LTC Bill Code Crosswalk - Texas Health and Human Services › ... › ltcbillcodecrosswalk.pdf · 1v0134 va daily care - pa1 rg pa1 0100 va i a 09/01/2008 12/31/2199 1 v0135 va daily

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DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE

PROC CD QUAL HCPCS CODECPT

CODE 1REVENUE CODE

POS

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MO

DIFIER 2

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DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D

ClaimType to File I=837I; P=837P;

D=837D; E=Expdtd; N=NAT

ACTIVE BEGIN DATE END DATE

1 RG001 NF - RAD 1 RG RAD 0100 I A 09/01/2008 12/31/21991 RG002 NF - RAC 1 RG RAC 0100 I A 09/01/2008 12/31/21991 RG003 NF - RAB 1 RG RAB 0100 I A 09/01/2008 12/31/21991 RG004 NF - RAA 1 RG RAA 0100 I A 09/01/2008 12/31/21991 RG005 NF - SE3 1 RG SE3 0100 I A 09/01/2008 12/31/21991 RG006 NF - SE2 1 RG SE2 0100 I A 09/01/2008 12/31/21991 RG007 NF - SE1 1 RG SE1 0100 I A 09/01/2008 12/31/21991 RG008 NF - SSC 1 RG SSC 0100 I A 09/01/2008 12/31/21991 RG009 NF - SSB 1 RG SSB 0100 I A 09/01/2008 12/31/21991 RG010 NF - SSA 1 RG SSA 0100 I A 09/01/2008 12/31/21991 RG011 NF - CC2 1 RG CC2 0100 I A 09/01/2008 12/31/21991 RG012 NF - CC1 1 RG CC1 0100 I A 09/01/2008 12/31/21991 RG013 NF - CB2 1 RG CB2 0100 I A 09/01/2008 12/31/21991 RG014 NF - CB1 1 RG CB1 0100 I A 09/01/2008 12/31/21991 RG015 NF - CA2 1 RG CA2 0100 I A 09/01/2008 12/31/21991 RG016 NF - CA1 1 RG CA1 0100 I A 09/01/2008 12/31/21991 RG017 NF - IB2 1 RG IB2 0100 I A 09/01/2008 12/31/21991 RG018 NF - IB1 1 RG IB1 0100 I A 09/01/2008 12/31/21991 RG019 NF - IA2 1 RG IA2 0100 I A 09/01/2008 12/31/21991 RG020 NF - IA1 1 RG IA1 0100 I A 09/01/2008 12/31/21991 RG021 NF - BB2 1 RG BB2 0100 I A 09/01/2008 12/31/21991 RG022 NF - BB1 1 RG BB1 0100 I A 09/01/2008 12/31/21991 RG023 NF - BA2 1 RG BA2 0100 I A 09/01/2008 12/31/21991 RG024 NF - BA1 1 RG BA1 0100 I A 09/01/2008 12/31/21991 RG025 NF - PE2 1 RG PE2 0100 I A 09/01/2008 12/31/21991 RG026 NF - PE1 1 RG PE1 0100 I A 09/01/2008 12/31/21991 RG027 NF - PD2 1 RG PD2 0100 I A 09/01/2008 12/31/21991 RG028 NF - PD1 1 RG PD1 0100 I A 09/01/2008 12/31/21991 RG029 NF - PC2 1 RG PC2 0100 I A 09/01/2008 12/31/21991 RG030 NF - PC1 1 RG PC1 0100 I A 09/01/2008 12/31/21991 RG031 NF - PB2 1 RG PB2 0100 I A 09/01/2008 12/31/21991 RG032 NF - PB1 1 RG PB1 0100 I A 09/01/2008 12/31/21991 RG033 NF - PA2 1 RG PA2 0100 I A 09/01/2008 12/31/21991 RG034 NF - PA1 1 RG PA1 0100 I A 09/01/2008 12/31/21991 RG035 NF - BC1 1 RG BC1 0100 I A 09/01/2008 12/31/21991 RG036 NF - PCE 1 RG PCE 0100 I A 09/01/2008 12/31/21991 V0101 VA DAILY CARE - RAD 1 RG RAD 0100 VA I A 09/01/2008 12/31/21991 V0102 VA DAILY CARE - RAC 1 RG RAC 0100 VA I A 09/01/2008 12/31/21991 V0103 VA DAILY CARE - RAB 1 RG RAB 0100 VA I A 09/01/2008 12/31/21991 V0104 VA DAILY CARE - RAA 1 RG RAA 0100 VA I A 09/01/2008 12/31/21991 V0105 VA DAILY CARE - SE3 1 RG SE3 0100 VA I A 09/01/2008 12/31/21991 V0106 VA DAILY CARE - SE2 1 RG SE2 0100 VA I A 09/01/2008 12/31/21991 V0107 VA DAILY CARE - SE1 1 RG SE1 0100 VA I A 09/01/2008 12/31/21991 V0108 VA DAILY CARE - SSC 1 RG SSC 0100 VA I A 09/01/2008 12/31/21991 V0109 VA DAILY CARE - SSB 1 RG SSB 0100 VA I A 09/01/2008 12/31/21991 V0110 VA DAILY CARE - SSA 1 RG SSA 0100 VA I A 09/01/2008 12/31/21991 V0111 VA DAILY CARE - CC2 1 RG CC2 0100 VA I A 09/01/2008 12/31/21991 V0112 VA DAILY CARE - CC1 1 RG CC1 0100 VA I A 09/01/2008 12/31/21991 V0113 VA DAILY CARE - CB2 1 RG CB2 0100 VA I A 09/01/2008 12/31/21991 V0114 VA DAILY CARE - CB1 1 RG CB1 0100 VA I A 09/01/2008 12/31/21991 V0115 VA DAILY CARE - CA2 1 RG CA2 0100 VA I A 09/01/2008 12/31/21991 V0116 VA DAILY CARE - CA1 1 RG CA1 0100 VA I A 09/01/2008 12/31/21991 V0117 VA DAILY CARE - IB2 1 RG IB2 0100 VA I A 09/01/2008 12/31/21991 V0118 VA DAILY CARE - IB1 1 RG IB1 0100 VA I A 09/01/2008 12/31/21991 V0119 VA DAILY CARE - IA2 1 RG IA2 0100 VA I A 09/01/2008 12/31/21991 V0120 VA DAILY CARE - IA1 1 RG IA1 0100 VA I A 09/01/2008 12/31/21991 V0121 VA DAILY CARE - BB2 1 RG BB2 0100 VA I A 09/01/2008 12/31/21991 V0122 VA DAILY CARE - BB1 1 RG BB1 0100 VA I A 09/01/2008 12/31/21991 V0123 VA DAILY CARE - BA2 1 RG BA2 0100 VA I A 09/01/2008 12/31/21991 V0124 VA DAILY CARE - BA1 1 RG BA1 0100 VA I A 09/01/2008 12/31/21991 V0125 VA DAILY CARE - PE2 1 RG PE2 0100 VA I A 09/01/2008 12/31/21991 V0126 VA DAILY CARE - PE1 1 RG PE1 0100 VA I A 09/01/2008 12/31/21991 V0127 VA DAILY CARE - PD2 1 RG PD2 0100 VA I A 09/01/2008 12/31/21991 V0128 VA DAILY CARE - PD1 1 RG PD1 0100 VA I A 09/01/2008 12/31/21991 V0129 VA DAILY CARE - PC2 1 RG PC2 0100 VA I A 09/01/2008 12/31/21991 V0130 VA DAILY CARE - PC1 1 RG PC1 0100 VA I A 09/01/2008 12/31/21991 V0131 VA DAILY CARE - PB2 1 RG PB2 0100 VA I A 09/01/2008 12/31/21991 V0132 VA DAILY CARE - PB1 1 RG PB1 0100 VA I A 09/01/2008 12/31/21991 V0133 VA DAILY CARE - PA2 1 RG PA2 0100 VA I A 09/01/2008 12/31/2199

LTC Bill Code Crosswalk

Texas LTC Local Codes National Codes

Page 1 of 20 Last Update 02/19/2020 1. CPT only copyright 2010 American Medical Association. All rights reserved.

SERVICEGROUP

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LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

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MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






1 V0134 VA DAILY CARE - PA1 1 RG PA1 0100 VA I A 09/01/2008 12/31/21991 V0135 VA DAILY CARE - BC1 1 RG BC1 0100 VA I A 09/01/2008 12/31/21991 V0136 VA DAILY CARE - PCE 1 RG PCE 0100 VA I A 09/01/2008 12/31/21991 N0400 MEDICARE SKILLED 3 HC 0101 I A 02/01/2015 12/31/21991 N0400 MEDICARE SKILLED 3 0100 I A 10/16/2003 01/31/20151 V0400 VA - MEDICARE SKILLED 3 HC 0101 VA I A 03/01/2015 12/31/21991 N0500 VENTILATOR - FULL 4 HC 94004 0230 U7 I A 02/01/2008 01/31/20151 N0500 VENTILATOR - FULL 4 HC 94005 0230 U7 I A 01/01/2010 12/31/21991 N0500 VENTILATOR-FULL 4 HC 94004 0230 U1 UA U7 I A 02/01/2015 12/31/21991 N0500 VENTILATOR-FULL 4 HC 94005 0230 U1 UA U7 I A 02/01/2015 12/31/21991 N0501 VENTILATOR - PARTIAL 4 HC 94004 0230 U8 I A 02/01/2008 01/31/20151 N0501 VENTILATOR - PARTIAL 4 HC 94005 0230 U8 I A 01/01/2010 12/31/21991 N0501 VENTILATOR-PARTIAL 4 HC 94004 0230 U1 UA U8 I A 02/01/2015 12/31/21991 N0501 VENTILATOR-PARTIAL 4 HC 94005 0230 U1 UA U8 I A 02/01/2015 12/31/21991 N0600 EMERGENCY DENTAL - CUT AND EVACUATE ABSCESS - INTRAORAL 5 AD D7510 D A 05/27/1999 12/31/2199

1 N0600 EXTRACTION ERUPTED TOOTH/EXR 5 AD D7140 D A 01/01/2006 12/31/21991 N0600

SUBSEQUENT 15 MINUTES 5 AD D9221 D A 05/27/1999 12/31/2199

1 N0600 EMERGENCY DENTAL - GENERAL NUMBING FIRST HALF HOUR 5 AD D9220 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - INITIAL X-RAY 5 AD D0220 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - LOCAL NUMBING 5 AD D9215 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - ORAL 5 AD D0140 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - PALLIATIVE 5 AD D9110 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - PULL IMPACTED TOOTH 5 AD D7220 D A 05/27/1999 12/31/2199

1 N0600 EMERGENCY DENTAL - PULL OF IMPACTED SLIGHTLY TOOTH - BONY 5 AD D7230 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - PULL OF IMPACTED TOOTH - BONY 5 AD D7240 D A 05/27/1999 12/31/2199

1 N0600 EMERGENCY DENTAL - PULL OF TOOTH DAMAGED 5 AD D7210 D A 05/27/1999 12/31/21991 N0600 EMERGENCY DENTAL - PULL REMAINING TOOTH ROOTS 5 AD D7250 D A 05/27/1999 12/31/21991 N0600

BONY COMPLICATIONS 5 AD D7241 D A 05/27/1999 12/31/2199

1 N0600 EMERGENCY DENTAL - SUBSEQUENCE X-RAYS 5 AD D0230 D A 05/27/1999 12/31/21991 N0600

EXTRAORAL 5 AD D7520 D A 05/27/1999 12/31/2199

1 N0700 NAT - TRAINING COURSE 6 ER N A 01/01/1900 12/31/2199

1 N0701 NAT - SKILLS TEST - PASSED 6 ER N A 01/01/1900 12/31/2199

1 N0702 NAT - SKILLS TEST - FAILED 6 ER N A 01/01/1900 12/31/2199

1 N0703 NAT - WRITTEN TEST - PASSED 6 ER N A 01/01/1900 12/31/21991 N0704 NAT - WRITTEN TEST - FAILED 6 ER N A 01/01/1900 12/31/21991 N0705 NAT-ORAL TEST - PASSED 6 ER N A 01/01/1900 12/31/21991 N0706 NAT-ORAL TEST - FAILED 6 ER N A 01/01/1900 12/31/21991 N0707 NAT - TRAINING MATERIALS 6 ER N A 01/01/1900 12/31/21991 N0708 NAT - INCOMPLETE TRAINING COURSE 6 ER N A 01/01/1900 12/31/21991 G0452 OT-REHABILITATIVE SERV 7 HC 97039 0431 I A 10/16/2003 01/31/20151 G0452 OT-REHABILITATIVE SERV 7 HC 97039 0431 U1 UA I A 02/01/2015 12/31/21991 G0453 OT EVAL HIGH COMPLEX 7 HC 97167 0434 U1 UA GO I A 01/01/2017 12/31/21991 G0453 OT EVAL LOW COMPLEX 7 HC 97165 0434 I A 01/01/2017 12/31/21991 G0453 OT ASSESSMENT-REHABILITATIVE SERV 7 HC 97003 0434 I A 10/16/2003 01/31/20151 G0453 OT ASSESSMENT-REHABILITATIVE SERV 7 HC 97003 0434 U1 UA I A 02/01/2015 12/31/21991 G0453 OT EVAL MOD COMPLEX 7 HC 97166 0434 U1 UA I A 01/01/2017 12/31/21991 G0467 OT-REHABILITATIVE SERVICE CONTRACTED 7 HC 97039 0431 GO I A 10/01/2008 01/31/20151 G0467 OT-REHABILITATIVE SERVICE CONTRACTED 7 HC 97039 0431 U1 UA GO I A 02/01/2015 12/31/2199

1 G0468 OT EVAL HIGH COMPLEX CONTRACTED 7 HC 97167 0434 U1 UA GO KX I A 01/01/2017 12/31/21991 G0468 OT EVAL LOW COMPLEX CONTRACTED 7 HC 97165 0434 U1 GO I A 01/01/2017 12/31/2199

1 G0468 OT EVAL MOD COMPLEX CONTRACTED 7 HC 97166 0434 U1 UA GO I A 01/01/2017 12/31/21991 G0468 OT-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 7 HC 97003 0434 GO I A 10/01/2008 01/31/20151 G0468 OT-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 7 HC 97003 0434 U1 UA GO I A 02/01/2015 12/31/21991 G0454 PT-REHABILITATIVE SERV 8 HC 97039 0421 I A 10/16/2003 01/31/20151 G0454 PT-REHABILITATIVE SERV 8 HC 97039 0421 U1 UA I A 02/01/2015 12/31/21991 G0455 PT EVAL HIGH COMPLEX 8 HC 97163 0424 U1 UA GP I A 01/01/2017 12/31/21991 G0455 PT EVAL LOW COMPLEX 8 HC 97161 0424 I A 01/01/2017 12/31/2199

1 G0455 PT ASSESSMENT-REHABILITATIVE SERV 8 HC 97001 0424 I A 10/16/2003 01/31/20151 G0455 PT ASSESSMENT-REHABILITATIVE SERV 8 HC 97001 0424 U1 UA I A 02/01/2015 12/31/21991 G0455 PT EVAL MOD COMPLEX 8 HC 97162 0424 U1 UA I A 01/01/2017 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






1 G0469 PT-REHABILITATIVE SERVICE CONTRACTED 8 HC 97039 0421 GP I A 10/01/2008 01/31/2015

1 G0469 PT-REHABILITATIVE SERVICE CONTRACTED 8 HC 97039 0421 U1 UA GP I A 02/01/2015 12/31/21991 G0470 PT EVAL HIGH COMPLEX CONTRACTED 8 HC 97163 0424 U1 UA GP KX I A 01/01/2017 12/31/2199

1 G0470 PT EVAL LOW COMPLEX CONTRACTED 8 HC 97161 0424 U1 GP I A 01/01/2017 12/31/21991 G0470 PT EVAL MOD COMPLEX CONTRACTED 8 HC 97162 0424 U1 UA GP I A 01/01/2017 12/31/21991 G0470 PT-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 8 HC 97001 0424 GP I A 10/01/2008 01/31/20151 G0470 PT-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 8 HC 97001 0424 U1 UA GP I A 02/01/2015 12/31/21991 G0456 ST-REHABILITATIVE SERV 9 HC 92507 0441 I A 10/16/2003 01/31/20151 G0456 ST-REHABILITATIVE SERV 9 HC 92507 0441 U1 UA I A 02/01/2015 12/31/21991 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC V5364 0444 U1 UA I A 02/01/2015 12/31/21991 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC V5364 0444 I A 10/16/2003 01/31/20151 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92521 0444 U1 UA I A 02/01/2015 12/31/21991 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92521 0444 I A 06/01/2014 01/31/20151 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92522 0444 U1 UA I A 02/01/2015 12/31/21991 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92522 0444 I A 06/01/2014 01/31/20151 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92523 0444 U1 UA I A 02/01/2015 12/31/21991 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92523 0444 I A 06/01/2014 01/31/20151 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92524 0444 U1 UA I A 02/01/2015 12/31/21991 G0457 ST ASSESSMENT-REHABILITATIVE SERV 9 HC 92524 0444 I A 06/01/2014 01/31/20151 G0471 ST-REHABILITATIVE SERVICE CONTRACTED 9 HC 92507 0441 U1 UA GN I A 02/01/2015 12/31/21991 G0471 ST-REHABILITATIVE SERVICE CONTRACTED 9 HC 92507 0441 GN I A 10/01/2008 01/31/20151 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC V5364 0444 U1 UA GN I A 02/01/2015 12/31/21991 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92506 0444 GN I A 10/01/2008 01/31/20151 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92506 0444 U1 UA GN I A 02/01/2015 01/31/20181 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92524 0444 U1 UA GN I A 02/01/2015 12/31/21991 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92521 0444 U1 UA GN I A 02/01/2015 12/31/21991 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92522 0444 GN I A 06/01/2014 01/31/20151 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92522 0444 U1 UA GN I A 02/01/2015 12/31/21991 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92523 0444 GN I A 06/01/2014 01/31/20151 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92523 0444 U1 UA GN I A 02/01/2015 12/31/21991 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92524 0444 GN I A 06/01/2014 01/31/20151 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC V5364 0444 GN I A 02/01/2015 12/31/21991 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC V5364 0444 GN I A 10/01/2008 01/31/20151 G0472 ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED 9 HC 92521 0444 GN I A 06/01/2014 01/31/2015

