UB-04 Form Locator Appendices

Condition Codes (continued)Form locators 18–28AccommodationsAPPENDIX BUse this condition code:If the accommodation was:36 General care patient in a special unit37 Ward accommodation at the patient’s request38 Semi-private room not available39 Private room medically necessary40 Same-day transfer41 Partial hospitalization42 Continuing care not related to inpatient admission43 Continuing care not provided within prescribed postdischargewindow44 Inpatient admission changed to outpatient7Facility Blue Book2010 - 2011

Condition Codes (continued)APPENDIX BForm locators 18–28Skilled Nursing Facility (SNF) InformationUse this condition code:If the:55 SNF bed not available (patient was discharged from ahospital and a SNF bed was not available for more than 30days)56 Medical appropriateness (admission to a SNF facility wasdelayed more than 30 days after the hospital dischargebecause the condition made it inappropriate to begin activecare within that period)57 SNF readmission (patient received Medicare-covered SNFcare within 30 days of this readmission)58 Terminated Medicare Advantage enrollee whose three dayhospital stay was waived.59 Non-primary end-stage renal disease (ESRD) facility8 Facility Blue Book2010 - 2011

Condition Codes (continued)APPENDIX BForm locators 18–28Prospective PaymentUse this condition code:If you are being paid under a prospective paymentsystem and :60 There is a day outlier61 There is a cost outlier66 The Provider does not wish cost outlier payment67 The Beneficiary elects not to use life-time reserve (LTR)days68 The Beneficiary elects to use LTR days69 An Indirect medical education (IME), direct graduatemedical education (DGME), nursing and allied health(N&AH) payment only.9Facility Blue Book2010 - 2011

Condition Codes (continued)APPENDIX BForm locators 18–28Renal Dialysis SettingUse this condition code:If the patient:70 Self-administered anemia management drug71 Received full care in unit72 Had self care in unit (patient managed his/her own dialysisservices without staff assistance in a hospital or renaldialysis facility)73 Had self-care training (is a renal dialysis patient and youare billing for special dialysis services where the patientand his helper, if necessary, were learning to performdialysis)74 Was home (received dialysis services at home, but code 75below does not apply)75 Was home – 100 percent reimbursement (received dialysisservices at home using a dialysis machine that waspurchased by Medicare under the 100% program)76 Received backup in-facility dialysis77 Is treated by a provider who accepts or isobligated/required due to a contractualarrangement or law to accept payment by a primary payeraspayment in full78 Has new coverage not implemented by HMO (Foroutpatient bills, condition code 04 should be omitted)79 Received Physical therapy (PT), occupational therapy(OT), speech therapy (ST), and comprehensive outpatientrehabilitation facility (CORF) services off-site10 Facility Blue Book2010 - 2011

Condition Codes (continued)APPENDIX BForm locators 18–28Program Indicator CodesUse this condition code:A1A2A3A4A5A6A9If the special program indicator is:Early and periodic screening diagnosis and treatment,community health accreditation program (EPSDT/CHAP)Physically handicapped children’s programSpecial federal fundingFamily planningDisabilityVaccines/Medicare 100% payment for pneumonia andinfluenzaSecond opinion surgery11Facility Blue Book2010 - 2011

Condition Codes (continued)APPENDIX BForm locators 18–28Peer Review Organization (PRO) Approval Indicator ServicesUse this condition code:C1C2C3C4C5C6C7If the admission/service was:Approved as billedAutomatically approval as billed based on focused reviewPartially approvalDeniedIs post-payment review applicableRequired admission pre-authorizationHad extended authorization (was authorized for anextended length of time, but the services provided have notbeen reviewed)12 Facility Blue Book2010 - 2011

Condition Codes (continued)APPENDIX BForm locators 18–28Claim Change ReasonsUse this condition code:D0D1D2D3D4D5D6D7D8D9E0G0H0H2W2W3W4W5If the reason for the claim change is:Changes to service datesChanges to chargesChanges in revenue codes/HCPCS/HIPPS rate codesSecond or subsequent interim prospective payment system(PPS) billChanges in ICD-9-CM diagnosis and/or procedure codesCancel to correct health insurance claim number (HICN)or provider identification numberCancel only to repay a duplicate or Office of InspectorGeneral (OIG) overpaymentChange to make Medicare the secondary payerChange to make Medicare the primary payerAny other changeChange in patient statusDistinct medical visitDelayed filing, statement of intent submittedDischarge by a hospice provider for causeDuplicate of original billLevel I appealLevel II appealLevel III appeal13Facility Blue Book2010 - 2011

Hour CodesAPPENDIX CForm locators 13 & 16Accident, Admission, and Discharge Hour/Inpatient & Outpatient ClaimsUse this hour code:If you want to indicate this time frame:00 12:00 midnight–12:59 a.m.01 01:00–01:59 a.m.02 02:00–02:59 a.m.03 03:00–03:59 a.m.04 04:00–04:59 a.m.05 05:00–05:59 a.m.06 06:00–06:59 a.m.07 07:00–07:59 a.m.08 08:00–08:59 a.m.09 09:00–09:59 a.m.10 10:00–10:59 a.m.11 11:00–11:59 a.m.12 12:00 noon–12:59 p.m.13 01:00–01:59 p.m.14 02:00–02:59 p.m.15 03:00–03:59 p.m.16 04:00–04:59 p.m.17 05:00– 05:59 p.m.18 06:00–06:59 p.m.19 07:00–07:59 p.m.20 08:00–08:59 p.m.21 09:00–09:59 p.m.22 10:00–10:59 p.m.23 11:00–11:59 p.m.14 Facility Blue Book2010 - 2011

Value CodesAPPENDIX EForm locators 39–41Use this code:If you are submitting a claim for:01 Most common semi-private room rate02 Hospital has no semi-private rooms04 Professional component charges, which are combined billed05 Professional component included in charges and also billed separately to carrier06 Medicare blood deductible08 Medicare lifetime reserve amount (in the first calendar year)09 Medicare co-insurance amount (in the first calendar year in billing period)10 Medicare lifetime reserve amount (in the second calendar year)11 Medicare co-insurance amount (in the second calendar year)12 A working-aged beneficiary/spouse with employer group health plan13 An end-stage renal disease (ESRD) beneficiary in a Medicare coordinationperiod with an employer group health plan14 No fault, including auto/other15 Workers’ compensation16 Public Health Service or other federal agency30 Pre-admission testing31 Patient liability amount32 Multiple patient ambulance transport15Facility Blue Book2010 - 2011

