016.06.05 Ark. Code R. 019 - Rehabilitative Hospital Provider Manual Update Transmittal #53

242.122 Procedure Codes Requiring Modifiers

Treatment and therapy procedure codes may not be billed in conjunction with revenue code 0459. The basic non-emergency service is included in the coverage of the therapies.

Procedure Code	Modifier	Description
T1015	U1	Outpatient Hospital Clinic Room Charge. This room charge includes supplies and non-physician staffing.
77417	U1	Therapeutic Radiology Port Film(s)
77417	U2	Therapeutic Radiology Port Film(s)
77417	U3	Therapeutic Radiology Port Film(s)
92507	UB	Individual Speech Therapy by SLPA
92508	UB	Group Speech Therapy by SLPA
97110	UB	Individual Physical Therapy by Physical Therapy Assistant
97150	U1 UB	Group Occupational Therapy by Occupational Therapy Assistant
97150	UB	Group Physical Therapy by Physical Therapy Assistant
97530	UB	Individual Occupational Therapy by Occupational Therapy Assistant
99401	UA	Outpatient Hospital Clinic Room Charge-Periodic Family Planning Visit
99402	UA	Outpatient Hospital Clinic Room Charge-Basic Family Planning Visit

Notes

016.06.05 Ark. Code R. 019

6/6/2005