1 G0500 DME/ADAPTIVE AIDS - COMMUNICATION DEVICE 15 HC E2510 0290 I A 01/01/2010 12/31/2199

1 G0500 DME/ADAPTIVE AIDS - COMMUNICATION OTHER 15 HC E1902 0290 I A 05/19/1998 12/31/2199

1 G0500 DME/ADAPTIVE AIDS - OTHER (IN HOME/NON-VEHICLE LIFT) 15 HC E0636 0290 I A 05/19/1998 12/31/21991 G0500 DME - MISCELLANEOUS (HOSPITAL BEDS VENTILATOR) 15 HC E1399 0290 I A 05/19/1998 12/31/21991 G0500 DME - ROLLABOUT CHAIR 15 HC E1031 0290 I A 05/19/1998 03/31/20151 G0500 DME - STANDARD WHEELCHAIR 15 HC E1130 0290 I A 05/19/1998 03/31/20151 N0502 CHILD TRACHEOSTOMY CARE 24 HC 99199 0410 I A 06/01/2014 12/31/21991 G0955 CUSTOMIZED POWER WHEELCHAIR 15A HC K0898 0290 I A 01/01/2008 12/31/2199

1 G0958 CPWC MODIFICATION 15B HC K0898 0294 I A 01/01/2008 12/31/2199

1 G0959 CPWC ADJUSTMENTS 15C HC K0898 0299 I A 01/01/2008 12/31/2199

1 G0970 CUSTOM MANUAL WHEELCHAIR (PASRR) 15D HC K0009 0290 I A 06/01/2012 12/31/21991 G0512 DME/ADAPTIVE AIDS-PROSTHETIC DEVICE (PASRR) 15P HC L7499 0290 KX I A 02/01/2015 11/30/20171 G0512 DME/ADAPTIVE AIDS-TRAVEL CHAIR/RESTRAINT (PASRR) 15P HC E1035 0290 KX I A 02/01/2015 11/30/20171 G0512

(PASRR) 15P HC E0642 0290 KX I A 12/01/2015 11/30/2017

1 G0512 STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (PASRR) 15P HC E0641 0290 KX I A 12/01/2015 11/30/20171 G0512 DME/ADAPTIVE AIDS-GAIT TRAINER (PASRR) 15P HC E8001 0290 KX I A 02/01/2015 11/30/20171 G0512 STANDING FRAME/TABLE SYSTEM, ONE POSITION (PASRR) 15P HC E0638 0290 KX I A 12/01/2015 11/30/20171 G0512 DME/ADAPTIVE AIDS- LOW AIR PRESSURE MATTRESS (PASRR) 15P HC E0186 0290 KX I A 02/01/2015 11/30/20171 G0512 DME/ADAPTIVE AIDS POSITIONING DEVICE/WEDGE (PASRR) 15P HC E0190 0290 KX I A 12/01/2015 11/30/20171 G0512 DME/ADAPTIVE AIDS- ORTHOTIC DEVICE (PASRR) 15P HC L1971 0290 KX I A 02/01/2015 11/30/20171 G0532 DME/ADAPTIVE AIDS – ASSESSMENT BY OT (PASRR) 15PA HC T2029 0434 I A 06/01/2016 12/31/21991 G0533 DME/ADAPTIVE AIDS – ASSESSMENT BY OT CONTRACTED (PASRR) 15PA HC T2029 0434 KX I A 06/01/2016 12/31/21991 G0534 DME/ADAPTIVE AIDS – ASSESSMENT BY PT (PASRR) 15PB HC T2029 0424 I A 06/01/2016 12/31/21991 G0535 DME/ADAPTIVE AIDS – ASSESSMENT BY PT CONTRACTED (PASRR) 15PB HC T2029 0424 KX I A 06/01/2016 12/31/21991 G0536 DME/ADAPTIVE AIDS – GAIT TRAINER (PASRR) 15PC HC E8001 0290 U7 KX I A 06/01/2017 12/31/21991 G0537 DME/ADAPTIVE AIDS – LOW AIR PRESSURE MATTRESS (PASRR) 15PD HC E0186 0290 U7 KX I A 06/01/2017 12/31/21991 G0538 DME/ADAPTIVE AIDS – ORTHOTIC DEVICE (PASRR) 15PE HC L1971 0290 U7 KX I A 06/01/2017 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






1 G0539 DME/ADAPTIVE AIDS – POSITIONING DEVICE/WEDGE (PASRR) 15PF HC E0190 0290 U7 KX I A 06/01/2017 12/31/21991 G0540 DME/ADAPTIVE AIDS – PROSTHETIC DEVICE (PASRR) 15PG HC L7499 0290 U7 KX I A 06/01/2017 12/31/21991 G0541

DYNAMIC STANDER (PASRR) 15PH HC E0642 0290 U7 KX I A 06/01/2017 12/31/2199

1 G0542

POSITION (PASRR) 15PH HC E0641 0290 U7 KX I A 06/01/2017 12/31/21991 G0543

POSITION (PASRR) 15PH HC E0638 0290 U7 KX I A 06/01/2017 12/31/2199

1 G0544 DME/ADAPTIVE AIDS – TRAVEL CHAIR/RESTRAINT (PASRR) 15PI HC E1035 0290 U7 KX I A 06/01/2017 12/31/21991 N0401 SNF PART A FULL MEDICARE 3A ER P A 05/01/2008 12/31/21991 G0461 OT - NF SPECIALIZED SERVICES 7A HC 97039 0431 I A 10/16/2003 12/31/21991 G0462 OT-NF ASSESSMENT-SPECIALIZED SERVICES, MOD COMPLEX 7A HC 97166 0434 I A 01/01/2017 06/30/2017

1 G0462 OT-NF ASSESSMENT-SPECIALIZED SERVICES, HIGH COMPLEX 7A HC 97167 0434 I A 01/01/2017 06/30/20171 G0462 OT-NF ASSESSMENT, SPECIALIZED SERVICE, LOW COMPLEX 7A HC 97165 0434 I A 01/01/2017 06/30/2017

1 G0462 OT - NF ASSESSMENT-SPECIALIZED SERV 7A HC 97003 0434 I A 10/16/2003 12/31/2016

1 G0473 OT-SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 7A HC 97039 0431 GO I A 10/01/2008 12/31/21991 G0474 OT-SPECIALIZED ASSESSMENT-REHAB SERVICE CONTRACTED 7A HC 97003 0434 GO I A 10/01/2008 12/31/20161 G0474

COMPLEX 7A HC 97165 0434 GO I A 01/01/2017 06/30/2017

1 G0474

COMPLEX 7A HC 97166 0434 GO I A 01/01/2017 06/30/20171 G0474

COMPLEX 7A HC 97167 0434 GO I A 01/01/2017 06/30/2017

1 G0526 OT-NF ASSESSMENT - SPECIALIZED SERVICES 7AE HC 97003 0434 KX I A 06/01/2016 12/31/2016

1 G0526 OT-NF ASSESSMENT-SPECIALIZED SERVICES, MOD COMPLEX 7AE HC 97166 0434 KX I A 01/01/2017 12/31/2199

1 G0526 OT-NF ASSESSMENT-SPECIALIZED SERVICES, LOW COMPLEX 7AE HC 97165 0434 KX I A 01/01/2017 12/31/2199

1 G0526 OT-NF ASSESSMENT, SPECIALIZED SERVICES, HIGH COMPLEX 7AE HC 97167 0434 KX I A 01/01/2017 12/31/21991 G0527 OT-NF ASSESSMENT - SPECIALIZED SERVICES, CONTRACTED 7AE HC 97003 0434 GO KX I A 06/01/2016 12/31/20161 G0527

COMPLEX 7AE HC 97167 0434 GO KX I A 01/01/2017 12/31/2199

1 G0527

COMPLEX 7AE HC 97165 0434 GO KX I A 01/01/2017 12/31/21991 G0527

COMPLEX 7AE HC 97166 0434 GO KX I A 01/01/2017 12/31/2199

1 G0479 CPWC ASSESSMENT BY OT SERVICE CONTRACTED 7B HC 97542 0434 U1 UA GO I A 02/01/2015 12/31/21991 G0479 CPWC ASSESSEMENTS BY OT SERVICE CONTRACTED. 7B HC 97542 0434 GO I A 10/01/2008 01/31/20151 G0956 CPWC ASSESSMENTS BY OT 7B HC 97542 0434 I A 01/01/2008 12/31/21991 G0481 CMWC ASSESSMENT BY OT CONTRACTED 7C HC 97542 0434 I A 06/01/2012 12/31/21991 G0973 CMWC ASSESSMENT BY OT STANDARD 7C HC 97542 0434 GO I A 06/01/2012 12/31/21991 G0463 PT - NF SPECIALIZED SERVICES 8A HC 97039 0421 I A 10/16/2003 12/31/21991 G0464 PT-NF ASSESSMENT-SPECIALIZED SERVICES, MOD COMPLEX 8A HC 97162 0424 I A 01/01/2017 06/30/20171 G0464 PT - NF ASSESSMENT-SPECIALIZED SERV 8A HC 97001 0424 I A 10/16/2003 12/31/20161 G0464 PT-NF ASSESSMENT-SPECIALIZED SERVICES, HIGH COMPLEX 8A HC 97163 0424 I A 01/01/2017 06/30/20171 G0464 PT-NF ASSESSMENT-SPECIALIZED SERVICES, LOW COMPLEX 8A HC 97161 0424 I A 01/01/2017 06/30/20171 G0475 PT- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 8A HC 97039 0421 GP I A 10/01/2008 12/31/21991 G0476

COMPLEX 8A HC 97162 0424 GP I A 01/01/2017 06/30/2017

1 G0476 PT- SPECIALIZED ASSESSMENT-REHAB SERVICE CONTRACTED 8A HC 97001 0424 GP I A 10/01/2008 12/31/20161 G0476

COMPLEX 8A HC 97161 0424 GP I A 01/01/2017 06/30/2017

1 G0476

COMPLEX 8A HC 97163 0424 GP I A 01/01/2017 06/30/20171 G0528 PT-NF ASSESSMENT - SPECIALIZED SERVICES 8AE HC 97001 0424 KX I A 06/01/2016 12/31/20161 G0528 PT-NF ASSESSMENT-SPECIALIZED SERVICES, HIGH COMPLEX 8AE HC 97163 0424 KX I A 01/01/2017 12/31/21991 G0528 PT-NF ASSESSMENT-SPECIALIZED SERVICES, LOW COMPLEX 8AE HC 97161 0424 KX I A 01/01/2017 12/31/21991 G0528 PT-NF ASSESSMENT-SPECIALIZED SERVICES, MOD COMPLEX 8AE HC 97162 0424 KX I A 01/01/2017 12/31/21991 G0529 PT-NF ASSESSMENT - SPECIALIZED SERVICES, CONTRACTED 8AE HC 97001 0424 GP KX I A 06/01/2016 12/31/20161 G0529

COMPLEX 8AE HC 97161 0424 GP KX I A 01/01/2017 12/31/2199

1 G0529

COMPLEX 8AE HC 97162 0424 GP KX I A 01/01/2017 12/31/21991 G0529

COMPLEX 8AE HC 97163 0424 GP KX I A 01/01/2017 12/31/2199

1 G0480 CPWC ASSESSEMENTS BY PT SERVICE CONTRACTED. 8B HC 97542 0424 GP I A 10/01/2008 01/31/20151 G0480 CPWC ASSESSMENTS BY PT SERVICE CONTRACTED 8B HC 97542 0424 U1 UA GP I A 02/01/2015 12/31/21991 G0957 CPWC ASSESSMENTS BY PT 8B HC 97542 0424 I A 01/01/2008 12/31/21991 G0482 CMWC ASSESSMENT BY PT CONTRACTED 8C HC 97542 0434 I A 06/01/2012 12/31/21991 G0974 CMWC ASSESSMENT BY PT STANDARD 8C HC 97542 0434 GP I A 06/01/2012 12/31/21991 G0465 ST - NF SPECIALIZED SERVICES - TREATMENT 9A HC 92507 0441 I A 10/16/2003 12/31/21991 G0466 ST - NF ASSESSMENT-SPECIALIZED SERV 9A HC 92524 0444 I A 06/01/2014 06/30/20171 G0466 ST - NF ASSESSMENT-SPECIALIZED SERV 9A HC V5364 0444 I A 10/16/2003 06/30/20171 G0466 ST - NF ASSESSMENT-SPECIALIZED SERV 9A HC 92521 0444 I A 06/01/2014 06/30/20171 G0466 ST - NF ASSESSMENT-SPECIALIZED SERV 9A HC 92523 0444 I A 06/01/2014 06/30/20171 G0466 ST - NF ASSESSMENT-SPECIALIZED SERV 9A HC 92522 0444 I A 06/01/2014 06/30/20171 G0477 ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 9A HC 92507 0441 GN I A 10/01/2008 12/31/21991 G0478 ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 9A HC 92523 0444 GN I A 06/01/2014 12/31/21991 G0478 ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 9A HC 92522 0444 GN I A 06/01/2014 12/31/21991 G0478 ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 9A HC 92521 0444 GN I A 06/01/2014 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






1 G0478 ST- SPECIALIZED ASSESSMENT-REHAB SERVICE CONTRACTED 9A HC V5364 0444 GN I A 10/01/2008 06/30/20171 G0478 ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED 9A HC 92524 0444 GN I A 06/01/2014 12/31/21991 G0530 ST-NF ASSESSMENT - SPECIALIZED SERVICES 9AE HC V5364 0444 KX I A 06/01/2016 12/31/21991 G0531 ST-NF ASSESSMENT - SPECIALIZED SERVICES, CONTRACTED 9AE HC V5364 0444 GN KX I A 06/01/2016 12/31/21991 G0483 ACD ASSESSMENT BY ST CONTRACTED 9D HC 0212T 0444 I A 06/01/2012 12/31/21991 G0976 ACD ASSESSMENT BY ST STANDARD 9D HC 0212T 0444 GN I A 06/01/2012 12/31/21992 G0400 OCCUPATIONAL THERAPY 7 HC G0152 GO P A 01/01/1900 12/31/21992 G0401 PHYSICAL THERAPY 8 HC G0151 GP P A 01/01/1900 12/31/21992 G0402 SPEECH THERAPY 9 HC G0153 GN P A 01/01/1900 12/31/21992 S0100 HABILITATION - TRAINING 10 HC T2016 U3 P A 10/16/2003 12/31/21992 S0101 HABILITATION - ADLS 10 HC T2021 U5 P A 10/16/2003 12/31/21992 S0124 AGENCY ADMIN - HABILITATION CDS 10 ER P A 10/16/2003 12/31/21992 G0100 RESPITE-IN HOME RESPITE-DSA 11 ER P A 01/01/1900 12/31/21992 G0101 RESPITE - IN-HOME CDS-INDIVIDUAL 11 ER P A 01/01/1900 12/31/21992 G0171 AGENCY ADMIN - IN HOME RESPITE CDS 11 ER P A 01/01/1900 12/31/21992 G0201 CASE MANAGEMENT - FIXED RATE 12 HC T2022 P A 01/01/1900 12/31/21992 G0300

REASSESSMENTS/HEALTH AND SAFETY/AND POST- 13 HC T1001 TD P A 01/01/1900 12/31/2199

2 G0300

AND SUPERVISION PARTIAL UNIT 13 HC T1002 TD P A 01/01/1900 12/31/21992 G0300

HOME 13 HC S9123 TD P A 01/01/1900 12/31/2199

2 G0301 LVN-NURSING SERVICES PARTIAL UNIT 13 HC T1003 TE P A 01/01/1900 12/31/21992 G0301

HOME 13 HC S9124 TE P A 01/01/1900 12/31/2199

2 G0403 PSYCHOLOGICAL SERVICES PROFESSIONAL ASSESSMENT -ABL 14 HC 96101 P A 10/16/2003 12/31/21992 G0500 ADAPTIVE AIDS - TRANSPORTATION 15 HC T2003 P A 05/19/1998 12/31/21992 G0500

SUPPLIES/DIAPER/BED PAD/ENSURE) 15 HC S5199 P A 01/01/2003 12/31/2199

2 G0500 DME - MISCELLANEOUS (HOSPITAL BEDS/VENTILATOR) 15 HC E1399 P A 05/19/1998 12/31/21992 G0500 DME - ROLLING CHAIR 15 HC E1031 P A 05/19/1998 12/31/21992 G0500 DME - VEHICLE MODIFICATIONS TO INCLUDE LIFT 15 HC T2039 P A 10/01/2003 12/31/21992 G0500 DME - WHEELCHAIR/STROLLERS 15 HC E1130 P A 05/19/1998 12/31/21992 G0500