Value Codes (continued)Form locators 39–41Use this code: If you are submitting a claim for:APPENDIX E37 Units of blood furnished38 Blood deductible units39 Pints of blood replaced40 New coverage not implemented by HMO (for inpatient claims only)41 Black lung42 Veteran’s Affairs43 Disabled beneficiary under age 65 with large group health plan44 Amount provider agreed to accept from the primary insurer when this amount is lessthan charges but greater than the primary insurer’s payment45 Accident hour*46 Number of grace days47 Any liability insurance48 Hemoglobin reading49 Hematocrit reading50 Physical therapy visits51 Occupational therapy visits52 Speech therapy visits53 Cardiac rehabilitation visits54 Newborn birth weight in grams55 Eligibility threshold for charity care56 Skilled nurse – home visit hours (HHA only)57 Home health aide – home visit hours (HHA only)58 Arterial blood gas (PO2/PA2)59 Oxygen saturation60 Home Health Agency branch MSA* See Appendix C16 Facility Blue Book2010 - 2011

Value Codes (continued)APPENDIX EForm locators 39–41Use this code:If you are submitting a claim for:61 Place of residence where service is furnished (home health aide and hospice)66 Medicaid spend down amount67 Peritoneal dialysis68 Epoetin Alfa (EPO) – drug69 State charity care precert80 Covered days81 Non-covered days82 Co-insurance days83 Lifetime reserve daysA0A1B1C1Special zip code reportingDeductible payer ADeductible payer BDeductible payer CE1 Deductible payer D; discontinued 3/1/07F1 Deductible payer E; discontinued 3/1/07G1 Deductible payer F; discontinued 3/1/07A2B2C2E2Co-insurance payer ACo-insurance payer BCo-insurance payer CCo-insurance payer DF2** Co-insurance payer E; code discontinued 3/1/07**For Medicare, use this code only for reporting Part B co-insurance amounts.17 Facility Blue Book2010 - 2011

Value Codes (continued)APPENDIX EForm locators 39–41Use this code:If you are submitting a claim for:G2** Co-insurance payer F; discontinued 3/1/07A3B3C3D3D4Estimated responsibility payer AEstimated responsibility payer BEstimated responsibility payer CEstimated responsibility patientClinical trial number assigned by National Library of Medicine(NLM)/National Institutes of Health (NIH)E3 Discontinued, effective with UB-04 implementation 3/1/07F3 Discontinued, effective with UB-04 implementation 3/1/07G3 Discontinued, effective with UB-04 implementation 3/1/07A4A5A6Covered self-administrable drugs–emergencyCovered self-administrable drugs not self-administrable in form and situationfurnished to patientCovered self-administrable drugs–diagnostic study and otherA7 Copayment payer A; this code is used only on paper claims; for electronic 837claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”).B7 Copayment payer B; this code is used only on paper claims; for electronic 837claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”).C7 Copayment payer C; this code is used only on paper claims; for electronic 837claim, use Loop ID 2320 CAS segment (Claim Adjustment Group Code “PR”).E7 Copayment payer E; discontinued 3/1/07F7 Copayment payer F; discontinued 3/1/07G7 Copayment payer G; discontinued 3/1/07G8MSA or Core-Based Statistical Area (CBSA) number (or rural state code) of thefacility where inpatient hospice service is delivered. Report the number indollar portion of the form locator right-justified to the left of the dollar/centsdelimiter.**For Medicare, use this code only for reporting Part B co-insurance amounts.18 Facility Blue Book2010 - 2011

Occurrence CodesAPPENDIX FForm locators 31–34Required for claims related to an accident, pre-admission testing, or claims secondary toMedicareUse this code:If the date on the claim is related to:01 Accident, auto/medical coverage02 No-fault insurance involved, including auto accident/other03 Accident, tort liability04 Accident, employment related05 Accident/no medical or liability coverage06 Crime victim09 Start of infertility treatment cycle10 Last menstrual period11 Onset of symptoms/illness12 Date of onset for a chronically dependent individual (home healthagency claims only)16 Date of last therapy17 Date outpatient occupational therapy plan established or last reviewed18 Date of retirement of patient/beneficiary19 Date of retirement of spouse20 Date guarantee of payment began21 Date utilization review (UR) notice received22 Date active care ended24 Date insurance denied25 Date benefits terminated by primary payer26 Date skilled nursing facility bed became available27 Date of hospice certification or recertification28 Date comprehensive outpatient rehabilitation plan established or last reviewed19 Facility Blue Book2010 - 2011

Occurrence Codes (continued)Form locators 31–34APPENDIX FUse this code:If the date on the claim is related to:29 Date outpatient physical therapy plan established or last reviewed30 Date outpatient speech pathology plan established or last reviewed31 Date beneficiary notified of intent to bill (accommodations)32 Date beneficiary notified of intent to bill (procedures or treatments)33 First day of Medicare coordination period for end-stage renal disease(ESRD) beneficiaries covered by an employee group health plan34 Date of election of extended care services35 Date treatment started for physical therapy36 Date of inpatient hospital discharge for covered transplant patient37 Date of inpatient hospital discharge for non-covered transplant patient38 Date treatment started for home IV therapy39 Date discharged on a continuous course of IV therapy40 Scheduled date of admission41 Date of first test for pre-admission testing42 Date of discharge43 Scheduled date of cancelled surgery44 Date treatment started for occupational therapy45 Date treatment started for speech therapy46 Date treatment started for cardiac rehabilitation47 Date cost outlier status beginsA1B1C1G1Birth date – insured ABirth date – insured BBirth date – insured CBirth date – insured F20 Facility Blue Book2010 - 2011

Occurrence Codes (continued)APPENDIX FForm locators 31–34Use this code:If the date on the claim is related to:A2B2C2A3B3C3A4Effective date – insured A policyEffective date – insured B policyEffective date – insured C policyBenefits exhausted - payer ABenefits exhausted - payer BBenefits exhausted - payer CSplit bill date21 Facility Blue Book2010 - 2011

Patient Status CodesForm locator 17 Discharge Status Claims Required for all claimsAPPENDIX GUse this code:If the patient status is:01 Discharged to home for self care (routine discharge)02 Discharged/transferred to a short-term general hospital for inpatient care03 Discharged/transferred to a skilled nursing facility (SNF) with Medicarecertification in anticipation of skilled care04 Discharged/transferred to an intermediate care facility (ICF)05 Discharged/transferred to a Designated Cancer Center or Children’s Hospital06 Discharged/transferred to home under care of organized homehealth service organization in anticipation of covered skilled care07 Left against medical advice or discontinued care09 Admitted as an inpatient to this hospital20 Expired30 Still a patient40 Expired at home41 Expired in a medical facility (e.g., hospital, SNF, ICF, or freestandinghospice)42 Expired – place unknown43 Discharged/transferred to a federal health care facility50 Hospice – home51 Hospice – medical facility (certified) providing hospice level of care61 Discharged/transferred to a hospital-based Medicare approved swing bed62 Discharged/transferred to an inpatient rehabilitation facility (IRF), includingrehabilitation distinct part units of a hospital.22 Facility Blue Book2010 - 2011

