***(Adaptive Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each	N	Purchase
E0168	EP	UB	6	***(Adaptive Commode Chair) Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each	N	Purchase

016.06.05 Ark. Code R. 092

11/4/2005