COMMUNICATION DEVICES/AIDS/EQUIPMENT 15 HC E2510 P A 01/01/2010 12/31/2199

2 G0500

COMMUNICATION DEVICES/AIDS/EQUIPMENT 15 HC E2510 P A 01/01/2011 12/31/21992 G0500

COMMUNICATIONS AIDS AND EQUIPMENT 15 HC E1902 P A 05/19/1998 12/31/2199

2 G0500 DME/ADAPTIVE AIDS - OTHER (IN HOME/NON-VEHICLE LIFT) 15 HC E0636 P A 05/19/1998 12/31/21992 G0500 MEDICAL SUPPLIES - (NOT OTHERWISE SPECIFIED) 15 HC T2028 P A 10/01/2003 12/31/21992 G0500 DME - MEDICAL EQUIPMENT (NOT OTHERWISE SPECIFIED) 15 HC T2029 P A 10/01/2003 12/31/21992 G0608 HOME MODIFICATIONS 16 HC S5165 P A 01/01/2003 12/31/21992 U0210 DIETARY/NUTRITIONAL SERVICES 34 HC S9470 P A 02/01/2010 12/31/21992 U0300 AUDIOLOGY 35 HC V5008 P A 12/01/2009 12/31/21992 H2025 CLASS SUPPORTED EMPLOYMENT 37 HC H2024 P A 11/01/2008 12/31/21992 G0203 CASE MANAGEMENT PARTIAL ASSESSMENT 40 HC T1023 U8 P A 10/16/2003 12/31/21992 G0204 CASE MANAGEMENT FULL ASSESSMENT 40 HC T1023 U7 P A 10/16/2003 12/31/21992 G0515 ADP AIDES/REQUISITION FEES 0.00 - 499.99 41 ER P A 01/01/1900 12/31/21992 G0516 ADP AIDES/REQUISITION FEES 500.00 - 999.99 41 ER P A 01/01/1900 12/31/21992 G0517 ADP AIDES/REQUISITION FEES 1000.00 - 1499.99 41 ER P A 01/01/1900 12/31/21992 G0518 ADP AIDES/REQUISITION FEES 1500.00 - 1999.99 41 ER P A 01/01/1900 12/31/21992 G0519 ADP AIDES/REQUISITION FEES 2000.00 - 2499.99 41 ER P A 01/01/1900 12/31/21992 G0520 ADP AIDES/REQUISITION FEES 2500.00 - 2999.99 41 ER P A 01/01/1900 12/31/21992 G0521 ADP AIDES/REQUISITION FEES 3000.00 - 3499.99 41 ER P A 01/01/1900 12/31/21992 G0522 ADP AIDES/REQUISITION FEES 3500.00 - 3999.99 41 ER P A 01/01/1900 12/31/21992 G0523 ADP AIDES/REQUISITION FEES 4000.00 - 4499.99 41 ER P A 01/01/1900 12/31/21992 G0524 ADP AIDES/REQUISITION FEES 4500.00 - 4999.99 41 ER P A 01/01/1900 12/31/21992 G0525 ADP AIDES/REQUISITION FEES 5000.00 - OVER 41 ER P A 01/01/1900 12/31/21992 G0404 SPECIALIZED THERAPIES - AT HOME 42 HC 97535 P A 01/01/1900 12/31/21992 G0404 SPECIALIZED THERAPIES - ACTIVITY THERAPY - FUTURE USE 42 HC H2032 P A 10/16/2003 12/31/21992 G0404 SPECIALIZED THERAPIES - IN COMMUNITY-FUTURE USE 42 HC 97537 P A 01/01/1900 12/31/21992 G0248 HAB TRANSPORTATION 48 HC T2001 P A 11/01/2015 12/31/21992 T2038 TRANSITION ASSISTANCE SERVICES (TAS) 53 HC T2038 P A 09/01/2004 12/31/21992 H2026 EMPLOYMENT ASSISTANCE 54 HC H2026 P A 08/01/2013 12/31/21992 S5145 SUPPORT FAMILY SERVICES 55 HC S5145 P A 09/01/2004 12/31/21992 G6089 COGNITIVE REHABILITATION THERAPY 61 HC 97532 P A 08/01/2014 01/31/20182 G6089 COGNITIVE REHABILITATION THERAPY 61 HC G0515 P A 02/01/2018 12/31/21992 S0105 HABILITATION ATTENDANT CARE SERVICES - DELEGATED NURSING 10A HC S5125 P A 10/16/2003 12/31/21992 S0105 HABILITATION PERSONAL CARE SERVICES - NURSING 10A HC T1019 P A 10/16/2003 12/31/21992 S0107 HABILITATION - PREVOCATIONAL 10B HC T2015 U4 P A 01/01/1900 12/31/21992 G1108 CFC PAS/HAB 10CFC HC T2026 P A 06/01/2015 12/31/21992 G1119 SPT MEETING 10CFC HC T2024 KX P A 3/1/2020 12/31/21992 G1109 CDS CFC PAS/HAB 10CFV HC T2016 P A 06/01/2015 12/31/21992 G1110 CDS CFC PAS/HAB; TAXES 10CFV HC T2016 UG P A 06/01/2015 12/31/21992 G1111 CDS CFC PAS/HAB, ES/BENEFITS 10CFV HC T2016 UF P A 06/01/2015 12/31/21992 G6085 CDS HABILITATION-TRAINING 10V HC T2016 P A 12/01/2013 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






2 G6086 CDS HABILITATION-ADL'S 10V HC T2016 U5 P A 12/01/2013 12/31/21992 G6087 CDS HABILITATION- TAXES 10V HC T2016 UG P A 12/01/2013 12/31/21992 G6088 CDS HABILITATION-ES/BENEFITS 10V HC T2016 UF P A 12/01/2013 12/31/21992 G0128 RESPITE - OUT-OF-HOME 11A HC S5151 P A 01/01/1900 12/31/21992 G0170 AGENCY ADMIN - OUT OF HOME RESPITE CDS 11A ER P A 01/01/1900 12/31/21992 G0196 CDS RESPITE OUT-OF-HOME 11AV HC S5151 P A 03/01/2008 12/31/21992 G6003 CDS RESPITE OUT-OF-HOME - TAXES 11AV HC S5151 UG P A 02/01/2013 12/31/21992 G6004 CDS RESPITE OUT-OF-HOME - ES/BENEFITS 11AV HC S5151 UF P A 02/01/2013 12/31/21992 G0197 CDS RESPITE IN-HOME 11PV HC S9125 P A 03/01/2008 12/31/21992 G6011 CDS RESPITE IN-HOME - TAXES 11PV HC S9125 UG P A 02/01/2013 12/31/21992 G6012 CDS RESPITE IN-HOME - ES/BENEFITS 11PV HC S9125 UF P A 02/01/2013 12/31/21992 G0302 NURSING SERVICES BY LPN/LVN 13A HC T1003 P A 01/01/1900 12/31/21992 G0305 CDS NURSING LVN 13AV HC T1003 UC TE P A 08/01/2009 12/31/21992 G6041 CDS NURSING LVN - TAXES 13AV HC T1003 UG TE P A 02/01/2013 12/31/2199

2 G6042 CDS NURSING LVN - ES/BENEFITS 13AV HC T1003 UF TE P A 02/01/2013 12/31/21992 G0303 NURSING SERVICES - RN 13B HC T1002 P A 01/01/1900 12/31/21992 G0304 CDS NURSING RN 13BV HC T1002 UC TD P A 08/01/2009 12/31/21992 G6043 CDS NURSING RN - TAXES 13BV HC T1002 UG TD P A 02/01/2013 12/31/21992 G6044 CDS NURSING RN - ES/BENEFITS 13BV HC T1002 UF TD P A 02/01/2013 12/31/21992 T1002 SPECIALIZED NURSING RN 13C HC T1002 TG TD P A 01/01/2008 12/31/21992 G0306 CDS SPECIALIZED NURSING RN 13CV HC T1002 TG UC TD P A 08/01/2009 12/31/21992 G6045 CDS SPECIALIZED NURSING RN - TAXES 13CV HC T1002 TG UG TD P A 02/01/2013 12/31/21992 G6046 CDS SPECIALIZED NURSING RN - ES/BENEFITS 13CV HC T1002 TG UF TD P A 02/01/2013 12/31/21992 T1003 SPECIALIZED NURSING LVN 13D HC T1003 TG TE P A 01/01/2008 12/31/21992 G0307 CDS SPECIALIZED NURSING LVN 13DV HC T1003 TG UC TE P A 08/01/2009 12/31/21992 G6049 CDS SPECIALIZED NURSING LVN - TAXES 13DV HC T1003 TG UG TE P A 02/01/2013 12/31/21992 G6050 CDS SPECIALIZED NURSING LVN - ES/BENEFITS 13DV HC T1003 TG UG TE P A 02/01/2013 12/31/21992 G0705 PAS DELEGATED (FOR FUTURE USE) 17A ER P A 01/01/1900 12/31/21992 G0706 PAS PROTECTIVE SUPERVISION (FOR FUTURE USE) 17B ER P A 01/01/1900 12/31/21992 G1112 CFC ERS; INITIAL MONTH 20CFC HC S5160 P A 06/01/2015 12/31/21992 G1113 CFC ERS PURCHASE ONLY 20CFC HC S5162 P A 06/01/2015 12/31/21992 G1114 CFC ERS ONGOING MONTHS 20CFC HC S5161 P A 06/01/2015 12/31/21992 G0722 CMPAS - CLIENT DIRECTED SERVICES 27A ER P A 01/01/1900 12/31/21992 G0723 CMPAS - CLIENT DIRECTED SERVICES - AGENCY 27A ER P A 01/01/1900 12/31/21992 U0306 AUDITORY INTEGRATION/ENHANCEMENT TRAINING 35B HC V5299 P A 12/01/2009 12/31/21992 G6067 CDS SUPPORTED EMPLOYMENT-TAXES 37V HC H2024 UG UC P A 08/01/2013 12/31/21992 G6068 CDS SUPPORTED EMPLOYMENT-ES/BENEFITS 37V HC H2024 UF UC P A 08/01/2013 12/31/21992 H2027 CLASS CDS-SUPPORTED EMPLOYMENT 37V HC H2024 UC P A 02/01/2012 12/31/21992 G0208 DSA FULL ASSESSMENTS 40B HC T1023 P A 12/01/2011 12/31/21992 G0209 DSA PARTIAL ASSESSMENTS 40B HC T2024 P A 12/01/2011 12/31/21992 G0607 SPECIFICATIONS ADAPTIVE AIDS 41C ER P A 01/01/1900 12/31/21992 G0604 SPECIFICATIONS HM MODS 41D ER P A 01/01/1900 12/31/21992 G0648 SPECIALIZED THERAPIES/REQ FEES 0.00 - 499.99 41F ER P A 09/01/2007 12/31/21992 G0649 SPECIALIZED THERAPIES/REQ FEES 500.00 - 999.99 41F ER P A 09/01/2007 12/31/21992 G0650 SPECIALIZED THERAPIES/REQ FEES 1000.00 - 1499.99 41F ER P A 09/01/2007 12/31/21992 G0651 SPECIALIZED THERAPIES/REQ FEES 1500.00 - 1999.99 41F ER P A 09/01/2007 12/31/21992 G0652 SPECIALIZED THERAPIES/REQ FEES 2000.00 - 2499.99 41F ER P A 09/01/2007 12/31/21992 G0653 SPECIALIZED THERAPIES/REQ FEES 2500.00 - 2999.99 41F ER P A 09/01/2007 12/31/21992 G0654 SPECIALIZED THERAPIES/REQ FEES 3000.00 - 3499.99 41F ER P A 09/01/2007 12/31/21992 G0655 SPECIALIZED THERAPIES/REQ FEES 3500.00 - 3499.99 41F ER P A 09/01/2007 12/31/21992 G0656 SPECIALIZED THERAPIES/REQ FEES 4000.00 - 4499.99 41F ER P A 09/01/2007 12/31/21992 G0657 SPECIALIZED THERAPIES/REQ FEES 4500.00 - 4999.99 41F ER P A 09/01/2007 12/31/21992 G0658 SPECIALIZED THERAPIES/REQ FEES 5000.00 - OVER 41F ER P A 09/01/2007 12/31/21992 G0659 INSPECTIONS HM MODS 41G ER P A 10/01/2011 12/31/21992 G0490 MASSAGE THERAPY 42A HC 97124 P A 05/01/2013 12/31/21992 G0491 RECREATIONAL THERAPY 42B HC H2032 P A 05/01/2013 12/31/21992 G0492 MUSIC THERAPY 42C HC G0176 P A 05/01/2013 12/31/21992 G0493 AQUATIC THERAPY 42D HC 97113 P A 05/01/2013 12/31/21992 G0494 HIPPOTHERAPY - CERTIFIED RIDING INSTRUCTOR 42E HC S8940 KX P A 05/01/2013 12/31/21992 G0495 HIPPOTHERAPY BY OT 42E HC S8940 GO P A 05/01/2013 12/31/21992 G0496 HIPPOTHERAPY BY PT 42E HC S8940 GP P A 05/01/2013 12/31/21992 G0498 THERAPEUTIC HORSEBACK RIDING 42F HC S8940 P A 05/01/2013 12/31/21992 H2019 BEHAVIORAL SUPPORT 43A HC H2019 P A 10/01/2011 12/31/21992 G0249 CDS HAB TRANSPORTATION 48V HC T2001 UC P A 11/01/2015 12/31/21992 G0250 CDS HAB TRANSPORTATION TAXES 48V HC T2001 UG P A 11/01/2015 12/31/21992 G0251 CDS HAB TRANSPORTATION ES/BENEFITS 48V HC T2001 UF P A 11/01/2015 12/31/21992 G0239 TAS FEES 53A ER P A 09/01/2004 12/31/21992 G6077 CDS EMPLOYMENT ASSISTANCE-TAXES 54V HC H2026 UG UC P A 08/01/2014 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






2 G6078 CDS EMPLOYMENT ASSISTANCE-ES/BENEFITS 54V HC H2026 UF UC P A 08/01/2014 12/31/21992 H2029 CDS EMPLOYMENT ASSISTANCE 54V HC H2026 UC P A 08/01/2014 12/31/21992 H0041 CONTINUED FAMILY SUPPORT 55A HC H0041 P A 06/01/2010 12/31/21992 G1115 CDS CFC SUPPORT CONSULTATION 57CFV ER P A 06/01/2015 12/31/21992 G1116 CDS CFC SUPPORT CONSULTATION TAXES 57CFV ER P A 06/01/2015 12/31/21992 G1117 CDS CFC SUPPORT CONSULTATION ES/BENEFITS 57CFV ER P A 06/01/2015 12/31/21992 G0757 CDS SUPPORT CONSULTATION 57V ER P A 01/01/2009 12/31/21992 N0601 DENTAL - WAIVER PROGRAM 5A AD D9999 D A 02/01/2010 12/31/21992 N0602 DENTAL SEDATION 5B AD D9220 D A 02/01/2010 12/31/21992 G6090 CDS COGNITIVE REHABILITATION THERAPY 61V HC 97532 UC P A 08/01/2014 01/31/20182 G6090 CDS COGNITIVE REHABILITATION THERAPY 61V HC G0515 UC P A 02/01/2018 12/31/21992 G6091 CDS COGNITIVE REHABILITATION THERAPY-TAXES 61V HC 97532 UG UC P A 08/01/2014 01/31/20182 G6091 CDS COGNITIVE REHABILITATION THERAPY-TAXES 61V HC G0515 UG UC P A 02/01/2018 12/31/21992 G6092 CDS COGNITIVE REHABILITATION THERAPY-ES/BENEFITS 61V HC 97532 UF UC P A 08/01/2014 12/31/20172 G6092 CDS COGNITIVE REHABILITATION THERAPY-ES/BENEFITS 61V HC G0515 UF UC P A 01/01/2018 12/31/21992 G0222 CDS - CLASS ORIENTATION FEE 62V ER P A 09/01/2007 12/31/21992 G1118 CDS CFC FMS 63CFV HC T2040 P A 06/01/2015 12/31/21992 G0226 CDS CLASS MONTHLY ADMINISTRATION FEE 63V ER P A 09/01/2007 12/31/21992 G0408 OCCUPATIONAL THERAPY - CDS 7V HC G0152 UC P A 08/01/2009 12/31/21992 G6079 OCCUPATIONAL THERAPY- CDS - TAXES 7V HC G0152 UG P A 02/01/2013 12/31/21992 G6080 OCCUPATIONAL THERAPY- CDS - ES/BENEFITS 7V HC G0152 UF P A 02/01/2013 12/31/21992 G0409 PHYSICAL THERAPY - CDS 8V HC G0151 UC P A 08/01/2009 12/31/21992 G6081 PHYSICAL THERAPY- CDS - TAXES 8V HC G0151 UG P A 02/01/2013 12/31/21992 G6082 PHYSICAL THERAPY- CDS - ES/BENEFITS 8V HC G0151 UF P A 02/01/2013 12/31/21992 G0410 SPEECH/LANGUAGE PATHOLOGY THERAPY - CDS 9V HC G0153 UC P A 08/01/2009 12/31/21992 G6083 SPEECH/LANGUAGE PATHOLOGY THERAPY- CDS - TAXES 9V HC G0153 UG P A 02/01/2013 12/31/21992 G6084 SPEECH/LANGUAGE PATHOLOGY THERAPY- CDS - ES/BENEFITS 9V HC G0153 UF P A 02/01/2013 12/31/21994 F0100 ICF/IID CAMPUS/STATE - LOC 1 CONTRACT SPECIFIC - WITH DRUGS 1 LC 1 0100 I A 01/01/1900 12/31/21994 F0103 ICF/IID CAMPUS/STATE - LOC 8 CONTRACT SPECIFIC 1 LC 8 0100 I A 01/01/1900 12/31/21994 F0225