Patient Status Codes (continued)APPENDIX GForm locator 17Use this code:If the claim is:63 Discharged/transferred to a Medicare certified long-term carehospital (LTCH)64 Discharged/transferred to a nursing facility certified under Medicaid,but not certified under Medicare65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part ofa hospital66 Discharged/transferred to a critical access hospital70 Discharged/transferred to another type of health care institution not definedelsewhere in this code list. (See code 05.)23 Facility Blue Book2010 - 2011

UB-04 Revenue Codes for Providers─Alphabetical General Code ListingAPPENDIX HFor revenue codes related to:See listing number:All-Inclusive Ancillary General………………………………………………………... 0240All-Inclusive Room & Board & Ancillary…………………………………………….. 0100Ambulance…………………………………………………………………………….. 0540Ambulatory Surgical Care…………………………………………………………….. 0490Anesthesia……………………………………………………………………………... 0370Audiology…………………………………………………………………………… 0470Blood………………………………………………………………………………….. 0380Blood Storage and Processing………………………………………………………………0390CAPD Outpatient or Home……………………………………………………………. 0840Cardiology…………………………………………………………………………….. 0480Cast Room…………………………………………………………………………….. 0700CCPD Outpatient or Home……………………………………………………………. 0850Clinic………………………………………………………………………………….. 0510Coronary Care…………………………………………………………………………. 0210CT Scan……………………………………………………………………………….. 0350Drugs Requiring Specific Identification……………………………………………….. 0630Durable Medical Equipment…………………………………………………………... 0290EEG (Electroencephalogram)………………………………………………………….. 0740EKG/ECG (Electrocardiogram)……………………………………………………….. 0730Emergency Room……………………………………………………………………… 0450Freestanding Clinic…………………………………………………………………... 0520Gastrointestinal………………………………………………………………………... 0750Hemodialysis Outpatient or Home…………………………………………………….. 0820Home Health Aide……………………………………………………………………... 0570Home IV Therapy Services…………………………………………………………..... 0640Hospice………………………………………………………………………………... 0650Incremental Nursing Charge Rate……………………………………………………... 0230Inpatient Renal Dialysis……………………………………………………………….. 0800Intensive Care…………………………………………………………………………. 0200IV Therapy…………………………………………………………………………….. 0260Labor Room/Delivery…………………………………………………………………. 0720Laboratory…………………………………………………………………………….. 0300Laboratory – Pathology……………………………………………………………….. 0310Leave of Absence……………………………………………………………………… 0180Lithotripsy…………………………………………………………………………….. 0790Medical Social Services……………………………………………………………….. 0560Medical/Surgical Supplies (extension of 0270)………………………………………... 062XMedical/Surgical Supplies…………………………………………………………….. 0270Miscellaneous Dialysis………………………………………………………………… 0880MRI (magnetic resonance imaging)…………………………………………………. 0610Nuclear Medicine……………………………………………………………………… 0340Occupational Therapy…………………………………………………………………. 0430Oncology……………………………………………………………………………… 0280Operating Room Services……………………………………………………………… 036024 Facility Blue Book2010 – 2011

UB-04 Revenue Codes for Providers─Alphabetical General Code ListingFor revenue codes related to:See listing number:APPENDIX HOrgan Acquisition (also see 0890)…………………………………………………...... 0810Osteopathic Services…………………………………………………………………... 0530Other Diagnostic Services……………………………………………………………... 0920Other Imaging Services………………………………………………………………... 0400Other Room & Board ……………………………………………………………….. 0160Other Therapeutic Services……………………………………………………………. 0940Other Visits (Home Health)…………………………………………………………... 0580Outpatient Services …………………………………………………………………. 0500Outpatient Special Residence Charges………………………………………………… 0670Oxygen (Home Health) ……………………………………………………………... 0600Patient Convenience Items…………………………………………………………….. 0990Peritoneal Dialysis Outpatient or Home……………………………………………….. 0830Pharmacy……………………………………………………………………………… 0250Physical Therapy………………………………………………………………………. 0420Preventive Care Services………………………………………………………………. 0770Professional Fees………………………………………………………………………. 0960Professional Fees………………………………………………………………………. 097XProfessional Fees………………………………………………………………………. 098XPsychiatric/Psychological Services …………………………………………………. 091XPsychiatric/Psychological Treatments…………………………………………………. 0900Pulmonary Function…………………………………………………………………… 0460Radiology – Diagnostic………………………………………………………………... 0320Radiology – Therapeutic………………………………………………………………. 0330Recovery Room ……………………………………………………………………... 0710Respiratory Services ………………………………………………………………... 0410Respite Care (Home Health Only) ………………………………………………….. 0660Room & Board – Nursery …………………………………………………………... 0170Room & Board – Private……………………………………………………………… 0110Room & Board – Private (Deluxe)…………………………………………………….. 0140Room & Board – Semi-private, 2 Beds………………………………………………... 0120Room & Board – Semi-private, 3-4 Beds……………………………………………. 0130Room & Board – Ward ……………………………………………………………... 0150Skilled Nursing………………………………………………………………………… 0550Special Charges……………………………………………………………………….. 0220Speech-Language Pathology………………………………………………………… 0440Sub-Acute Care ……………………………………………………………………... 0190Telemedicine………………………………………………………………………….. 0780Total Charges ……………………………………………………………………….. 0001Treatment or Observation Room………………………………………………………. 0760Units of Service (Home Health)……………………………………………………….. 059025 Facility Blue Book2010 - 2011

APPENDIX H1UB-04 Revenue Codes for Providers─Numeric Listing0001 Total Charges0020 Health Insurance – Prospective PaymentSystem (PPS)0022 SNF – (PPS)0023 Home Health – PPS0024 Inpatient Rehab Facility – PPS0100 All-inclusive Room & Board & Ancillary0101 All-inclusive room & board0110 Room & Board - Private0111 Medical/surgical/gyn0112 Obstetrics (OB)0113 Pediatric0114 Psychiatric0115 Hospice0116 Detox0117 Oncology0118 Rehab0119 Other0120 Room & Board – Semi-private, 2 Beds0121 Medical/surgical/gyn0122 Obstetrics (OB)0123 Pediatric0124 Psychiatric0125 Hospice0126 Detox0127 Oncology0128 Rehab0129 Other0130 Room & Board – Semi-private, 3-4 Beds0131 Medical/surgical/gyn0132 Obstetrics (OB)0133 Pediatric0134 Psychiatric0135 Hospice0136 Detox0137 Oncology0138 Rehab0139 Other0140 Room & Board – Private (Deluxe)0141 Medical/surgical/gyn0142 Obstetrics (OB)0143 Pediatric0144 Psychiatric0145 Hospice0146 Detox0147 Oncology0148 Rehab0149 Other0150 Room & Board - Ward0151 Medical/surgical/gyn0152 Obstetrics (OB)0153 Pediatric0154 Psychiatric0155 Hospice0156 Detox0157 Oncology0158 Rehab0159 Other0160 Nursery0164 Sterile environment0167 Self care0169 Other0170 Nursery0171 Newborn – Level I0172 Newborn – Level II0173 Newborn – Level III0174 Newborn – Level IV0179 Other0180 Leave of Absence0182 Patient convenience0183 Therapeutic leave0185 Nursing Home (for hospitalization)0189 Other leave of absence0190 Sub-Acute Care0191 Level I0192 Level II0193 Level III0194 Level IV0199 Other sub-acute care0200 Intensive Care0201 Surgical0202 Medical0203 Pediatric0204 Psychiatric0206 Intermediate ICU0207 Burn care0208 Trauma0209 Other26 Facility Blue Book2010 – 2011

APPENDIX H1UB-04 Revenue Codes for Providers─Numeric Listing0210 Coronary Care0211 Myocardial infarction0212 Pulmonary care0213 Heart transplant0214 Intermediate critical care unit (CCU)0219 Other0220 Special Charges0221 Admission0222 Technical support0223 UR service0224 Late discharge – medically necessary0229 Other0230 Incremental Nursing Charge Rate0231 Nursery0232 Obstetrics (OB)0233 Intensive care unit (ICU)0234 Critical care unit (CCU)0235 Hospice0239 Other0240 All-Inclusive Ancillary – General0241 Basic0242 Comprehensive0243 Specialty0249 Other0250 Pharmacy0251 Generic drugs0252 Non-generic drugs0253 Take home drugs0254 Incident to other diagnostic services0255 Incident to radiology0256 Experimental drugs0257 Non-Rx0258 IV solutions0259 Other0260 IV Therapy0261 Infusion pump0262 IV therapy/pharmacy services0263 IV therapy/drug/supply delivery0264 IV therapy/supplies0269 Other0270 Medical/Surgical Supplies and Devices0271 Non-sterile supplies0272 Sterile supplies0273 Take-home supplies0274 Prosthetic/orthotic devices0275 Pacemaker0276 Intraocular lens0277 Oxygen – take home0278 Other implants0279 Other supplies/devices0280 Oncology0289 Other oncology0290 Durable Medical Equipment (not renal)0291 Rental0292 Purchase – new equipment0293 Purchase – used equipment0294 Supplies/drugs for DME (HHA only)0299 Other equipment0300 Laboratory0301 Chemistry0302 Immunology0303 Renal patient (home)0304 Non-routine dialysis0305 Hematology0306 Bacteriology and microbiology0307 Urology0309 Other0310 Laboratory - Pathology0311 Cytology0312 Histology0314 Biopsy0319 Other0320 Radiology - Diagnostic0321 Angiocardiography0323 Arthrography0324 Arteriography0324 Chest X-ray0329 Other27 Facility Blue Book2010 - 2011

APPENDIX H1UB-04 Revenue Codes for Providers–Numeric Listing0330 Radiology - Therapeutic and/orChemotherapy Administration0331 Chemotherapy – injected0332 Chemotherapy – oral0333 Radiation therapy0335 Chemotherapy – IV0339 Other0340 Nuclear Medicine0341 Diagnostic0342 Therapeutic0343 Diagnostic radiopharmaceuticals0344 Therapeutic radiopharmaceuticals0349 Other0350 Computerized Tomography (CT Scan)0351 Head scan0352 Body scan0359 Other CT scans0360 Operating Room Services0361 Minor surgery0362 Organ transplant, not kidney0367 Kidney transplant0369 Other0370 Anesthesia0371 Incident to radiology0372 Incident to other diagnostic services0374 Acupuncture0379 Other0380 Blood0381 Packed red cells0382 Whole blood0383 Plasma0384 Platelets0385 Leukocytes0386 Other components0387 Other derivatives (cryoprecipitates)0389 Other0390 Blood Storage/Processing0391 Blood administration0392 Processing and storage0399 Other blood handling0400 Other Imaging Services0401 Diagnostic mammography0402 Ultrasound0403 Screening mammography0404 Positron emission tomography (PET scan)0409 Other imaging services0410 Respiratory Services0412 Inhalation therapy0413 Hyperbaric oxygen therapy0419 Other0420 Physical Therapy0421 Visit charge0422 Hourly charge0423 Group rate0424 Evaluation or re-evaluation0429 Other0430 Occupational Therapy0431 Visit charge0432 Hourly charge0433 Group rate0434 Evaluation or re-evaluation0439 Other0440 Speech Therapy – Language Pathology0441 Visit charge0442 Hourly charge0443 Group rate0444 Evaluation or re-evaluation0449 Other0450 Emergency Room (ER)0451 EMTALA emergency medical screening0452 ER beyond EMTALA screening0456 Urgent Care0459 Other emergency room0460 Pulmonary Function0469 Other pulmonary function0470 Audiology0471 Diagnostic0472 Treatment0479 Other0480 Cardiology0481 Cardiac catheter lab0482 Stress test0483 Echocardiography0489 Other28 Facility Blue Book2010 – 2011

APPENDIX H1UB-04 Revenue Codes for Providers–Numeric Listing0490 Ambulatory Surgical Care0499 Other0500 Outpatient Services0509 Other0510 Clinic0511 Chronic pain center0512 Dental clinic0513 Psychiatric clinic0514 OB/Gyn clinic0515 Pediatric clinic0516 Urgent care clinic0517 Family practice clinic0519 Other clinic0520 Free-Standing Clinic0521 Rural health clinic0522 Rural health – home0523 Family practice clinic0524 Rural Health Family Clinic0525 Rural Health – other residential facility0526 Urgent care clinic0527 Rural Health – visiting nurse0528 Rural Health – other site0529 Other freestanding clinic0530 Osteopathic Services0531 Osteopathic therapy0539 Other0540 Ambulance0541 Supplies0542 Medical transport0543 Heart mobile0544 Oxygen0545 Air ambulance0546 Neonatal ambulance services0547 Pharmacy0548 Telephone transmission EKG0549 Other (ALS)0550 Skilled Nursing0551 Visit charge0552 Hourly charge0559 Other0560 Home Health - Medical Social Services0561 Visit charge0562 Hourly charge0569 Other*Note: This service requires authorization.0570 Home Health Aide0571 Visit charge0572 Hourly charge0579 Other0580 Other Visits (Home Health)0581 Visit charge0582 Hourly charge0589 Other0590 Units of Service (Home Health)0600 Oxygen (Home Health)0601 Oxygen – state/equip/suppt/or cont0602 Oxygen – state/equip/under 1 LPM0603 Oxygen – state/equip/over 4 LPM0604 Oxygen – portable add-on0609 Other0610 Magnetic Resonance Imaging (MRI)0611 MRI brain (including brain stem)0612 MRI spinal cord (including spine)0614 MRI – other0615 MRA – head and neck0616 MRA – lower extremities0618 MRA – other0619 Other0620 Medical/Surgical Supplies - Extension of2700621 Supplies incident to radiology0622 Supplies incident to other diagnosticservices0623 Surgical dressings0624* FDA investigational devices0630 Drugs Requiring SpecificationIdentification0631 Single source drug0632 Multiple source drug0633 Restrictive prescription0634 Erythropoietin (EPO) less than 10,000units0635 Erythropoietin (EPO) greater than 10,000units0636 Drugs requiring detailed coding0637 Self-administrable drugs29 Facility Blue Book2010 - 2011