DRUGS 1 LC 1 0101 I A 01/01/2006 12/31/2199

5 F0108

SPECIFIC - WITH DRUGS 1 LC 8 0100 I A 01/01/1900 12/31/21995 F0109

SPECIFIC - WITH DRUGS 1 LC 1 0100 I A 01/01/1900 12/31/2199

5 F0226

SPECIFIC - WITHOUT DRUGS 1 LC 8 0101 I A 01/01/2006 12/31/21995 F0227

SPECIFIC - WITHOUT DRUGS 1 LC 1 0101 I A 01/01/2006 12/31/2199

6 F0205 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 1 1 LN 1 0100 I A 01/01/1900 12/31/21996 F0206 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 5 1 LN 5 0100 I A 01/01/1900 12/31/21996 F0207 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 6 1 LN 6 0100 I A 01/01/1900 12/31/21996 F0208 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 8 1 LN 8 0100 I A 01/01/1900 12/31/21996 F0209 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 9 1 LN 9 0100 I A 01/01/1900 12/31/21996 F0228 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 2 1 LN 2 HC 0100 A 01/01/2015 10/31/20186 F0229 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 3 1 LN 3 HC 0100 A 01/01/2015 10/31/20186 F0230 ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 4 1 LN 4 HC 0100 A 01/01/2015 10/31/20186 G0508 DME/ADAPTIVE AIDS (LON 5) - STANDING BOARD 15 LN 5 HC E1399 0290 I A 05/19/1998 12/31/21996 G0508 DME/ADAPTIVE AIDS (LON 5) - TRAVEL CHAIR 15 LN 5 HC E1035 0290 I A 05/19/1998 12/31/21996 G0508 DME/ADAPTIVE AIDS -LON 5 - AIR MATTRESS 15 LN 5 HC E0186 0290 I A 05/19/1998 12/31/21996 G0508 DME/ADAPTIVE AIDS (LON 5) - COMMUNICATION OTHER 15 LN 5 HC E1902 0290 I A 05/19/1998 12/31/21996 G0508 DME/ADAPTIVE AIDS (LON 5) - COMMUNICATION DEVICE 15 LN 5 HC E2510 0290 I A 01/01/2010 12/31/2199

6 G0508 DME/ADAPTIVE AIDS (LON 5) - ADAPTIVE STROLLER 15 LN 5 HC E1031 0290 I A 05/19/1998 12/31/21996 G0508 DME/ ADAPTIVE AIDS (LON 5) - REFURBISHED WHEELCHAIR 15 LN 5 HC K0739 0290 I A 01/01/2010 12/31/21996 G0508 DME - ADAPTIVE AIDS - LON 5 - PROSTHETIC/ORTHOTIC 15 LN 5 HC L7499 0290 I A 01/01/2015 12/31/21996 G0508 DME/ADAPTIVE AIDS -LON 5 - HOSPITAL WATERBED 15 LN 5 HC E0250 0290 I A 05/19/1998 12/31/21996 G0508 DME - ADAPTIVE AIDS - LON 5 - GAIT TRAINERS 15 LN 5 HC E8001 0290 I A 02/01/2008 12/31/21996 G0508 DME (LON 5) - STANDARD WHEELCHAIR 15 LN 5 HC E1130 0290 I A 05/19/1998 12/31/21996 G0509 DME/ADAPTIVE AIDS (LON 6) - GAIT TRAINERS 15 LN 6 HC E8001 0290 I A 02/01/2008 12/31/21996 G0509 DME (LON 6) - ADAPTIVE STROLLER 15 LN 6 HC E1031 0290 I A 05/19/1998 12/31/21996 G0509 DME/ADAPTIVE AIDS -LON 6 - HOSPITALBED 15 LN 6 HC E0250 0290 I A 05/19/1998 12/31/21996 G0509 DME/ADAPTIVE AIDS -LON 6 - AIR MATTRESS 15 LN 6 HC E0186 0290 I A 05/19/1998 12/31/21996 G0509 DME/ADAPTIVE AIDS (LON 6) - TRAVEL CHAIR 15 LN 6 HC E1035 0290 I A 05/19/1998 12/31/21996 G0509 DME/ADAPTIVE AIDS (LON 6) - STANDING BOARD 15 LN 6 HC E1399 0290 I A 05/19/1998 12/31/21996 G0509 DME/ADAPTIVE AIDS (LON 6) - COMMUNICATION DEVICE 15 LN 6 HC E2510 0290 I A 01/01/2010 12/31/21996 G0509 DME - ADAPTIVE AIDS - LON 6 -PROSTHETIC/ORTHOTIC 15 LN 6 HC L7499 0290 I A 01/01/2015 12/31/21996 G0509 DME - ADAPTIVE AIDS - LON 6 - COMMUNICATION OTHER 15 LN 6 HC E1902 0290 I A 05/19/1998 12/31/21996 G0509 DME (LON 6) - STANDARD WHEELCHAIR 15 LN 6 HC E1130 0290 I A 05/19/1998 12/31/21996 G0509 DME (LON 6) - REFURBISHED WHEELCHAIR 15 LN 6 HC K0739 0290 I A 01/01/2010 12/31/21996 G0510 DME (LON 8) - REFURBISHED WHEELCHAIR 15 LN 8 HC K0739 0290 I A 01/01/2010 12/31/21996 G0510 DME/ADAPTIVE AIDS - LON 8 - GAIT TRAINERS 15 LN 8 HC E8001 0290 I A 02/01/2008 12/31/21996 G0510 DME/ADAPTIVE AIDS -LON 8 - AIR MATTRESS 15 LN 8 HC E0186 0290 I A 05/19/1998 12/31/21996 G0510 DME/ADAPTIVE AIDS - LON 8 -PROSTHETIC/ORTHOTIC 15 LN 8 HC L7499 0290 I A 01/01/2015 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






6 G0510 DME/ADAPTIVE AIDS - LON 8 - COMMUNICATION OTHER 15 LN 8 HC E1902 0290 I A 05/19/1998 12/31/21996 G0510 DME/ADAPTIVE AIDS -LON 8 - HOSPITAL WATERBED 15 LN 8 HC E0250 0290 I A 05/19/1998 12/31/21996 G0510 DME/ADAPTIVE AIDS (LON 8) - STANDING BOARD 15 LN 8 HC E1399 0290 I A 05/19/1998 12/31/2199

6 G0510 DME/ADAPTIVE AIDS (LON 8) - COMMUNICATION DEVICE 15 LN 8 HC E2510 0290 I A 01/01/2010 12/31/2199

6 G0510 DME - STANDARD WHEELCHAIR 15 LN 8 HC E1130 0290 I A 05/19/1998 12/31/2199

6 G0510 DME (LON 8) - ADAPTIVE STROLLER 15 LN 8 HC E1031 0290 I A 05/19/1998 12/31/21996 G0510 DME/ADAPTIVE AIDS (LON 8) - TRAVEL CHAIR 15 LN 8 HC E1035 0290 I A 05/19/1998 12/31/2199

6 G0511 DME (LON 9) - REFURBISHED WHEELCHAIR 15 LN 9 HC K0739 0290 I A 01/01/2010 12/31/21996 G0511 DME/ADAPTIVE AIDS - LON 9 - GAIT TRAINERS 15 LN 9 HC E8001 0290 I A 02/01/2008 12/31/21996 G0511 DME (LON 9) - STANDARD WHEELCHAIR 15 LN 9 HC E1130 0290 I A 05/19/1998 12/31/21996 G0511 DME (LON 9) ADAPTIVE STROLLER 15 LN 9 HC E1031 0290 I A 05/19/1998 12/31/21996 G0511 DME/ADAPTIVE AIDS (LON 9) - COMMUNICATION DEVICE 15 LN 9 HC E2510 0290 I A 01/01/2010 12/31/21996 G0511 DME/ADAPTIVE AIDS (LON 9) - STANDING BOARD 15 LN 9 HC E1399 0290 I A 05/19/1998 12/31/21996 G0511 DME/ADAPTIVE AIDS (LON 9) - TRAVEL CHAIR 15 LN 9 HC E1035 0290 I A 05/19/1998 12/31/21996 G0511 DME/ADAPTIVE AIDS - LON 9 - COMMUNICATION OTHER 15 LN 9 HC E1902 0290 I A 05/19/1998 12/31/21996 G0511 DME/ADAPTIVE AIDS - LON 9 -PROSTHETIC/ORTHOTIC 15 LN 9 HC L7499 0290 I A 01/01/2015 12/31/21996 G0511 DME/ADAPTIVE AIDS -LON 9 - AIR MATTRESS 15 LN 9 HC E0186 0290 I A 05/19/1998 12/31/21996 G0511 DME/ADAPTIVE AIDS -LON 9 - HOSPITAL WATERBED 15 LN 9 HC E0250 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS - LON 1 - GAIT TRAINERS 15 LN 1 HC E8001 0290 I A 02/01/2008 12/31/21996 G0512 DME (LON 1) - STANDARD WHEELCHAIR 15 LN 1 HC E1130 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS -LON 1 - HOSPITAL WATERBED 15 LN 1 HC E0250 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS -LON 1 - AIR MATTRESS 15 LN 1 HC E0186 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS - LON 1 -PROSTHETIC/ORTHOTIC 15 LN 1 HC L7499 0290 I A 01/01/2015 12/31/21996 G0512 DME/ADAPTIVE AIDS - LON 1 - COMMUNICATION OTHER 15 LN 1 HC E1902 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS (LON 1) - TRAVEL CHAIR 15 LN 1 HC E1035 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS (LON 1) - STANDING BOARD 15 LN 1 HC E1399 0290 I A 05/19/1998 12/31/2199

6 G0512 DME (LON 1) - STANDARD WHEELCHAIR 15 LN 1 HC K0739 0290 I A 01/01/2010 12/31/21996 G0512 DME (LON 1) ADAPTIVE STROLLER 15 LN 1 HC E1031 0290 I A 05/19/1998 12/31/21996 G0512 DME/ADAPTIVE AIDS (LON 1) - COMMUNICATION DEVICE 15 LN 1 HC E2510 0290 I A 01/01/2010 12/31/21996 F0231 ICF/IID NON-STATE COMM RES ADD-ON 1 1B HC 0160 I A 09/01/2016 12/31/21996 F0232 ICF/IID NON-STATE COMM RES ADD-ON 2 1C HC 0160 I A 09/01/2016 12/31/2199

6 F0233 ICF/IID NON-STATE COMM RES ADD-ON 3 1D HC 0160 I A 09/01/2016 12/31/2199

6 F0220 TRANSITIONAL ADD-ON/NON-STATE OPERATED LON 1 1T LN 1 0100 I A 01/01/1900 12/31/2199

6 F0221 TRANSITIONAL ADD-ON/NON-STATE OPERATED LON 5 1T LN 5 0100 I A 01/01/1900 12/31/21996 F0222 TRANSITIONAL ADD-ON/NON-STATE OPERATED LON 6 1T LN 6 0100 I A 01/01/1900 12/31/21996 F0223 TRANSITIONAL ADD-ON/NON-STATE OPERATED LON 8 1T LN 8 0100 I A 01/01/1900 12/31/21996 F0224 TRANSITIONAL ADD-ON/NON-STATE OPERATED LON 9 1T LN 9 0100 I A 01/01/1900 12/31/21997 G0121 RESPITE - PERSONAL ASSISTANCE SERVICES 11 HC S5150 P A 01/01/1900 12/31/21997 G0122 RESPITE - SITTER SERVICES 11 ER P A 01/01/1900 12/31/21997 G0701 PERSONAL ASSISTANCE SERVICES - LEVEL 2 - PRIORITY 17 PR 2 HC S5125 P A 01/01/1900 12/31/21997 G0702 PERSONAL ASSISTANCE SERVICES - LEVEL 1 - NON-PRIORITY 17 PR 1 HC S5125 P A 01/01/1900 12/31/21997 G0803 ADULT FOSTER CARE - CCAD LEVEL 18 HC S5140 P A 01/01/1900 12/31/21997 G1000 EMERGENCY RESPONSE SERVICES - ALL SERVICES 20 HC S5162 P A 01/01/1900 12/31/21997 G1000 EMERGENCY RESPONSE SERVICES - INITIAL MONTH 20 HC S5160 P A 01/01/1900 12/31/21997 G1000 EMERGENCY RESPONSE SERVICES - ONGOING MONTH 20 HC S5161 P A 01/01/1900 12/31/21997 C0100 HOME DELIVERED MEALS 25 HC S5170 P A 01/01/1900 12/31/21997 C0400 IHFS CAPITAL EXPENDITURES 26 ER P A 01/01/1900 08/31/20167 G0720 CONSUMER MANAGED PERSONAL ATTENDANT SERVICES 27 ER P A 01/01/1900 12/31/21997 C0300 SSPD - DAY CARE (HALF DAY) 28 HC S5101 P A 01/01/1900 12/31/21997 N0201 SSPD - 24 HOUR ATTENDANT CARE (TILE 201) 28 ST 201 HC S5126 P A 10/16/2003 12/31/21997 N0202 SSPD - 24 HOUR ATTENDANT CARE (TILE 202) 28 ST 202 HC S5126 P A 10/16/2003 12/31/21997 N0203 SSPD - 24 HOUR ATTENDANT CARE (TILE 203) 28 ST 203 HC S5126 P A 10/16/2003 12/31/21997 N0204 SSPD - 24 HOUR ATTENDANT CARE (TILE 204) 28 ST 204 HC S5126 P A 10/16/2003 12/31/21997 N0205 SSPD - 24 HOUR ATTENDANT CARE (TILE 205) 28 ST 205 HC S5126 P A 10/16/2003 12/31/21997 N0206 SSPD - 24 HOUR ATTENDANT CARE (TILE 206) 28 ST 206 HC S5126 P A 10/16/2003 12/31/21997 N0207 SSPD - 24 HOUR ATTENDANT CARE (TILE 207) 28 ST 207 HC S5126 P A 10/16/2003 12/31/21997 N0208 SSPD - 24 HOUR ATTENDANT CARE (TILE 208) 28 ST 208 HC S5126 P A 10/16/2003 12/31/21997 N0209 SSPD - 24 HOUR ATTENDANT CARE (TILE 209) 28 ST 209 HC S5126 P A 10/16/2003 12/31/21997 N0210 SSPD - 24 HOUR ATTENDANT CARE (TILE 210) 28 ST 210 HC S5126 P A 10/16/2003 12/31/21997 N0211 SSPD - 24 HOUR ATTENDANT CARE (TILE 211) 28 ST 211 HC S5126 P A 10/16/2003 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