APPENDIX H1UB-04 Revenue Codes for Providers–Numeric Listing0640 Home IV Therapy Services0641 Non-routine nursing/central line0642 IV site care, central line0643 IV start/care/peripheral line0644 Non-routine nursing/peripheral line0645 Training patient/caregiver/central line0646 Training disabled patient/central line0647 Training patient/caregiver/peripheral line0648 Training disabled patient/peripheral line0649 Other0650 Hospice0651 Routine home care0652 Continuous home care0655 Inpatient respite care0656 General inpatient care (non-respite)0657 Physician services0658 Hospice R&B Nursing Facility0659 Other0660 General Respite Care (Home HealthOnly)0661 Hourly charge/skilled nursing0662 Hourly charge/home health aide/homemaker/companion0633 Daily Respite Charge0669 Other Respite0670 Outpatient Special Residence Charges0671 Hospital owned0672 Contracted0679 Other special residence charges0680 Trauma Response0681 Level I Trauma0682 Level II Trauma0683 Level III Trauma0684 Level IV Trauma0689 Other0700 Cast Room0710 Recovery Room0720 Labor Room/Delivery0721 Labor0722 Delivery0723 Circumcision0724 Birthing center0729 Other0730 EKG/ECG (Electrocardiogram)0731 Holter monitor0732 Telemetry0739 Other0740 EEG (Electroencephalogram)0750 Gastrointestinal0760 Treatment or Observation Room0761 Treatment room0762 Observation room0769 Other specialty rooms0770 Preventive Care Services0771 Vaccine administration0780 Telemedicine0790 Extra-Corporeal Shock Wave Therapy0800 Inpatient Renal Dialysis0801 Hemodialysis0802 Peritoneal dialysis (non-CAPD)0803 Continuous ambulatory peritoneal dialysis(CAPD)0804 Continuous cycling peritoneal dialysis(CCPD)0809 Other0810 Organ Acquisition0811 Living donor0812 Cadaver donor0813 Unknown donor0814 Unsuccessful organ search – donor bankcharges0819 Other donor0820 Hemodialysis Outpatient or Home0821 Hemodialysis – composite or other rate0822 Home supplies0823 Home equipment0824 Maintenance – 100%0825 Support services0829 Other30 Facility Blue Book2010 – 2011

APPENDIX H1UB-04 Revenue Codes for Providers–Numeric Listing0830 Peritoneal Dialysis Outpatient or Home0831 Peritoneal dialysis – composite or otherrate0832 Home supplies0833 Home equipment0834 Maintenance – 100%0835 Support services0839 Other0840 CAPD (Dialysis) Outpatient or Home0841 CAPD - composite or other rate0842 Home supplies0843 Home equipment0844 Maintenance – 100%0845 Support services0849 Other0850 CCPD (Dialysis) Outpatient or Home0851 CCPD – composite or other rate0852 Home supplies0853 Home equipment0854 Maintenance – 100%0855 Support services0859 Other0880 Miscellaneous Dialysis0881 Ultra-filtration0882 Home dialysis aid visit0889 Other0900 Behavioral Health Treatment0901 Electroshock treatment0902 Milieu therapy0903 Play therapy0904 Activity therapy0905 Intensive outpatient services – psychiatric0906 Intensive outpatient services – chemicaldependency0907 Community Behavioral Health Program(DayTreatment091X Behavioral Health Treatment -Reserved0911 Rehabilitation0912 Partial hospitalization – less intensive0913 Partial hospitalization – intensive0914 Individual therapy0915 Group therapy0916 Family therapy0917 Biofeedback0918 Testing0919 Other0920 Other Diagnostic Services0921 Peripheral vascular lab0922 Electromyelgram0923 Pap smear0924 Allergy test0925 Pregnancy test0929 Other diagnostic service0930 Medical rehab day program-Reserved0931 Medical rehab day program – half-day0932 Medical rehab day program – full-day0940 Other Therapeutic Services0941 Recreational therapy0942 Education/training0943 Cardiac rehabilitation0944 Drug rehabilitation0945 Alcohol rehabilitation0946 Complex medical equipment – routine0947 Complex medical equipment – ancillary0948 Pulmonary rehab0949 Other therapeutic services0950 Other therapeutic services – reserved0951 Athletic training0952 Kinesiotherapy0960 Professional Fees0961 Psychiatric0962 Ophthalmology0963 Anesthesia – MD0964 Anesthesia – CRNA0969 Other31 Facility Blue Book2010 - 2011

APPENDIX H1UB-04 Revenue Codes for Providers–Numeric Listing0970 Professional Fees - Reserved0971 Laboratory0972 Radiology – diagnostic0973 Radiology – therapeutic0974 Radiology – nuclear medicine0975 Operating room0976 Respiratory therapy0977 Physical therapy0978 Occupational therapy0979 Speech therapy0980 Professional Fees - Reserved0981 Emergency room0982 OPD0983 Clinic0984 Medical/social services0985 Electrocardiogram (EKG)0986 Electroencephalogram (EEG)0987 Hospital visit0988 Consultation0989 Private duty nurse2100 Alternative Therapy Services2101 Acupuncture2102 Acupressure2103 Massage2104 Reflexology2105 Biofeedback2106 Hypnosis2109 Other alternative therapy services3100 Adult Day Care - Reserved3101 Adult day care, medical, social – hourly3102 Adult day care, social – hourly3103 Adult day care, medical, social – daily3104 Adult daycare, social – daily3105 Adult foster care – daily3109 Other adult care0990 Patient Convenience Items0991 Cafeteria/guest tray0992 Private linen services0993 Telephone/telegraph0994 TV/radio0995 Nonpatient room rentals0996 Late discharge charge0997 Admission kits0998 Beauty shop/barber0999 Other1000 Behavioral Health Accommodations1001 Residential treatment – psychiatric1002 Residential treatment – chemicaldependency1003 Supervised living1004 Halfway house1005 Group home32 Facility Blue Book2010- 2011

Revenue Codes/Pre-Admission TestingAPPENDIX H2Form locator 42Required for services provided to a member up to three days prior to an inpatient admission(Applies to these plans: HMO, group Indemnity, non-group indemnity, group PPO, and Medex ®´.Employer group plan requirements may differ; please refer to the covered member’sidentification card.)Use this code:If the patient receives these services:254 Drugs incident to other diagnostic services255 Drugs incident to radiology300–309 Laboratory310–319 Laboratory pathological320–329 Radiology diagnostic341 Nuclear medicine, diagnostic350–359 CT scan (computerized tomography)400–409 Other imaging services460–469 Pulmonary function480–489 Cardiology with HCPCS codes 93015, 93307, 93308, 93320,93501, 93503, 93505, 93510, 93526, 93541, 93541–93562530–539 Osteopathic services610–619 MRI (magnetic resonance imaging)620–622 Medical/surgical supplies, incident to radiology or otherdiagnostic services730–739 EKG/ECG (electrocardiogram)740 EEG (electroencephalogram)920–929 Other diagnostic services33 Facility Blue Book2010- 2011

APPENDIX H3Revenue Code Ranges* That Do Not Require HCPCSCodesForm locator 44Use these outpatient revenue codes:If the service is for:001 Total charge250–259 Pharmacy270–273, 275-279 Medical-surgical supplies and devices**370–379 Anesthesia380–389 Blood620–622 Medical-surgical supplies, extension of 270-279**710 Recovery room/other recovery room990–999 Patient convenience itemsFor other codes not listed hereSee Appendix H*All other revenue code ranges require the submission of a HCPCS code.**Coordinated Home Health Care providers must use HCPCS codes for these revenue codes.34 Facility Blue Book2010- 2011

Relationship CodesAPPENDIX IForm locator 59Required for all inpatient and outpatient claimsUse this relationship code:If the patient has this relationship with the subscriber:01 Spouse18 Self19 Child20 Employee21 Unknown39 Organ donor40 Cadaver donor53 Life partnerG8Other relationship35 Facility Blue Book2010- 2011

Source of Admission (SOA) CodesAPPENDIX JForm locator 15Code structure for emergency, elective, or other type of admission. (Required for allinpatient claims and some outpatient claims. Use these codes on outpatient claims with revenuecodes: 360: operating room; 450: emergency room; and 490: ambulatory surgical care.)Use this SOA code:If the patient was admitted under these circumstances:1. Non-health care facility point oforiginUsage note: Includes patientscoming from home, aphysician’s office, orworkplace.Inpatient: The patient was admitted to this facility upon an orderof a physician.Outpatient: The patient presents to this facility with an orderfrom a physician for services or seeks scheduled services forwhich an order is not required (e.g., mammography). Includesnon-emergent self-referrals.2. Clinic Inpatient: The patient was admitted to this facility as a transferfrom a freestanding or non-freestanding claim.Outpatient: the patient was referred to this facility for outpatientor referenced diagnostic services.4. Transfer from a hospitalUsage note: Excludes transfersfrom hospital inpatient in thesame facility.Inpatient: The patient was admitted to this facility as a hospitaltransfer from an acute care facility where he or she was aninpatient or an outpatient.Outpatient: The patient was transferred to this facility as anoutpatient from an acute care facility.5. Transfer from a skilled nursingfacility (SNF) or intermediatecare facility (ICF)Inpatient: The patient was admitted to this facility as a transferfrom a SNF or ICF where he or she was a resident.Outpatient: The patient was referred to this facility foroutpatient or referenced diagnostic services from a SNF or ICFwhere he or she was a resident.6. Transfer from another health carefacilityInpatient: The patient was admitted to this facility as a hospitaltransfer from another type of health care facility not definedelsewhere in this code list.Outpatient: The patient was transferred to this facility forservices by (a physician of) another health care facility notdefined elsewhere in this code list where he or she was aninpatient or outpatient.36 Facility Blue Book2010 - 2011

Source of Admission (SOA) Codes (continued)APPENDIX IUse this SOA code:7 Emergency roomUsage notes: Excludespatients who came to theemergency room from anotherhealth care facility8 Court/law enforcementUsage notes: Includestransfers from incarcerationfacilitiesIf the patient was admitted under these circumstances:Inpatient: The patient was admitted to this facility afterreceiving services in this facility’s emergency department.Outpatient: The patient received unscheduled services in thisfacility’s emergency department and discharged without aninpatient admission. Includes self-referrals in emergencysituations that require immediate medical attention.Inpatient: The patient was admitted to this facility upon thedirection of a court of law, or upon the request of a lawenforcement agency representative.Outpatient: The patient was referred to this facility upon thedirection of a court of law, or upon the request of a lawenforcement agency representative for outpatient orreferenced diagnostic services.9 Information not available Inpatient: The means by which the patient was admitted tothis hospital is not known.Outpatient: The means by which the patient was referred tothis hospital’s outpatient department is not known.BCDEFTransfer from another HomeHealth AgencyReadmission to the sameHome Health AgencyTransfer from one district unitof the hospital to anotherdistinct unit of the samehospital resulting in a separateclaim to the payerTransfer from AmbulatorySurgery CenterTransfer from hospice and isunder a hospice plan of care orenrolled in a hospice programThe patient was admitted to this home health agency as atransfer from another home health agency.The patient was readmitted to this home health agency withinthe existing 60-day payment (for use with Medicare bill type032X).Inpatient: The patient was admitted to this facility as atransfer from hospital inpatient within this hospital resultingin a separate claim to the payer.Outpatient: The patient received outpatient services in thisfacility as a transfer from within this hospital resulting in aseparate claim to the payer.Inpatient: The patient was admitted to this facility as atransfer from an ambulatory surgery center.Outpatient: The patient was referred to this facility foroutpatient or referenced diagnostic services from anambulatory surgery center.Inpatient: The patient was admitted to this facility as atransfer from hospice.Outpatient: The patient was referred to this facility foroutpatient or referenced diagnostic services from a hospice.37 Facility Blue Book2010- 2011

Newborn Source of Admission CodesAPPENDIX JForm locator 15Required for all inpatient maternity claimsUse this SOA code:If the baby was delivered:5A baby born inside this hospital6 A baby born outside of this hospitalOnly use “Newborn Source of Admission Codes” if your type of admission is “4”.See Appendix L, “Type of Admission Codes”38 Facility Blue Book2010 - 2011