7 N0212 SSPD - 24 HOUR ATTENDANT CARE (TILE 212) 28 ST 212 HC S5126 P A 10/16/2003 12/31/21997 N1201 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 201) 28 ST 201 HC S5151 P A 10/16/2003 12/31/21997 N1202 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 202) 28 ST 202 HC S5151 P A 10/16/2003 12/31/21997 N1203 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 203) 28 ST 203 HC S5151 P A 10/16/2003 12/31/21997 N1204 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 204) 28 ST 204 HC S5151 P A 10/16/2003 12/31/21997 N1205 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 205) 28 ST 205 HC S5151 P A 10/16/2003 12/31/21997 N1206 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 206) 28 ST 206 HC S5151 P A 10/16/2003 12/31/21997 N1207 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 207) 28 ST 207 HC S5151 P A 10/16/2003 12/31/21997 N1208 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 208) 28 ST 208 HC S5151 P A 10/16/2003 12/31/21997 N1209 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 209) 28 ST 209 HC S5151 P A 10/16/2003 12/31/21997 N1210 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 210) 28 ST 210 HC S5151 P A 10/16/2003 12/31/21997 N1211 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 211) 28 ST 211 HC S5151 P A 10/16/2003 12/31/21997 N1212 SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 212) 28 ST 212 HC S5151 P A 10/16/2003 12/31/21997 RG001 SSPD - 24 HOUR ATTENDANT CARE - RAD 28 SR RAD HC S5126 P A 09/01/2008 12/31/21997 RG002 SSPD - 24 HOUR ATTENDANT CARE - RAC 28 SR RAC HC S5126 P A 09/01/2008 12/31/21997 RG003 SSPD - 24 HOUR ATTENDANT CARE - RAB 28 SR RAB HC S5126 P A 09/01/2008 12/31/21997 RG004 SSPD - 24 HOUR ATTENDANT CARE - RAA 28 SR RAA HC S5126 P A 09/01/2008 12/31/21997 RG005 SSPD - 24 HOUR ATTENDANT CARE - SE3 28 SR SE3 HC S5126 P A 09/01/2008 12/31/21997 RG006 SSPD - 24 HOUR ATTENDANT CARE - SE2 28 SR SE2 HC S5126 P A 09/01/2008 12/31/21997 RG007 SSPD - 24 HOUR ATTENDANT CARE - SE1 28 SR SE1 HC S5126 P A 09/01/2008 12/31/21997 RG008 SSPD - 24 HOUR ATTENDANT CARE - SSC 28 SR SSC HC S5126 P A 09/01/2008 12/31/21997 RG009 SSPD - 24 HOUR ATTENDANT CARE - SSB 28 SR SSB HC S5126 P A 09/01/2008 12/31/21997 RG010 SSPD - 24 HOUR ATTENDANT CARE - SSA 28 SR SSA HC S5126 P A 09/01/2008 12/31/21997 RG011 SSPD - 24 HOUR ATTENDANT CARE - CC2 28 SR CC2 HC S5126 P A 09/01/2008 12/31/21997 RG012 SSPD - 24 HOUR ATTENDANT CARE - CC1 28 SR CC1 HC S5126 P A 09/01/2008 12/31/21997 RG013 SSPD - 24 HOUR ATTENDANT CARE - CB2 28 SR CB2 HC S5126 P A 09/01/2008 12/31/21997 RG014 SSPD - 24 HOUR ATTENDANT CARE - CB1 28 SR CB1 HC S5126 P A 09/01/2008 12/31/21997 RG015 SSPD - 24 HOUR ATTENDANT CARE - CA2 28 SR CA2 HC S5126 P A 09/01/2008 12/31/21997 RG016 SSPD - 24 HOUR ATTENDANT CARE - CA1 28 SR CA1 HC S5126 P A 09/01/2008 12/31/21997 RG017 SSPD - 24 HOUR ATTENDANT CARE - IB2 28 SR IB2 HC S5126 P A 09/01/2008 12/31/21997 RG018 SSPD - 24 HOUR ATTENDANT CARE - IB1 28 SR IB1 HC S5126 P A 09/01/2008 12/31/21997 RG019 SSPD - 24 HOUR ATTENDANT CARE - IA2 28 SR IA2 HC S5126 P A 09/01/2008 12/31/21997 RG020 SSPD - 24 HOUR ATTENDANT CARE - IA1 28 SR IA1 HC S5126 P A 09/01/2008 12/31/21997 RG021 SSPD - 24 HOUR ATTENDANT CARE - BB2 28 SR BB2 HC S5126 P A 09/01/2008 12/31/21997 RG022 SSPD - 24 HOUR ATTENDANT CARE - BB1 28 SR BB1 HC S5126 P A 09/01/2008 12/31/21997 RG023 SSPD - 24 HOUR ATTENDANT CARE - BA2 28 SR BA2 HC S5126 P A 09/01/2008 12/31/21997 RG024 SSPD - 24 HOUR ATTENDANT CARE - BA1 28 SR BA1 HC S5126 P A 09/01/2008 12/31/21997 RG025 SSPD - 24 HOUR ATTENDANT CARE - PE2 28 SR PE2 HC S5126 P A 09/01/2008 12/31/21997 RG026 SSPD - 24 HOUR ATTENDANT CARE - PE1 28 SR PE1 HC S5126 P A 09/01/2008 12/31/21997 RG027 SSPD - 24 HOUR ATTENDANT CARE - PD2 28 SR PD2 HC S5126 P A 09/01/2008 12/31/21997 RG028 SSPD - 24 HOUR ATTENDANT CARE - PD1 28 SR PD1 HC S5126 P A 09/01/2008 12/31/21997 RG029 SSPD - 24 HOUR ATTENDANT CARE - PC2 28 SR PC2 HC S5126 P A 09/01/2008 12/31/21997 RG030 SSPD - 24 HOUR ATTENDANT CARE - PC1 28 SR PC1 HC S5126 P A 09/01/2008 12/31/21997 RG031 SSPD - 24 HOUR ATTENDANT CARE - PB2 28 SR PB2 HC S5126 P A 09/01/2008 12/31/21997 RG032 SSPD - 24 HOUR ATTENDANT CARE - PB1 28 SR PB1 HC S5126 P A 09/01/2008 12/31/21997 RG033 SSPD - 24 HOUR ATTENDANT CARE - PA2 28 SR PA2 HC S5126 P A 09/01/2008 12/31/21997 RG034 SSPD - 24 HOUR ATTENDANT CARE - PA1 28 SR PA1 HC S5126 P A 09/01/2008 12/31/21997 RG035 SSPD - 24 HOUR ATTENDANT CARE - BC1 28 SR BC1 HC S5126 P A 09/01/2008 12/31/21997 RG036 SSPD - 24 HOUR ATTENDANT CARE - PCE 28 SR PCE HC S5126 P A 09/01/2008 12/31/21997 RG101 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAD 28 SR RAD HC S5151 P A 09/01/2008 12/31/21997 RG102 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAC 28 SR RAC HC S5151 P A 09/01/2008 12/31/21997 RG103 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAB 28 SR RAB HC S5151 P A 09/01/2008 12/31/21997 RG104 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAA 28 SR RAA HC S5151 P A 09/01/2008 12/31/21997 RG105 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SE3 28 SR SE3 HC S5151 P A 09/01/2008 12/31/21997 RG106 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SE2 28 SR SE2 HC S5151 P A 09/01/2008 12/31/21997 RG107 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SE1 28 SR SE1 HC S5151 P A 09/01/2008 12/31/21997 RG108 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SSC 28 SR SSC HC S5151 P A 09/01/2008 12/31/21997 RG109 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SSB 28 SR SSB HC S5151 P A 09/01/2008 12/31/21997 RG110 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SSA 28 SR SSA HC S5151 P A 09/01/2008 12/31/21997 RG111 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CC2 28 SR CC2 HC S5151 P A 09/01/2008 12/31/21997 RG112 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CC1 28 SR CC1 HC S5151 P A 09/01/2008 12/31/21997 RG113 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CB2 28 SR CB2 HC S5151 P A 09/01/2008 12/31/21997 RG114 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CB1 28 SR CB1 HC S5151 P A 09/01/2008 12/31/21997 RG115 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CA2 28 SR CA2 HC S5151 P A 09/01/2008 12/31/21997 RG116 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CA1 28 SR CA1 HC S5151 P A 09/01/2008 12/31/21997 RG117 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IB2 28 SR IB2 HC S5151 P A 09/01/2008 12/31/21997 RG118 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IB1 28 SR IB1 HC S5151 P A 09/01/2008 12/31/21997 RG119 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IA2 28 SR IA2 HC S5151 P A 09/01/2008 12/31/21997 RG120 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IA1 28 SR IA1 HC S5151 P A 09/01/2008 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






7 RG121 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BB2 28 SR BB2 HC S5151 P A 09/01/2008 12/31/21997 RG122 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BB1 28 SR BB1 HC S5151 P A 09/01/2008 12/31/21997 RG123 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BA2 28 SR BA2 HC S5151 P A 09/01/2008 12/31/21997 RG124 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BA1 28 SR BA1 HC S5151 P A 09/01/2008 12/31/21997 RG125 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PE2 28 SR PE2 HC S5151 P A 09/01/2008 12/31/21997 RG126 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PE1 28 SR PE1 HC S5151 P A 09/01/2008 12/31/21997 RG127 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PD2 28 SR PD2 HC S5151 P A 09/01/2008 12/31/21997 RG128 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PD1 28 SR PD1 HC S5151 P A 09/01/2008 12/31/2199

7 RG129 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PC2 28 SR PC2 HC S5151 P A 09/01/2008 12/31/21997 RG130 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PC1 28 SR PC1 HC S5151 P A 09/01/2008 12/31/2199

7 RG131 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PB2 28 SR PB2 HC S5151 P A 09/01/2008 12/31/2199

7 RG132 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PB1 28 SR PB1 HC S5151 P A 09/01/2008 12/31/2199

7 RG133 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PA2 28 SR PA2 HC S5151 P A 09/01/2008 12/31/2199

7 RG134 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PA1 28 SR PA1 HC S5151 P A 09/01/2008 12/31/2199

7 RG135 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BC1 28 SR BC1 HC S5151 P A 09/01/2008 12/31/21997 RG136 SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PCE 28 SR PCE HC S5151 P A 09/01/2008 12/31/21997 C0200 DAY ACTIVITY AND HEALTH SERVICES (TITLE XIX) 29 HC S5101 P A 01/01/1900 12/31/21997 G0817 OVERNIGHT SUPPORT SERVICES 65 ER P A 03/01/2012 12/31/21997 G0129 RESPITE - ADULT DAY CARE 11A ER P A 01/01/1900 12/31/21997 G0130 RESPITE - HOSPITAL 11A 0660 32 I A 01/01/1900 12/31/21997 G0130 RESPITE - HOSPITAL 11A 0660 89 I A 01/01/1900 12/31/21997 G0131 RESPITE - ADULT FOSTER CARE - CCAD LEVEL 11B 0660 I A 01/01/1900 12/31/21997 G0141 RESPITE - RESIDENTIAL CARE - APT (CCAD) 11D HC S5151 U2 U1 P A 01/01/1900 12/31/21997 G0148 RESPITE - RESIDENTIAL CARE - NON APT (CCAD) 11E HC S5151 U1 U2 P A 01/01/1900 12/31/21997 G0155 RESPITE - NURSING FACILITY (CCAD) 11F 0660 21 I A 01/01/1900 12/31/21997 G0155 RESPITE - NURSING FACILITY (CCAD) 11F 0660 27 I A 01/01/1900 12/31/21997 G0740 PAS FAMILY CARE - LVL 2 (PRIORITY) 17C PR 2 HC S5125 P A 01/01/1900 12/31/21997 G0741 PAS FAMILY CARE - LVL 1 (NON-PRIORITY) 17C PR 1 HC S5125 P A 01/01/1900 12/31/21997 G0753 PAS FAMILY CARE SRO - PRIORITY 17CS PR 2 ER P A 01/02/2006 12/31/21997 G0754 PAS FAMILY CARE SRO - NON-PRIORITY 17CS PR 1 ER P A 01/02/2006 12/31/21997 G0745 PARTICIPANT - PAS FAMILY CARE CDS - LVL 2 (PRIORITY) 17CV ER P A 01/01/1900 12/31/21997 G0746 PARTICIPANT PAS FAMILY CARE CDS - LVL 1 (NON-PRIORITY) 17CV ER P A 01/01/1900 12/31/21997 G0747 AGENCY ADMIN - PAS FAMILY CARE CDS 17CV ER P A 01/01/1900 12/31/21997 G6059

TAXES 17CV ER P A 02/01/2013 12/31/2199

7 G6060

ES/BENEFITS 17CV ER P A 02/01/2013 12/31/21997 G6061 PARTICIPANT - PAS FAMILY CARE CDS - LVL 2 (PRIORITY) - TAXES 17CV ER P A 02/01/2013 12/31/21997 G6062

ES/BENEFITS 17CV ER P A 02/01/2013 12/31/2199

7 G0742 PAS COMMUNITY ATTENDANT SERVICES (1929B) - LVL 2 (PRIORITY) 17D PR 2 HC S5125 P A 01/01/1900 12/31/21997 G0743

PRIORITY) 17D PR 1 HC S5125 P A 01/01/1900 12/31/2199

7 G0755 CAS SERVICE RESPONSIBILTY OPTON - PRIORITY 17DS PR 2 ER P A 01/02/2006 12/31/21997 G0756 CAS SERVICE RESPONSIBILTY OPTON - NON-PRIORITY 17DS PR 1 ER P A 01/02/2006 12/31/21997 G0748

(PRIORITY) 17DV ER P A 01/01/1900 12/31/2199

7 G0749

PRIORITY) 17DV ER P A 01/01/1900 12/31/21997 G0750 PAS COMMUNITY ATTENDANT SERVICES - CDS - AGENCY 17DV ER P A 01/01/1900 12/31/21997 G6063

PRIORITY) - TAXES 17DV ER P A 02/01/2013 12/31/2199

7 G6064

PRIORITY) - ES/BENEFITS 17DV ER P A 02/01/2013 12/31/21997 G6065

(PRIORITY) - TAXES 17DV ER P A 02/01/2013 12/31/2199

7 G6066

(PRIORITY) - ES/BENEFITS 17DV ER P A 02/01/2013 12/31/21997 G0751 PAS SERVICE RESPONSIBILITY OPTION PRIORITY 17S PR 2 ER P A 01/02/2006 12/31/21997 G0752 PAS SERVICE RESPONSIBILITY OPTION NON-PRIORITY 17S PR 1 ER P A 01/02/2006 12/31/21997 G0717 CDS-PERSONAL ASSISTANCE SERVICES (PAS) - IND 17V HC S5125 UB P A 06/01/2005 12/31/21997 G0718 CDS-PERSONAL ASSISTANCE SERVICES (PAS) - IND 17V ER P A 01/01/1900 12/31/21997 G6001 CDS-PERSONAL ASSISTANCE SERVICES (PAS) - IND - TAXES 17V HC S5125 UG UB P A 02/01/2013 12/31/21997 G6002 CDS-PERSONAL ASSISTANCE SERVICES (PAS) - IND - ES/BENEFITS 17V HC S5125 UF UB P A 02/01/2013 12/31/21997 G0943 RESIDENTIAL CARE BED HOLD - NON-APARTMENT TITLE XX 19I ER P A 01/01/1900 12/31/21997 G0944 RESIDENTIAL CARE BED HOLD - APARTMENT TITLE XX 19J ER P A 01/01/1900 12/31/21997 G0945 RESIDENTIAL CARE - APARTMENT TITLE XX 19K HC T1020 U2 U1 P A 01/01/1900 12/31/21997 G0946 RESIDENTIAL CARE - NON-APARTMENT TITLE XX 19L HC T1020 U1 U2 P A 01/01/1900 12/31/21997 G0947 RESIDENTIAL CARE EMERGENCY CARE 19M HC T1020 P A 01/01/1900 12/31/21997 G0948 RESIDENTIAL CARE - ROOM & BOARD NON-APARTMENT 19N ER P A 01/01/1900 12/31/21997 G0949 RESIDENTIAL CARE - ROOM & BOARD APARTMENT 19O ER P A 01/01/1900 12/31/21997 C0401 IHFSP SERVICE SUBSIDY 26A ER P A 02/01/2009 08/31/20167 C0403 IHFS SPENDDOWN 26B ER P A 09/01/2009 08/31/2016


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






7 C0404 IHFS-REPAYMENT 26C ER A 11/01/2011 08/31/20167 G0722 CMPAS - CLIENT DIRECTED SERVICES 27A ER P A 01/01/1900 12/31/21997 C0303 SSPD - CASE MANAGEMENT 28A HC T1016 P A 01/01/1900 12/31/21997 C0202 DAY ACTIVITY/HEALTH SERVICES (DAHS) - TITLE 20 29A HC S5101 P A 01/01/1900 12/31/21997 G0758 CDS FC SUPPORT CONSULTATION 57CV ER P A 01/01/2009 12/31/21997 G0759 CDS CAS SUPPORT CONSULTATION 57DV ER P A 01/01/2009 12/31/21997 G0757 CDS SUPPORT CONSULTATION 57V ER P A 01/01/2009 12/31/21997 G0223 CDS - CCAD ORIENTATION FEE 62V ER P A 09/01/2007 12/31/21997 G0227 CDS CCAD MONTHLY ADMINISTRATION FEE 63V ER P A 09/01/2007 12/31/21998 T0100 ROUTINE IN HOME CARE 1 HC T2042 0651 I A 01/01/1900 12/31/21998 T0101 ROUTINE IN-HOME CARE DAYS 1-60 1 HC T2042 0651 KX I A 12/01/2015 12/31/21998 T0200 CONTINUOUS HOME CARE 1 HC T2043 0652 I A 01/01/1900 12/31/21998 T0300 INPATIENT RESPITE CARE 1 HC T2044 0655 I A 01/01/1900 12/31/21998 T0301 GENERAL INPATIENT CARE 1 HC T2045 0656 I A 01/01/1900 12/31/21998 N0500 VENTILATOR FULL 4 HC 94005 0659 I A 01/01/2010 12/31/21998 N0501 VENTILATOR PARTIAL 4 HC 94004 0659 I A 05/01/2009 12/31/21998 N0502 CHILD TRACHEOSTOMY 24 HC 99199 P A 06/01/2010 12/31/21998 T0302 PHYSICIAN DIRECT CARE 30 HC 49082 0657 I A 01/01/2015 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 71010 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 74000 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 74020 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85004 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85007 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85008 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85009 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85013 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85014 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85018 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85025 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85027 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85032 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85041 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85044 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85045 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85046 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85048 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 85049 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99201 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99202 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99203 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99204 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99205 0657 I A 05/19/1998 09/30/2015

8 T0302 PHYSICIAN DIRECT CARE 30 HC 99211 0657 I A 05/19/1998 09/30/2015

8 T0302 PHYSICIAN DIRECT CARE 30 HC 99212 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99213 0657 I A 05/19/1998 09/30/2015



8 T0302 PHYSICIAN DIRECT CARE 30 HC 99221 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99222 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99223 0657 I A 05/19/1998 09/30/2015








SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






8 T0302 PHYSICIAN DIRECT CARE 30 HC 99244 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99245 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99251 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99252 0657 I A 02/24/1999 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99253 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99254 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99255 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99304 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99305 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99306 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99307 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99308 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99309 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99310 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99315 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99316 0657 I A 08/01/2004 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99318 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99324 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99325 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99326 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99334 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99335 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99336 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99337 0657 I A 02/01/2008 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99341 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99342 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99343 0657 I A 05/19/1998 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99344 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99345 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99347 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99348 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99349 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99350 0657 I A 12/01/2002 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99354 0657 I A 03/29/2001 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99355 0657 I A 03/29/2001 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99356 0657 I A 03/29/2001 09/30/20158 T0302 PHYSICIAN DIRECT CARE 30 HC 99357 0657 I A 03/29/2001 09/30/20158 T0303 PHYSICAN DIRECT CARE-SPECIAL 30 HC 71260 0657 I A 09/01/2005 09/30/20158 T0303 PHYSICAN DIRECT CARE-SPECIAL 30 HC 72193 0657 I A 09/01/2005 09/01/20158 T0303 PHYSICAN DIRECT CARE-SPECIAL 30 HC 74170 0657 I A 09/01/2005 09/30/20158 T0310 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99357 0657 I A 10/01/2015 12/31/21998 T0311 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99357 0657 KX I A 10/01/2015 12/31/21998 T0312 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99356 0657 I A 10/01/2015 12/31/21998 T0313 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99356 0657 KX I A 10/01/2015 12/31/21998 T0314 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99355 0657 I A 10/01/2015 12/31/21998 T0315 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99355 0657 KX I A 10/01/2015 12/31/21998 T0316 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99354 0657 I A 10/01/2015 12/31/21998 T0317 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99354 0657 KX I A 10/01/2015 12/31/21998 T0318 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99350 0657 I A 10/01/2015 12/31/21998 T0319 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99350 0657 KX I A 10/01/2015 12/31/21998 T0320 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99349 0657 I A 10/01/2015 12/31/21998 T0321 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99349 0657 KX I A 10/01/2015 12/31/21998 T0322 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99348 0657 I A 10/01/2015 12/31/21998 T0323 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99348 0657 KX I A 10/01/2015 12/31/21998 T0324 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99347 0657 I A 10/01/2015 12/31/21998 T0325 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99347 0657 KX I A 10/01/2015 12/31/21998 T0326 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99345 0657 I A 10/01/2015 12/31/21998 T0327 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99345 0657 KX I A 10/01/2015 12/31/21998 T0328 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99344 0657 I A 10/01/2015 12/31/21998 T0329 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99344 0657 KX I A 10/01/2015 12/31/21998 T0330 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99343 0657 I A 10/01/2015 12/31/21998 T0331 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99343 0657 KX I A 10/01/2015 12/31/21998 T0332 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99342 0657 I A 10/01/2015 12/31/21998 T0333 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99342 0657 KX I A 10/01/2015 12/31/21998 T0334 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99341 0657 I A 10/01/2015 12/31/21998 T0335 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99341 0657 KX I A 10/01/2015 12/31/21998 T0336 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99337 0657 I A 10/01/2015 12/31/21998 T0337 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99337 0657 KX I A 10/01/2015 12/31/21998 T0338 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99336 0657 I A 10/01/2015 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






8 T0339 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99336 0657 KX I A 10/01/2015 12/31/21998 T0340 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99335 0657 I A 10/01/2015 12/31/21998 T0341 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99335 0657 KX I A 10/01/2015 12/31/21998 T0342 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99334 0657 I A 10/01/2015 12/31/21998 T0343 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99334 0657 KX I A 10/01/2015 12/31/21998 T0344 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99326 0657 I A 10/01/2015 12/31/21998 T0345 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99326 0657 KX I A 10/01/2015 12/31/21998 T0346 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99325 0657 I A 10/01/2015 12/31/21998 T0347 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99325 0657 KX I A 10/01/2015 12/31/21998 T0348 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99324 0657 I A 10/01/2015 12/31/21998 T0349 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99324 0657 KX I A 10/01/2015 12/31/21998 T0350 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99318 0657 I A 10/01/2015 12/31/21998 T0351 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99318 0657 KX I A 10/01/2015 12/31/21998 T0352 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99316 0657 I A 10/01/2015 12/31/21998 T0353 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99316 0657 KX I A 10/01/2015 12/31/21998 T0354 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99315 0657 I A 10/01/2015 12/31/21998 T0355 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99315 0657 KX I A 10/01/2015 12/31/21998 T0356 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99310 0657 I A 10/01/2015 12/31/21998 T0357 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99310 0657 KX I A 10/01/2015 12/31/21998 T0358 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99309 0657 I A 10/01/2015 12/31/21998 T0359 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99309 0657 KX I A 10/01/2015 12/31/21998 T0360 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99308 0657 I A 10/01/2015 12/31/21998 T0361 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99308 0657 KX I A 10/01/2015 12/31/21998 T0362 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99307 0657 I A 10/01/2015 12/31/21998 T0363 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99307 0657 KX I A 10/01/2015 12/31/21998 T0364 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99306 0657 I A 10/01/2015 12/31/21998 T0365 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99306 0657 KX I A 10/01/2015 12/31/21998 T0366 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99305 0657 I A 10/01/2015 12/31/21998 T0367 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99305 0657 KX I A 10/01/2015 12/31/21998 T0368 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99304 0657 I A 10/01/2015 12/31/21998 T0369 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99304 0657 KX I A 10/01/2015 12/31/21998 T0370 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99255 0657 I A 10/01/2015 12/31/21998 T0371 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99255 0657 KX I A 10/01/2015 12/31/21998 T0372 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99254 0657 I A 10/01/2015 12/31/21998 T0373 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99254 0657 KX I A 10/01/2015 12/31/21998 T0374 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99253 0657 I A 10/01/2015 12/31/21998 T0375 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99253 0657 KX I A 10/01/2015 12/31/21998 T0376 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99252 0657 I A 10/01/2015 12/31/21998 T0377 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99252 0657 KX I A 10/01/2015 12/31/21998 T0378 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99251 0657 I A 10/01/2015 12/31/21998 T0379 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99251 0657 KX I A 10/01/2015 12/31/21998 T0380 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99245 0657 I A 10/01/2015 12/31/21998 T0381 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99245 0657 KX I A 10/01/2015 12/31/21998 T0382 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99244 0657 I A 10/01/2015 12/31/21998 T0383 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99244 0657 KX I A 10/01/2015 12/31/21998 T0384 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99243 0657 I A 10/01/2015 12/31/21998 T0385 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99243 0657 KX I A 10/01/2015 12/31/21998 T0386 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99242 0657 I A 10/01/2015 12/31/21998 T0387 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99242 0657 KX I A 10/01/2015 12/31/21998 T0388 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99241 0657 I A 10/01/2015 12/31/21998 T0389 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99241 0657 KX I A 10/01/2015 12/31/21998 T0390 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99239 0657 I A 10/01/2015 12/31/21998 T0391 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99239 0657 KX I A 10/01/2015 12/31/21998 T0392 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99238 0657 I A 10/01/2015 12/31/21998 T0393 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99238 0657 KX I A 10/01/2015 12/31/21998 T0394 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99233 0657 I A 10/01/2015 12/31/21998 T0395 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99233 0657 KX I A 10/01/2015 12/31/21998 T0396 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99232 0657 I A 10/01/2015 12/31/21998 T0397 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99232 0657 KX I A 10/01/2015 12/31/21998 T0398 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99231 0657 I A 10/01/2015 12/31/21998 T0399 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99231 0657 KX I A 10/01/2015 12/31/21998 T0410 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99223 0657 I A 10/01/2015 12/31/21998 T0411 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99223 0657 KX I A 10/01/2015 12/31/21998 T0412 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99222 0657 I A 10/01/2015 12/31/21998 T0413 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99222 0657 KX I A 10/01/2015 12/31/21998 T0414 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99221 0657 I A 10/01/2015 12/31/21998 T0415 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99221 0657 KX I A 10/01/2015 12/31/21998 T0416 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99215 0657 I A 10/01/2015 12/31/21998 T0417 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99215 0657 KX I A 10/01/2015 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






8 T0418 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99214 0657 I A 10/01/2015 12/31/21998 T0419 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99214 0657 KX I A 10/01/2015 12/31/21998 T0420 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99213 0657 I A 10/01/2015 12/31/21998 T0421 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99213 0657 KX I A 10/01/2015 12/31/21998 T0422 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99212 0657 I A 10/01/2015 12/31/21998 T0423 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99212 0657 KX I A 10/01/2015 12/31/21998 T0424 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99211 0657 I A 10/01/2015 12/31/21998 T0425 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99211 0657 KX I A 10/01/2015 12/31/21998 T0426 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99205 0657 I A 10/01/2015 12/31/21998 T0427 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99205 0657 KX I A 10/01/2015 12/31/21998 T0428 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99204 0657 I A 10/01/2015 12/31/21998 T0429 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99204 0657 KX I A 10/01/2015 12/31/21998 T0430 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99203 0657 I A 10/01/2015 12/31/21998 T0431 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99203 0657 KX I A 10/01/2015 12/31/21998 T0432 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99202 0657 I A 10/01/2015 12/31/21998 T0433 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99202 0657 KX I A 10/01/2015 12/31/21998 T0434 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 99201 0657 I A 10/01/2015 12/31/21998 T0435 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 99201 0657 KX I A 10/01/2015 12/31/21998 T0436 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85049 0657 I A 10/01/2015 12/31/21998 T0437 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85049 0657 KX I A 10/01/2015 12/31/21998 T0438 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85048 0657 I A 10/01/2015 12/31/21998 T0439 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85048 0657 KX I A 10/01/2015 12/31/21998 T0440 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85046 0657 I A 10/01/2015 12/31/21998 T0441 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85046 0657 KX I A 10/01/2015 12/31/21998 T0442 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85045 0657 I A 10/01/2015 12/31/21998 T0443 PHYSICIAN DIRECT CARE-21 AND OLDER 30 85045 0657 KX I A 10/01/2015 12/31/21998 T0444 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85044 0657 I A 10/01/2015 12/31/21998 T0445 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85044 0657 KX I A 10/01/2015 12/31/21998 T0446 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85041 0657 I A 10/01/2015 12/31/21998 T0447 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85041 0657 KX I A 10/01/2015 12/31/21998 T0448 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85032 0657 I A 10/01/2015 12/31/21998 T0449 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85032 0657 KX I A 10/01/2015 12/31/21998 T0450 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85027 0657 I A 10/01/2015 12/31/21998 T0451 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85027 0657 KX I A 10/01/2015 12/31/21998 T0452 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85025 0657 I A 10/01/2015 12/31/21998 T0453 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85025 0657 KX I A 10/01/2015 12/31/21998 T0454 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85018 0657 I A 10/01/2015 12/31/21998 T0455 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85018 0657 KX I A 10/01/2015 12/31/21998 T0456 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85014 0657 I A 10/01/2015 12/31/21998 T0457 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85014 0657 KX I A 10/01/2015 12/31/21998 T0458 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85013 0657 I A 10/01/2015 12/31/21998 T0459 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85013 0657 KX I A 10/01/2015 12/31/21998 T0460 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85009 0657 I A 10/01/2015 12/31/21998 T0461 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85009 0657 KX I A 10/01/2015 12/31/21998 T0462 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85008 0657 I A 10/01/2015 12/31/21998 T0463 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85008 0657 KX I A 10/01/2015 12/31/21998 T0464 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85007 0657 I A 10/01/2015 12/31/21998 T0465 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85007 0657 KX I A 10/01/2015 12/31/21998 T0466 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 85004 0657 I A 10/01/2015 12/31/21998 T0467 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 85004 0657 KX I A 10/01/2015 12/31/21998 T0468 PHYSICIAN DIRECT CARE-SPECIAL-UNDER 21 30 HC 74170 0657 I A 10/01/2015 12/31/21998 T0469 PHYSICIAN DIRECT CARE-SPECIAL-21 AND OLDER 30 HC 74170 0657 KX I A 10/01/2015 12/31/21998 T0470 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 74020 0657 I A 10/01/2015 01/31/20188 T0471 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 74020 0657 KX I A 10/01/2015 01/31/20188 T0472 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 74000 0657 I A 10/01/2015 01/31/20188 T0473 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 74000 0657 KX I A 10/01/2015 01/31/20188 T0474 PHYSICIAN DIRECT CARE-SPECIAL-UNDER 21 30 HC 72193 0657 I A 10/01/2015 12/31/21998 T0475 PHYSICIAN DIRECT CARE-SPECIAL-21 AND OLDER 30 HC 72193 0657 KX I A 10/01/2015 12/31/21998 T0476 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 71260 0657 I A 10/01/2015 12/31/21998 T0477 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 71260 0657 KX I A 10/01/2015 12/31/21998 T0478 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 71010 0657 I A 10/01/2015 01/31/20188 T0479 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 71010 0657 KX I A 10/01/2015 01/31/20188 T0480 PHYSICIAN DIRECT CARE-UNDER 21 30 HC 49082 0657 I A 10/01/2015 12/31/21998 T0481 PHYSICIAN DIRECT CARE-21 AND OLDER 30 HC 49082 0657 KX I A 10/01/2015 12/31/21998 F0100 ICF/MR CAMPUS/STATE - LOC 1 CONTRACT SPECIFIC - WITH DRUGS 31 LC 1 HC T2046 0658 U3 I A 01/01/1900 8/22/20198 F0100 ICF/MR CAMPUS/STATE - LOC 1 CONTRACT SPECIFIC - WITH DRUGS 31 LC 1 HC T2046 0659 U3 I A 01/01/1900 8/22/20198 F0103 ICF/MR CAMPUS/STATE - LOC 8 CONTRACT SPECIFIC 31 LC 8 HC T2046 0658 UA I A 01/01/1900 8/22/20198 F0103 ICF/MR CAMPUS/STATE - LOC 8 CONTRACT SPECIFIC 31 LC 8 HC T2046 0659 UA I A 01/01/1900 8/22/20198 F0108

SPECIFIC - WITH DRUGS 31 LC 8 HC T2046 0658 I A 01/01/1900 8/22/2019


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






8 F0108

SPECIFIC - WITH DRUGS 31 LC 8 HC T2046 0659 I A 01/01/1900 8/22/20198 F0109

SPECIFIC - WITH DRUGS 31 LC 1 HC T2046 0658 I A 01/01/1900 8/22/2019

8 F0109

SPECIFIC - WITH DRUGS 31 LC 1 HC T2046 0659 I A 01/01/1900 8/22/20198 F0205 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 1 31 LN 1 HC T2046 0658 I A 01/01/1900 8/22/20198 F0205 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 1 31 LN 1 HC T2046 0659 I A 01/01/1900 8/22/20198 F0206 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 5 31 LN 5 HC T2046 0658 I A 01/01/1900 8/22/20198 F0206 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 5 31 LN 5 HC T2046 0659 I A 01/01/1900 8/22/20198 F0207 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 6 31 LN 6 HC T2046 0658 I A 01/01/1900 8/22/20198 F0207 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 6 31 LN 6 HC T2046 0659 I A 01/01/1900 8/22/20198 F0208 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 8 31 LN 8 HC T2046 0658 I A 01/01/1900 8/22/20198 F0208 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 8 31 LN 8 HC T2046 0659 I A 01/01/1900 8/22/20198 F0209 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 9 31 LN 9 HC T2046 0658 I A 01/01/1900 8/22/20198 F0209 ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 9 31 LN 9 HC T2046 0659 I A 01/01/1900 8/22/20198 F0225