Type of Admission CodesAPPENDIX KForm locator 14Required for all inpatient claimsIf you use this TOA code:It means the patient:1 Emergency Required immediate medical intervention as a result ofsevere, life threatening, or potentially disabling conditions.(Generally, these patients are admitted through theemergency room.)2 Urgent Required immediate attention for the care and treatment ofa physical or mental disorder. (Generally, these patientsare admitted to the first available and suitableaccommodation.)3 Elective Had a condition which permitted adequate time toschedule a suitable accommodation.4 Newborn Is a baby born at your facility. (If you use this code, youshould also use a special source of admission code. SeeAppendix J for a complete list.)5 Trauma center Visited a trauma center/hospital as licensed ordesignated by the state or local government authorityauthorized to do so, or as verified by the AmericanCollege of Surgeons and involving a trauma activation.9 Information not available39 Facility Blue Book2010 - 2011

Type of Bill Code ListingAPPENDIX LForm locator 4Three-digit number required for all claims:First digit = type of facilitySecond digit = type of care being billed (bill classification)Third digit = the sequence of the bill for a specific episode of care (frequency of bill)Table M-1: 1 st digitUse this first digit:If you are this type of facility:And to identify the seconddigit, go to:1 Hospital Table M-22 Skilled nursing Table M-23 Home health Table M-24 Religious non-medical health careinstitutions5 Religious non-medical health careinstitutions post-hospital extended careservicesTable M-2Table M-26 Intermediate care Table M-27 Clinic Table M-38 Special facility – Inpatient or Outpatient Table M-4Table M-2: 2 nd DigitUse this secondary digit:If your bill classification is:1 Inpatient (including Medicare Part A)2 Inpatient (Medicare Part B only)3 Outpatient4 Other for home health or hospital laboratory services provided tonon-patients5 Intermediate Care – Level 16 Intermediate Care – Level 118 Swing beds40 Facility Blue Book2010 - 2011

Type of Bill Code Listing (continued)APPENDIXMTable M-3: 2 nd DigitUse 7 as your first digit and thefollowing as your second digit:If the clinic is:1 A rural health clinic2 A hospital-based or independent renal dialysis center3 Freestanding4 An outpatient rehabilitation facility (ORF)5 A comprehensive outpatient rehabilitation facility (CORFs)6 Counseling and Mental Health Center (CMHC)9 OtherTable M-4: 2 nd DigitUse 8 as your first digit and thefollowing as your second digit:If the special facility is a(n):1 Hospice (non-hospital-based)2 Hospice (hospital-based)3 Ambulatory surgery center4 Freestanding birthing center5 Critical access hospital6 Residential facility9 Other41 Facility Blue Book2010 - 2011

APPENDIX MType of Bill Code Listing (continued)Form locator 4Table M-5: 2 nd DigitUse thisthirddigit:If you aresubmitting thistype of bill:Definition:1 Admit throughdischarge claim2 Interim – first claim(inpatient only)3 Interim – continuingclaim (inpatientonly)4 Interim – last claim(inpatient only)5 Late charge(s) onlyclaim7 Replacement of priorclaimUse for a bill that is expected to be the only bill for a course oftreatment or inpatient confinement. This includes billsrepresenting a total confinement or course of treatment and billsthat represent an entire benefit period.Use for the first of a series of bills for the same confinement orcourse of treatment.Use when you have previously submitted a bill for the sameconfinement or course of treatment, and you expect to submitadditional bills for the same confinement or course of treatment.Use for the last of a series of bills for the same confinement orcourse of treatment. This code is not intended to be used in lieuof a code for late charges, adjustments, or non-payment/zeroclaims.Use for submitting charges that you received after you submittedthe admit through discharge or the last interim claim. This code isnot intended to be used in lieu of an adjustment claim orreplacement claim.Use this code when you have submitted a bill and now need torestate it in its entirety, except for the identity information. Whenyou use this code, please remember that the original bill willbecome null and void, and the information on the new billrepresents a complete replacement of the original.42 Facility Blue Book2010 - 2011

Type of Bill Code Listing (continued)APPENDIX MForm locator 4Table M-5: 3rd DigitUse thisthirddigit:If you aresubmitting thistype of bill:Definition:8 Void/cancel of priorclaim0 Non-payment/zeroclaimThis code is not intended to be used in lieu of a late charge(s)only claim.Use this code when you submit a bill, but do not anticipatepayment as a result; use when you need to inform us of nonreimbursableperiods of confinement or termination of care.43 Facility Blue Book2010-2011

APPENDIX NValid Outpatient HCPCS CodesForm locator 44Required for outpatient claimsUse this HCPCS code:If the outpatient claim is related to:H0001–H2037Alcohol and drug abuse treatment services95115–95199 Allergy immunotherapy95004–95075 Allergy testsAlcoholism day treatment (for use by alcohol/drug treatment facilitiesonly)A0021–A0999Ambulance90901–90911 Biofeedback93000–93278 Cardiography93501–93581 Cardiac catheterization76000 Cardiac fluoroscopy93797–93798 Cardiac rehabilitation92950–92998 Cardiovascular therapeutic services0001F–6005F0016T–0170TCategory II tracking codes for performance measurementCategory III codes for emerging technology96101–96120 Central nervous system assessments/tests96401–96549 Chemotherapy administration (or services)70010–79999 Diagnostic radiology and nuclear medicine90935–90999 DialysisK0001–K0899E0100–E8002Durable medical equipment (DME) temporary codesDurable medical equipment93303–93350 Echocardiography95250 Endocrinology44 Facility Blue Book2010 - 2011

APPENDIX NValid Outpatient HCPCS Codes (continued)Form locator 44Required for outpatient claimsUse this HCPCS code:If the outpatient claim is related to:B4034–B9999Enteral and parenteral therapy (for use by CHHC only)99201–99499 Evaluation and management – office or other outpatient services91000–91299 Gastroenterology96150–96155 Health and behavior assessment/interventionsV5008–V5299Hearing services99500–99600 Home health procedures/services99601–99602 Home infusion procedures90281–90399 Immune globulins90465–90474 Immunization administration90476–90749 Immunization injections93600–93662 Intracardiac electrophysiological procedures/studies80048–87999 Laboratory98940–98943 Manipulative treatment, chiropractic98925–98929 Manipulative treatment, osteopathic97802–97804 Medical nutrition therapyA4206–A4640A5051–A5200T1000–T5999Medical and surgical supplies (for use by CHHC only)National T codes for state Medicaid agencies95805–96020 Neurology and neuromuscular services97003–97004 Occupational therapy (evaluation and re-evaluation)92002–92014 Ophthalmological services45 Facility Blue Book2010-2011

Valid Outpatient HCPCS Codes (continued)APPENDIX NForm locator 44Required for outpatient claimsUse this HCPCS code:If the outpatient claim is related to:90215–92499 Ophthalmological special servicesL0112–L9900Orthotics and prosthetics93701–93799 Other cardiovascular servicesM0064–M0301Other medical services99170–99199 Other services and procedures92502–92597 Otorhinolaryngologic services88000–89240 PathologyP2028–P9615Pathology and laboratory services97010–97799 Physical medicine and rehabilitation97001–97002 Physical therapy evaluation/treatment per visit96567–96571 Photodynamic therapy99354–99359 Prolonged services90801–90899 Psychiatry94010–94799 Pulmonary tests and therapy96900–96999 Special dermatological procedures99000–99091 Special services, procedures and reportsV5336–V5364Speech/language pathology services92506–92508 Speech therapy10021–69990 SurgeryG0008–G9139Temporary procedures90765–90779 Therapeutic, prophylactic and diagnostic injections and infusionsV2020–V2799Vision services46 Facility Blue Book2010 - 2011

Valid Outpatient HCPCS Codes for ChemotherapyDrugsForm locator 44Required for outpatient claimsAPPENDIX NUse this code:J9000J9001J9010J9015J9017J9020J9025J9027J9031J9035J9040J9041J9045J9050J9060J9062J9065J9070J9080J9090J9091J9092J9093J9094J9095J9096J9097If you use this chemotherapy drug:Doxorubicin HCL, 10 mgDoxorubicin HCL, all lipid formulations, 10 mgAlemtuzumab, 10 mgAldesleukin, per single use vialArsenic trioxide, 1 mgAsparaginase, 10,000 unitsAzacitidine, 1 mgClofarabine, 1 mgBCG Live (intravesical), per installationBevacizumab, 10 mgBleomycin sulfate, 15 unitsBortezomib, 0.1 mgCarboplatin, 50 mgCarmustine, 100 mgCisplatin, powder or solution, per 10 mgCisplatin, 50 mgInjection, cladribine, per 1 mgCyclophosphamide, 100 mgCyclophosphamide, 200 mgCyclophosphamide, 500 mgCyclophosphamide, 1 gmCyclophosphamide, 2 gmCyclophosphamide, lyophilized, 100 mgCyclophosphamide, lyophilized, 200 mgCyclophosphamide, lyophilized, 500 mgCyclophosphamide, lyophilized, 1 gmCyclophosphamide, lyophilized, 2 gm47 Facility Blue Book2010 - 2011

Valid Outpatient HCPCS Codes for ChemotherapyDrugs (continued)Form locator 44Required for outpatient claimsAPPENDIX N1Use this code:J9098J9100J9110J9120J9130J9140J9150J9151J9160J9165J9170J9178J9180J9181J9182J9185J9190J9200J9201J9202J9206J9208If you use this chemotherapy drug:Cytarabine liposome, 100 mgCytarabine, 100 mgCytarabine, 500 mgDactinomycin, 0.5 mgDacarbazine, 100 mgDacarbazine, 200 mgDaunorubicin HCL, 10 mgDaunorubicin citrate, liposomal formulation, 10 mgDeni leukin diftitox, 300mgDiethylstilbestrol diphosophate, 250 mgDocetaxel, 20 mgInjection, epirubicin HC1, 2mgEpirubicin hydrochloride, 50 mgEtoposide, 10 mgEtoposide, 100 mgFludarabine phosphate, 50 mgFluorouracil, 500mgFloxuridine, 500 mgGemcitabine HCI, 200 mgGoserelin acetate implant, per 3.6 mgIrinotecan, 20 mgIfosomide, 1 g48 Facility Blue Book2010 - 2011

Valid Outpatient HCPCS Codes for ChemotherapyDrugs (continued)Form locator 44Required for outpatient claimsAPPENDIX N1Use this code:If you use this chemotherapy drug:J9209J9211J9212J9213J9214J9215J9216J9217J9218J9219J9230J9245J9250J9260J9263J9265J9266J9268J9270J9280J9290J9291Mesna, 200 mgIdarubicin hydrochloride, 5mgInjection, interferon Alfacon-1, recombinant, 1 mcgInterferon, alfa-2A, recombinant, 3 million unitsInterferon, alfa-2B, recombinant, 1 million unitsInterferon, alfa-N3, (human leukocyte derived), 250,000 IUInterferon, gamma 1-b, 3 million unitsLeuprolide acetate (for depot suspension), 7.5 mgLeuprolide acetate, per 1 mgLeuprolide acetate implant, 65 mgMechlorethamine HCI, (nitrogen mustard), 10 mgInjection, melphan hydrochloride, 50 mgMethotrexate sodium, 5mgMethotrexate sodium, 50 mgInjection, oxaliplation, 0.5 mgPaclitaxel, 30mgPegaspargase, per single dose vialPentostatin, per 10 mgPlicamycin, 2.5 mgMitomycin, 5 mgMitomycin, 20mgMitomycin, 40 mg49 Facility Blue Book2010 - 2011

Valid Outpatient HCPCS Codes for ChemotherapyDrugs (continued)Form locator 44Required for outpatient claimsAPPENDIX N1Use this code:J9293J9300J9310J9320J9340J9350J9355J9357J9360J9370J9375J9395J9380J9390J9600J9999If you use this chemotherapy drug:Injection, mitoxantrone HCI, per 5 mgGemtuzumab ozogamioin, 5 mgRituximab, 100 mgStreptozocin, 1 gThiotepa, 15 mgTopotecan, 4 mgTrastuzumab, 10 mgValrubicin, intravesical, 200 mgVinblastine sulfate, 1 mgVincristine sulfate, 1 mgVincristine sulfate, 2 mgInjection, fulvestrant, 25 mgVincristine sulfate, 5mgVinorelbine tartrate, per 10 mgPorfimer sodium, 75 mgNot otherwise classified, antineoplastic drugs50 Facility Blue Book2010 - 2011

Occurrence Span CodesAPPENDIX OForm locator 35–36Required for claims related to one of the following conditionsUse this code:If the dates on the claim are related to:70 Qualifying stay dates for skilled nursing facility (SNF) use only71 Prior stay dates72 First/last visit73 Benefit eligibility period74 Non-covered level of care (LOA)75 SNF level of care76 Patient liability77 Provider liability period78 SNF prior stay datesM0M1M2M3M4Quality Improvement Organization (QIO)/Utilization Review (UR)approved stay datesProvider liability-no utilizationInpatient respite datesIntermediate Care Facility (ICF) level of careResidential level of care51 Facility Blue Book2010 - 2011