DRUGS 31 LC 1 HC T2046 0658 U3 U4 I A 10/01/2008 8/22/2019

8 F0225

DRUGS 31 LC 1 HC T2046 0659 U3 U4 I A 10/01/2008 8/22/20198 RG001 NURSING FACILITY - ROOM & BOARD - RAD 31 RG RAD HC T2046 0658 I A 09/01/2008 12/31/21998 RG001 NURSING FACILITY - ROOM & BOARD - RAD 31 RG RAD HC T2046 0659 I A 09/01/2008 12/31/21998 RG002 NURSING FACILITY - ROOM & BOARD - RAC 31 RG RAC HC T2046 0658 I A 09/01/2008 12/31/21998 RG002 NURSING FACILITY - ROOM & BOARD - RAC 31 RG RAC HC T2046 0659 I A 09/01/2008 12/31/21998 RG003 NURSING FACILITY - ROOM & BOARD - RAB 31 RG RAB HC T2046 0658 I A 09/01/2008 12/31/21998 RG003 NURSING FACILITY - ROOM & BOARD - RAB 31 RG RAB HC T2046 0659 I A 09/01/2008 12/31/21998 RG004 NURSING FACILITY - ROOM & BOARD - RAA 31 RG RAA HC T2046 0658 I A 09/01/2008 12/31/21998 RG004 NURSING FACILITY - ROOM & BOARD - RAA 31 RG RAA HC T2046 0659 I A 09/01/2008 12/31/21998 RG005 NURSING FACILITY - ROOM & BOARD - SE3 31 RG SE3 HC T2046 0658 I A 09/01/2008 12/31/21998 RG005 NURSING FACILITY - ROOM & BOARD - SE3 31 RG SE3 HC T2046 0659 I A 09/01/2008 12/31/21998 RG006 NURSING FACILITY - ROOM & BOARD - SE2 31 RG SE2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG006 NURSING FACILITY - ROOM & BOARD - SE2 31 RG SE2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG007 NURSING FACILITY - ROOM & BOARD - SE1 31 RG SE1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG007 NURSING FACILITY - ROOM & BOARD - SE1 31 RG SE1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG008 NURSING FACILITY - ROOM & BOARD - SSC 31 RG SSC HC T2046 0658 I A 09/01/2008 12/31/21998 RG008 NURSING FACILITY - ROOM & BOARD - SSC 31 RG SSC HC T2046 0659 I A 09/01/2008 12/31/21998 RG009 NURSING FACILITY - ROOM & BOARD - SSB 31 RG SSB HC T2046 0658 I A 09/01/2008 12/31/21998 RG009 NURSING FACILITY - ROOM & BOARD - SSB 31 RG SSB HC T2046 0659 I A 09/01/2008 12/31/21998 RG010 NURSING FACILITY - ROOM & BOARD - SSA 31 RG SSA HC T2046 0658 I A 09/01/2008 12/31/21998 RG010 NURSING FACILITY - ROOM & BOARD - SSA 31 RG SSA HC T2046 0659 I A 09/01/2008 12/31/21998 RG011 NURSING FACILITY - ROOM & BOARD - CC2 31 RG CC2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG011 NURSING FACILITY - ROOM & BOARD - CC2 31 RG CC2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG012 NURSING FACILITY - ROOM & BOARD - CC1 31 RG CC1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG012 NURSING FACILITY - ROOM & BOARD - CC1 31 RG CC1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG013 NURSING FACILITY - ROOM & BOARD - CB2 31 RG CB2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG013 NURSING FACILITY - ROOM & BOARD - CB2 31 RG CB2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG014 NURSING FACILITY - ROOM & BOARD - CB1 31 RG CB1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG014 NURSING FACILITY - ROOM & BOARD - CB1 31 RG CB1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG015 NURSING FACILITY - ROOM & BOARD - CA2 31 RG CA2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG015 NURSING FACILITY - ROOM & BOARD - CA2 31 RG CA2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG016 NURSING FACILITY - ROOM & BOARD - CA1 31 RG CA1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG016 NURSING FACILITY - ROOM & BOARD - CA1 31 RG CA1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG017 NURSING FACILITY - ROOM & BOARD - IB2 31 RG IB2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG017 NURSING FACILITY - ROOM & BOARD - IB2 31 RG IB2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG018 NURSING FACILITY - ROOM & BOARD - IB1 31 RG IB1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG018 NURSING FACILITY - ROOM & BOARD - IB1 31 RG IB1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG019 NURSING FACILITY - ROOM & BOARD - IA2 31 RG IA2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG019 NURSING FACILITY - ROOM & BOARD - IA2 31 RG IA2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG020 NURSING FACILITY - ROOM & BOARD - IA1 31 RG IA1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG020 NURSING FACILITY - ROOM & BOARD - IA1 31 RG IA1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG021 NURSING FACILITY - ROOM & BOARD - BB2 31 RG BB2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG021 NURSING FACILITY - ROOM & BOARD - BB2 31 RG BB2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG022 NURSING FACILITY - ROOM & BOARD - BB1 31 RG BB1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG022 NURSING FACILITY - ROOM & BOARD - BB1 31 RG BB1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG023 NURSING FACILITY - ROOM & BOARD - BA2 31 RG BA2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG023 NURSING FACILITY - ROOM & BOARD - BA2 31 RG BA2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG024 NURSING FACILITY - ROOM & BOARD - BA1 31 RG BA1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG024 NURSING FACILITY - ROOM & BOARD - BA1 31 RG BA1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG025 NURSING FACILITY - ROOM & BOARD - PE2 31 RG PE2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG025 NURSING FACILITY - ROOM & BOARD - PE2 31 RG PE2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG026 NURSING FACILITY - ROOM & BOARD - PE1 31 RG PE1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG026 NURSING FACILITY - ROOM & BOARD - PE1 31 RG PE1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG027 NURSING FACILITY - ROOM & BOARD - PD2 31 RG PD2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG027 NURSING FACILITY - ROOM & BOARD - PD2 31 RG PD2 HC T2046 0659 I A 09/01/2008 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






8 RG028 NURSING FACILITY - ROOM & BOARD - PD1 31 RG PD1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG028 NURSING FACILITY - ROOM & BOARD - PD1 31 RG PD1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG029 NURSING FACILITY - ROOM & BOARD - PC2 31 RG PC2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG029 NURSING FACILITY - ROOM & BOARD - PC2 31 RG PC2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG030 NURSING FACILITY - ROOM & BOARD - PC1 31 RG PC1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG030 NURSING FACILITY - ROOM & BOARD - PC1 31 RG PC1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG031 NURSING FACILITY - ROOM & BOARD - PB2 31 RG PB2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG031 NURSING FACILITY - ROOM & BOARD - PB2 31 RG PB2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG032 NURSING FACILITY - ROOM & BOARD - PB1 31 RG PB1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG032 NURSING FACILITY - ROOM & BOARD - PB1 31 RG PB1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG033 NURSING FACILITY - ROOM & BOARD - PA2 31 RG PA2 HC T2046 0658 I A 09/01/2008 12/31/21998 RG033 NURSING FACILITY - ROOM & BOARD - PA2 31 RG PA2 HC T2046 0659 I A 09/01/2008 12/31/21998 RG034 NURSING FACILITY - ROOM & BOARD - PA1 31 RG PA1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG034 NURSING FACILITY - ROOM & BOARD - PA1 31 RG PA1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG035 NURSING FACILITY - ROOM & BOARD - BC1 31 RG BC1 HC T2046 0658 I A 09/01/2008 12/31/21998 RG035 NURSING FACILITY - ROOM & BOARD - BC1 31 RG BC1 HC T2046 0659 I A 09/01/2008 12/31/21998 RG036 NURSING FACILITY - ROOM & BOARD - PCE 31 RG PCE HC T2046 0658 I A 09/01/2008 12/31/21998 RG036 NURSING FACILITY - ROOM & BOARD - PCE 31 RG PCE HC T2046 0659 I A 09/01/2008 12/31/21998 V0101 VA DAILY CARE - RAD 31 RG RAD HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0101 VA DAILY CARE - RAD 31 RG RAD HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0102 VA DAILY CARE - RAC 31 RG RAC HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0102 VA DAILY CARE - RAC 31 RG RAC HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0103 VA DAILY CARE - RAB 31 RG RAB HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0103 VA DAILY CARE - RAB 31 RG RAB HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0104 VA DAILY CARE - RAA 31 RG RAA HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0104 VA DAILY CARE - RAA 31 RG RAA HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0105 VA DAILY CARE - SE3 31 RG SE3 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0105 VA DAILY CARE - SE3 31 RG SE3 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0106 VA DAILY CARE - SE2 31 RG SE2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0106 VA DAILY CARE - SE2 31 RG SE2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0107 VA DAILY CARE - SE1 31 RG SE1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0107 VA DAILY CARE - SE1 31 RG SE1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0108 VA DAILY CARE - SSC 31 RG SSC HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0108 VA DAILY CARE - SSC 31 RG SSC HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0109 VA DAILY CARE - SSB 31 RG SSB HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0109 VA DAILY CARE SSB 31 RG SSB HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0110 VA DAILY CARE SSA 31 RG SSA HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0110 VA DAILY CARE SSA 31 RG SSA HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0111 VA DAILY CARE CC2 31 RG CC2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0111 VA DAILY CARE CC2 31 RG CC2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0112 VA DAILY CARE CC1 31 RG CC1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0112 VA DAILY CARE CC1 31 RG CC1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0113 VA DAILY CARE CB2 31 RG CB2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0113 VA DAILY CARE CB2 31 RG CB2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0114 VA DAILY CARE CB1 31 RG CB1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0114 VA DAILY CARE CB1 31 RG CB1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0115 VA DAILY CARE CA2 31 RG CA2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0115 VA DAILY CARE CA2 31 RG CA2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0116 VA DAILY CARE CA1 31 RG CA1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0116 VA DAILY CARE CA1 31 RG CA1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0117 VA DAILY CARE IB2 31 RG IB2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0117 VA DAILY CARE IB2 31 RG IB2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0118 VA DAILY CARE IB1 31 RG IB1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0118 VA DAILY CARE IB1 31 RG IB1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0119 VA DAILY CARE IA2 31 RG IA2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0119 VA DAILY CARE IA2 31 RG IA2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0120 VA DAILY CARE IA1 31 RG IA1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0120 VA DAILY CARE IA1 31 RG IA1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0121 VA DAILY CARE BB2 31 RG BB2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0121 VA DAILY CARE BB2 31 RG BB2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0122 VA DAILY CARE BB1 31 RG BB1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0122 VA DAILY CARE BB1 31 RG BB1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0123 VA DAILY CARE BA2 31 RG BA2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0123 VA DAILY CARE BA2 31 RG BA2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0124 VA DAILY CARE BA1 31 RG BA1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0124 VA DAILY CARE BA1 31 RG BA1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0125 VA DAILY CARE PE2 31 RG PE2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0125 VA DAILY CARE PE2 31 RG PE2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0126 VA DAILY CARE PE1 31 RG PE1 HC T2046 0658 VA I A 09/01/2008 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






8 V0126 VA DAILY CARE PE1 31 RG PE1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0127 VA DAILY CARE PD2 31 RG PD2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0127 VA DAILY CARE PD2 31 RG PD2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0128 VA DAILY CARE PD1 31 RG PD1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0128 VA DAILY CARE PD1 31 RG PD1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0129 VA DAILY CARE PC2 31 RG PC2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0129 VA DAILY CARE PC2 31 RG PC2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0130 VA DAILY CARE PC1 31 RG PC1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0130 VA DAILY CARE PC1 31 RG PC1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0131 VA DAILY CARE PB2 31 RG PB2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0131 VA DAILY CARE PB2 31 RG PB2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0132 VA DAILY CARE PB1 31 RG PB1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0132 VA DAILY CARE PB1 31 RG PB1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0133 VA DAILY CARE PA2 31 RG PA2 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0133 VA DAILY CARE PA2 31 RG PA2 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0134 VA DAILY CARE PA1 31 RG PA1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0134 VA DAILY CARE PA1 31 RG PA1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0135 VA DAILY CARE BC1 31 RG BC1 HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0135 VA DAILY CARE BC1 31 RG BC1 HC T2046 0659 VA I A 09/01/2008 12/31/21998 V0136 VA DAILY CARE PCE 31 RG PCE HC T2046 0658 VA I A 09/01/2008 12/31/21998 V0136 VA DAILY CARE PCE 31 RG PCE HC T2046 0659 VA I A 09/01/2008 12/31/21998 T0400 MEDICARE PHARMACY COINSURANCE 32 ER P A 01/01/1900 12/31/21998 T0401 MEDICARE RESPITE COINSURANCE 33 ER P A 01/01/1900 12/31/21998 T0201 CHC END OF LIFE - RN 1A HC T2043 TD P A 12/01/2015 12/31/21998 T0202 CHC END OF LIFE - SOCIAL WORKER 1A HC T2043 AJ P A 12/01/2015 12/31/21998 F0234

WITH DRUGS 31A LC 1 HC T2046 0658 U3 I A 8/23/2019 12/31/2199

8 F0234

WITH DRUGS 31A LC 1 HC T2046 0659 U3 I A 8/23/2019 12/31/21998 F0235 HOSPICE IN ICF/IID CAMPUS/STATE - LOC 8 CONTRACT SPECIFIC 31A LC 8 HC T2046 0658 UA I A 8/23/2019 12/31/21998 F0235 HOSPICE IN ICF/IID CAMPUS/STATE - LOC 8 CONTRACT SPECIFIC 31A LC 8 HC T2046 0659 UA I A 8/23/2019 12/31/21998 F0236

CONTRACT SPECIFIC - WITH DRUGS 31A LC 8 HC T2046 0658 I A 8/23/2019 12/31/2199

8 F0236

CONTRACT SPECIFIC - WITH DRUGS 31A LC 8 HC T2046 0659 I A 8/23/2019 12/31/21998 F0237

CONTRACT SPECIFIC - WITH DRUGS 31A LC 1 HC T2046 0658 I A 8/23/2019 12/31/2199

8 F0237

CONTRACT SPECIFIC - WITH DRUGS 31A LC 1 HC T2046 0659 I A 8/23/2019 12/31/21998 F0238 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 1 31A LN 1 HC T2046 0658 I A 8/23/2019 12/31/21998 F0238 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 1 31A LN 1 HC T2046 0659 I A 8/23/2019 12/31/2199

8 F0239 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 5 31A LN 5 HC T2046 0658 I A 8/23/2019 12/31/2199

8 F0239 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 5 31A LN 5 HC T2046 0659 I A 8/23/2019 12/31/21998 F0240 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 6 31A LN 6 HC T2046 0658 I A 8/23/2019 12/31/21998 F0240 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 6 31A LN 6 HC T2046 0659 I A 8/23/2019 12/31/2199




8 F0242 HOSPICE IN ICF/IID NON-STATE COMMUNITY RESIDENTIAL LON 9 31A LN 9 HC T2046 0659 I A 8/23/2019 12/31/21998 F0243

WITHOUT DRUGS 31A LC 1 HC T2046 0658 U3 U4 I A 8/23/2019 12/31/2199

8 F0243

WITHOUT DRUGS 31A LC 1 HC T2046 0659 U3 U4 I A 8/23/2019 12/31/219910 RG001 NF - RAD 1 SW RAD 0100 I A 09/01/2008 12/31/219910 RG002 NF - RAC 1 SW RAC 0100 I A 09/01/2008 12/31/219910 RG003 NF - RAB 1 SW RAB 0100 I A 09/01/2008 12/31/219910 RG004 NF - RAA 1 SW RAA 0100 I A 09/01/2008 12/31/219910 RG005 NF - SE3 1 SW SE3 0100 I A 09/01/2008 12/31/219910 RG006 NF - SB2 1 SW SE2 0100 I A 09/01/2008 12/31/219910 RG007 NF - SE1 1 SW SE1 0100 I A 09/01/2008 12/31/219910 RG008 NF - SSC 1 SW SSC 0100 I A 09/01/2008 12/31/2199

10 RG009 NF - SSB 1 SW SSB 0100 I A 09/01/2008 12/31/2199

10 RG010 NF - SSA 1 SW SSA 0100 I A 09/01/2008 12/31/219910 RG011 NF - CC2 1 SW CC2 0100 I A 09/01/2008 12/31/219910 RG012 NF - CC1 1 SW CC1 0100 I A 09/01/2008 12/31/219910 RG013 NF - CB2 1 SW CB2 0100 I A 09/01/2008 12/31/219910 RG014 NF - CB1 1 SW CB1 0100 I A 09/01/2008 12/31/219910 RG015 NF - CA2 1 SW CA2 0100 I A 09/01/2008 12/31/219910 RG016 NF - CA1 1 SW CA1 0100 I A 09/01/2008 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






10 RG017 NF - IB2 1 SW IB2 0100 I A 09/01/2008 12/31/219910 RG018 NF - IB1 1 SW IB1 0100 I A 09/01/2008 12/31/219910 RG019 NF - IA2 1 SW IA2 0100 I A 09/01/2008 12/31/219910 RG020 NF - IA1 1 SW IA1 0100 I A 09/01/2008 12/31/219910 RG021 NF - BB2 1 SW BB2 0100 I A 09/01/2008 12/31/219910 RG022 NF - BB1 1 SW BB1 0100 I A 09/01/2008 12/31/219910 RG023 NF - BA2 1 SW BA2 0100 I A 09/01/2008 12/31/219910 RG024 NF - BA1 1 SW BA1 0100 I A 09/01/2008 12/31/219910 RG025 NF - PE2 1 SW PE2 0100 I A 09/01/2008 12/31/219910 RG026 NF - PE1 1 SW PE1 0100 I A 09/01/2008 12/31/219910 RG027 NF - PD2 1 SW PD2 0100 I A 09/01/2008 12/31/219910 RG028 NF - PD1 1 SW PD1 0100 I A 09/01/2008 12/31/219910 RG029 NF - PC2 1 SW PC2 0100 I A 09/01/2008 12/31/219910 RG030 NF - PC1 1 SW PC1 0100 I A 09/01/2008 12/31/219910 RG031 NF - PB2 1 SW PB2 0100 I A 09/01/2008 12/31/219910 RG032 NF - PB1 1 SW PB1 0100 I A 09/01/2008 12/31/219910 RG033 NF - PA2 1 SW PA2 0100 I A 09/01/2008 12/31/219910 RG034 NF - PA1 1 SW PA1 0100 I A 09/01/2008 12/31/219910 RG035 NF - BC1 1 SW BC1 HC 0100 I A 09/01/2008 12/31/219910 RG036 NF - PCE 1 SW PCE HC 0100 I A 09/01/2008 12/31/219910 N0400 MEDICARE SKILLED 3 HC 0101 I A 04/01/2007 12/31/219911 G2000 PACE - DUAL ELIGIBLE 39 ER P A 01/01/1900 12/31/219911 G2001 PACE - MEDICAID ONLY 39A ER P A 01/01/1900 12/31/219911 G2002 PACE - QMB 39B ER P A 07/01/2003 12/31/219914 M0326 ELAUATION FOR IDD 80 HC T2011 KX P A 06/01/2012 12/31/219914 M0327 EVALUATION FOR MI 81 HC T2011 P A 06/01/2012 12/31/219914 M0324 TCM COMPREHENSIVE 12A HC T1017 P A 06/01/2011 12/31/219914 M0325 TCM FOLLOW-UP 12C HC T1017 KX P A 06/01/2011 12/31/219916 G0400 OCCUPATIONAL THERAPY 7 HC G0152 GO P A 01/01/1900 12/31/219916 G0401 PHYSICAL THERAPY 8 HC G0151 GP P A 01/01/1900 12/31/219916 G0402 SPEECH THERAPY 9 HC G0153 GN P A 01/01/1900 12/31/219916 S0101 HABILITATION - ADL'S 10 HC T2021 U5 P A 01/01/1900 12/31/219916 G0100 RESPITE - IN HOME 11 ER P A 01/01/1900 12/31/219916 G0101 RESPITE - IN-HOME CDS (INDIVIDUAL) 11 ER P A 01/01/1900 12/31/219916 G0171 AGENCY ADMIN - IN HOME RESPITE CDS 11 ER P A 01/01/1900 12/31/219916 G0200 CASE MANAGEMENT 12 HC T1016 P A 01/01/1900 12/31/219916 G0500 DME/ADAPTIVE AIDS - COMMUNICATION DEVICE 15 HC E2510 P A 01/01/2011 12/31/219916 G0500 DME/ADAPTIVE AIDS - COMMUNICATION DEVICE 15 HC E2510 P A 01/01/2010 12/31/219916 G0500 MEDICAL SUPPLIES 15 HC T2028 P A 10/01/2003 12/31/219916 G0500 DME/ADAPTIVE AIDS - OTHER (IN HOME/NON-VEHICLE LIFT) 15 HC E0636 P A 05/19/1998 12/31/219916 G0500 DME/ADAPTIVE AIDS - COMMUNICATION OTHER 15 HC E1902 P A 05/19/1998 12/31/219916 G0500 DME - STANDARD WHEELCHAIR 15 HC E1130 P A 05/19/1998 12/31/219916 G0500 DME - VEHICLE MODIFICATIONS TO INCLUDE LIFT 15 HC T2039 P A 10/01/2003 12/31/219916 G0500 DME - ROLLABOUT CHAIR 15 HC E1031 P A 05/19/1998 12/31/219916 G0500 DME - MISCELLANEOUS (HOSPITAL BEDS/VENTILATOR) 15 HC E1399 P A 05/19/1998 12/31/219916 G0500 DME - MEDICAL EQUIPMENT (NOS) 15 HC T2029 P A 10/01/2003 12/31/219916 G0500 ADAPTIVE AIDS - TRANSPORTATION 15 HC T2003 P A 05/19/1998 12/31/219916 G0500

SUPPLIES/DIAPERS/BED PADS/ENSURE) 15 HC S5199 P A 01/01/2003 12/31/2199

16 G0608 HOME MODIFICATIONS 16 HC S5165 P A 01/01/2003 12/31/219916 G0730 RESIDENTIAL HABILITATION - HOURLY 17 HC T2016 P A 10/16/2003 12/31/219916 G0900 ASSISTED LIVING - APT (LEVEL 6) 19 HC T2031 U1 U1 P A 01/01/1900 12/31/219916 U0210 DIETARY SERVICES - EVALUATION 34 HC 97802 P A 01/01/1900 12/31/219916 U0210 DIETARY - DIABETIC SERVICES 34 HC S9465 P A 01/01/1900 12/31/219916 U0210 DIETARY - NUTRITIONAL SERVICES 34 HC S9470 P A 01/01/1900 12/31/219916 U0300 AUDIOLOGY 35 HC V5008 P A 12/01/2009 12/31/219916 H2024 SUPPORTED EMPLOYMENT 37 HC H2024 P A 08/01/2008 12/31/219916 G0515 ADP AIDES/REQUISITION FEES 0-499.99 41 BL ER P A 08/01/2009 12/31/219916 G0516 ADP AIDES/REQUISITION FEES 500.00-999.99 41 BL ER P A 08/01/2009 12/31/219916 G0517 ADP AIDES/REQUISITION FEES 1000.00-1499.99 41 BL ER P A 08/01/2009 12/31/219916 G0518 ADP AIDES/REQUISITION FEES 1500.00-1999.99 41 BL ER P A 08/01/2009 12/31/219916 G0519 ADP AIDES/REQUISITION FEES 2000.00-2499.99 41 BL ER P A 08/01/2009 12/31/219916 G0520 ADP AIDES/REQUISITION FEES 2500.00-2999.99 41 BL ER P A 08/01/2009 12/31/219916 G0521 ADP AIDES/REQUISITION FEES 3000.00-3499.99 41 BL ER P A 08/01/2009 12/31/219916 G0522 ADP AIDES/REQUISITION FEES 3500.00-3999.99 41 BL ER P A 08/01/2009 12/31/219916 G0523 ADP AIDES/REQUISITION FEES 4000.00-4499.99 41 BL ER P A 08/01/2009 12/31/219916 G0524 ADP AIDES/REQUISITION FEES 4500.00-4999.99 41 BL ER P A 08/01/2009 12/31/219916 G0525 ADP AIDES/REQUISITION FEES 5000.00-OVER 41 BL ER P A 08/01/2009 12/31/219916 G0231 ORIENTATION & MOBILITY - OUT OF HOME 44 HC 97537 P A 01/01/1900 12/31/219916 G0231 ORIENTATION & MOBILITY - IN HOME 44 HC 97535 P A 01/01/1900 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






16 G0232 INTERVENOR 45 HC T1013 P A 10/16/2003 12/31/219916 G0252 HAB TRANSPORTATION 48 HC T2001 P A 11/01/2015 12/31/219916 T2038 TRANSITION ASSISTANCE SERVICES (TAS) 53 HC T2038 P A 09/01/2004 12/31/219916 H2026 EMPLOYMENT ASSISTANCE 54 HC H2026 P A 08/01/2008 12/31/219916 G1108 CFC PAS/HAB 10CFC HC T2026 P A 06/01/2015 12/31/219916 G1119 SPT MEETING 10CFC HC T2024 KX P A 3/1/2020 12/31/219916 G1109 CDS CFC PAS/HAB 10CFV HC T2016 UC P A 06/01/2015 12/31/219916 G1110 CDS CFC PAS/HAB TAXES 10CFV HC T2016 UG P A 06/01/2015 12/31/219916 G1111 CDS CFC PAS/HAB, ES/BENEFITS 10CFV HC T2016 UF P A 06/01/2015 12/31/219916 G0128 RESPITE - OUT-OF-HOME 11A HC S5151 P A 01/01/1900 12/31/219916 G0170 AGENCY ADMIN - OUT OF HOME RESPITE CDS 11A ER P A 01/01/1900 12/31/219916 G0196 CDS RESPITE OUT-OF-HOME 11AV HC S5151 P A 12/01/2008 12/31/219916 G6003 CDS RESPITE OUT-OF-HOME - TAXES 11AV HC S5151 UG P A 02/01/2013 12/31/219916 G6004 CDS RESPITE OUT-OF-HOME - ES/BENEFITS 11AV HC S5151 UF P A 02/01/2013 12/31/219916 G0197 CDS RESPITE IN-HOME 11PV HC S9125 P A 12/01/2008 12/31/219916 G6011 CDS RESPITE IN-HOME - TAXES 11PV HC S9125 UG P A 02/01/2013 12/31/219916 G6012 CDS RESPITE IN-HOME - ES/BENEFITS 11PV HC S9125 UF P A 02/01/2013 12/31/219916 G0302 NURSING SERVICES - LVN 13A HC T1003 P A 12/01/2008 12/31/219916 G0303 NURSING SERVICES - RN 13B HC T1002 P A 12/01/2008 12/31/219916 T1002 SPECIALIZED NURSING RN 13C HC T1002 TG TD P A 01/01/2008 12/31/219916 T1003 SPECIALIZED NURSING LVN 13D HC T1003 TG TE P A 01/01/2008 12/31/219916 G0744 PAS CHORE 17E HC S5120 P A 01/01/1900 12/31/219916 G0717 RESIDENTIAL HABILITATION - CDS (INDIVIDUAL) 17V HC S5125 UB P A 06/01/2005 12/31/219916 G0718 CDS-PERSONAL ASSISTANCE SERVICES (PAS) - IND 17V ER P A 01/01/1900 12/31/219916 G6001 RESIDENTIAL HABILITATION - CDS (INDIVIDUAL) - TAXES 17V HC S5125 UG UB P A 02/01/2013 12/31/219916 G6002 RESIDENTIAL HABILITATION - CDS (INDIVIDUAL) - ES/BENEFITS 17V HC S5125 UF UB P A 02/01/2013 12/31/219916 G0937 ASSISTED LIVING - HABILITATION 24 HR 19E HC T2033 U1 P A 01/01/1900 12/31/219916 G0938 18 HOUR RESIDENTIAL HABILITATION 19F HC T1020 P A 01/01/1900 12/31/219916 G0938 18 HOUR ASSISTED LIVING 19F 0240 I A 01/01/1900 12/31/219916 G1112 CFC ERS INITIAL MONTH 20CFC HC S5160 P A 06/01/2015 12/31/219916 G1113 CFC ERS PURCHASE ONLY 20CFC HC S5162 P A 06/01/2015 12/31/219916 G1114 CFC ERS ONGOING MONTHS 20CFC HC S5161 P A 06/01/2015 12/31/219916 U0306 AUDITORY INTEGRATION/ENHANCEMENT TRAINING 35B HC V5299 P A 12/01/2009 12/31/219916 G6067 CDS-SUPPORTED EMPLOYMENT - TAXES 37V HC H2024 UG UC P A 02/01/2013 12/31/219916 G6068 CDS-SUPPORTED EMPLOYMENT - ES/BENEFITS 37V HC H2024 UF UC P A 02/01/2013 12/31/219916 H2027 CDS-SUPPORTED EMPLOYMENT 37V HC H2024 UC P A 10/01/2011 12/31/219916 G0207 PRE-ASSESSMENT 40A HC T2024 P A 01/01/1900 12/31/219916 G0623 MH MODS/REQUISITION FEES 0-499.99 41B BL ER P A 08/01/2009 12/31/219916 G0624 MH MODS/REQUISITION FEES 500.00-999.99 41B BL ER P A 08/01/2009 12/31/219916 G0625 MH MODS/REQUISITION FEES 1000.00-1499.99 41B BL ER P A 08/01/2009 12/31/219916 G0626 MH MODS/REQUISITION FEES 1500.00-1999.99 41B BL ER P A 08/01/2009 12/31/219916 G0627 MH MODS/REQUISITION FEES 2000.00-2499.99 41B BL ER P A 08/01/2009 12/31/219916 G0628 MH MODS/REQUISITION FEES 2500.00-2999.99 41B BL ER P A 08/01/2009 12/31/219916 G0629 MH MODS/REQUISITION FEES 3000.00-3499.99 41B BL ER P A 08/01/2009 12/31/219916 G0630 MH MODS/REQUISITION FEES 3500.00-3999.99 41B BL ER P A 08/01/2009 12/31/219916 G0631 MH MODS/REQUISITION FEES 4000.00-4499.99 41B BL ER P A 08/01/2009 12/31/219916 G0632 MH MODS/REQUISITION FEES 4500.00-4999.99 41B BL ER P A 08/01/2009 12/31/219916 G0633 MH MODS/REQUISITION FEES 5000.00-5499.99 41B BL ER P A 08/01/2009 12/31/219916 G0634 MH MODS/REQUISITION FEES 5500.00-5999.99 41B BL ER P A 08/01/2009 12/31/219916 G0635 MH MODS/REQUISITION FEES 6000.00-6499.99 41B BL ER P A 08/01/2009 12/31/219916 G0636 MH MODS/REQUISITION FEES 6500.00-OVER 41B BL ER P A 08/01/2009 12/31/219916 G0607 SPECIFICATION FEES ADAPTIVE AIDS 41C ER P A 05/01/2013 12/31/219916 G0604 SPECIFICATION FEES MINOR HOME MODS 41D ER P A 05/01/2013 12/31/219916 G0637 DENTAL/REQUISITION FEES 0 - 499.99 41E ER P A 02/01/2010 12/31/219916 G0638 DENTAL/REQUISITION FEES 500.00 - 999.99 41E ER P A 02/01/2010 12/31/219916 G0639 DENTAL/REQUISITION FEES 1000.00 - 1499.99 41E ER P A 02/01/2010 12/31/219916 G0640 DENTAL/REQUISITION FEES 1500.00 - 1999.99 41E ER P A 02/01/2010 12/31/219916 G0641 DENTAL/REQUISITION FEES 2000.00 - 2499.99 41E ER P A 02/01/2010 12/31/219916 G0642 DENTAL/REQUISITION FEES 2500.00 - OVER 41E ER P A 02/01/2010 12/31/219916 H2019 BEHAVIORAL SUPPORT 43A HC H2019 P A 07/01/2008 12/31/219916 G0242 INTERVENOR I 45A HC T1013 U3 P A 04/01/2010 12/31/219916 G0245 CDS INTERVENOR I 45AV HC T1013 U3 UC P A 04/01/2010 12/31/219916 G6069 CDS INTERVENOR I - TAXES 45AV HC T1013 U3 UG UC P A 02/01/2013 12/31/219916 G6070 CDS INTERVENOR I - ES/BENEFITS 45AV HC T1013 U3 UF UC P A 02/01/2013 12/31/219916 G0243 INTERVENOR II 45B HC T1013 U4 P A 04/01/2010 12/31/219916 G0246 CDS INTERVENOR II 45BV HC T1013 U4 UC P A 04/01/2010 12/31/219916 G6071 CDS INTERVENOR II - TAXES 45BV HC T1013 U4 UG UC P A 02/01/2013 12/31/219916 G6072 CDS INTERVENOR II - ES/BENEFITS 45BV HC T1013 U4 UF UC P A 02/01/2013 12/31/219916 G0244 INTERVENOR III 45C HC T1013 U5 P A 04/01/2010 12/31/2199


SERVICEGROUP

BILLCODE

DESCRIPTIONSERVICE

CODELEVELTYPE

LEVELVALUE


CODE 1REVENUE CODE

POS

MO

DIFIER 1

MO

DIFIER 2

MO

DIFIER 3

MO

DIFIER 4

CLAIM FIL IN

D






16 G0247 CDS INTERVENOR III 45CV HC T1013 U5 UC P A 04/01/2010 12/31/2199

16 G6073 CDS INTERVENOR III - TAXES 45CV HC T1013 U5 UG UC P A 02/01/2013 12/31/219916 G6074 CDS INTERVENOR III - ES/BENEFITS 45CV HC T1013 U5 UF UC P A 02/01/2013 12/31/219916 G0240 CDS INTERVENER 45V HC T1013 UC P A 04/01/2010 12/31/2199

16 G6075 CDS INTERVENER - TAXES 45V HC T1013 UG UC P A 02/01/2013 12/31/2199

16 G6076 CDS INTERVENER - ES/BENEFITS 45V HC T1013 UF UC P A 02/01/2013 12/31/2199

16 G0253 CDS HAB TRANSPORTATION 48V HC T2001 UC P A 11/01/2015 12/31/2199

16 G0254 CDS HAB TRANSPORTATION TAXES 48V HC T2001 UG P A 11/01/2015 12/31/2199

16 G0255 CDS HAB TRANSPORTATION ES/BENEFIT 48V HC T2001 UF P A 11/01/2015 12/31/2199

16 G0239 TAS FEES 53A ER P A 09/01/2004 12/31/2199

16 G6077 CDS-EMPLOYMENT ASSISTANCE - TAXES 54V HC H2026 UG UC P A 02/01/2013 12/31/2199

16 G6078 CDS-EMPLOYMENT ASSISTANCE - ES/BENEFITS 54V HC H2026 UF UC P A 02/01/2013 12/31/2199

16 H2029 CDS-EMPLOYMENT ASSISTANCE 54V HC H2026 UC P A 10/01/2011 12/31/2199

16 G1115 CDS CFC SUPPORT CONSULTATION 57CFV ER P A 06/01/2015 12/31/2199

16 G1116 CDS CFC SUPPORT CONSULTATION TAXES 57CFV ER P A 06/01/2015 12/31/2199

16 G1117 CDS CFC SUPPORT CONSULTATION ES/BENEFITS 57CFV ER P A 06/01/2015 12/31/2199

16 G0757 CDS SUPPORT CONSULTATION 57V ER P A 01/01/2009 12/31/2199

16 N0601 DENTAL WAIVER SERVICES 5A AD D9999 D A 09/01/2008 12/31/2199

16 N0602 DBMD DENTAL SEDATION 5B D9220 D A 09/01/2008 12/31/2199

16 G1118 CDS CFC FMS 63CFV HC T2040 P A 06/01/2015 12/31/219916 G0228 CDS DBMD MONTHLY ADMINISTRATION FEE 63V ER P A 06/01/2008 12/31/219920 G1800 GUARDIANSHIP OF THE PERSON 70 ER P A 02/01/2012 12/31/219920 G1801 GUARDIANSHIP OF THE ESTATE 71 ER P A 02/01/2012 12/31/219920 G1802 GUARDIANSHIP OF THE PERSON/ESTATE 72 ER P A 02/01/2012 12/31/2199


Documents

LTC Bill Code Crosswalk - Texas Health and Human Services › ... › ltcbillcodecrosswalk.pdf · 1v0134 va daily care - pa1 rg pa1 0100 va i a 09/01/2008 12/31/2199 1 v0135 va daily