016.06.11 Ark. Code R. 022 - Physician Update #5-10 and Hospital Update #6-10

Section II Physician/Independent Lab/CRNA/Radiation therapy Center roc

262.000 Procedures That Require Prior Authorization

The following procedure codes require prior authorization:

Procedi	ire Codes
D9220*	J7319	J7320	J7330	S2112	V2623	V2625	01966
11960	11970	11971	15400	15830	15847	19318	19324
19325	19328	19330	19340	19342	19350	19355	19357
19361	19364	19366	19367	19368	19369	19370	19371
19380	20974	20975	21076	21077	21079	21080	21081
21082	21083	21084	21085	21086	21087	21088	21089
21120	21121	21122	21123	21125	21127	21137	21138
21139	21141	21142	21143	21145	21146	21147	21150
21151	21154	21155	21159	21160	21172	21175	21179
21180	21181	21182	21183	21184	21188	21193	21194
21195	21196	21198	,21199	21208	21209	21244	21245
21246	21247	21248	21249	21255	21256	27412	27415
27416	28446	29866	29867	29868	30220	30400	30410
30420	30430	30435	30450	30460	30462	32851	32852
32853	32854	33140	33282	33284	33945	36470	36471
37785	37788	38240	38241	38242	42820	42821	42825
42826	42842	42844	42845	42860	42870	43257	43644
43645	43770	43771	43772	43773	43774	43842	43845
43846	43847	43848	43850	43855	43860	43865	47135
48155	48160	48554	48556	50320	50340	50360	50365
50370	50380	51925	54360	54400	54415	54416	54417
55400	57335	58150	58152	58180	58260	58262	58263
58267	58270	58275	58280	58290	58291	58292	58293
58294	58345	58541	58542	58543	58544	58550	58552
58553	58554	58570	58571	58572	58573	58672	58673
58750	58752	59135	59840	59841	59850	59851	59852
59855	59856	59857	59866	61850	61860	61862	61870
61875	61880	61885	61886	61888	63650	63655	63660
63685	63688	64555	64573	64585	64809	64818	65710
65730	65750	65755	67900	69300	69310	69320	69714
69715	69717	69718	69930	87901	87903	87904	92326

* Manually Priced

244.000 Procedures that Require Prior Authorization

The procedures represented by the CPT and HCPCS codes in the following table require prior authorization (PA). The performing physician or dentist (or the referring physician or dentist, when lab work is ordered or injections are given by non-physician staff) is responsible for obtaining required PA and forwarding the PA control number to appropriate hospital staff for documentation and billing purposes. A claim for any hospital services that involve a PA-required procedure must contain the assigned PA control number or Medicaid will deny it. (See Sections 240.000 -244.000 of this manual for instructions for obtaining prior authorization.)

J2501	J7330	J9300	S2066	S2067	S2ri2	S3800	11960
11970	11971	15400	15830	19318	19324	19325	19328
19330	19340	19342	19350	19355	19357	19361	19364
19366	19367	19368	19369	19370	19371	19380	20974
20975	21076	21077	21079	21080	21081	21082	21083
21084	21085	21086	21087	21088	21089	21120	21121
21122	21123	21125	21127	21137	21138	21139	21141
21142	21143	21145	21146	21147	21150	21151	21154
21155	21159	21160	21172	21175	21179	21180	21181
21182	21183	21184	21188	21193	21194	21195	21196
21198	21199	21208	21209	21244	21245	21246	21247
21248	21249	21255	21256	27412	27415	27416	28446
29866	29867	29868	30220	30400	30410	30420	30430
30435	30450	30460	30462	33282	33284	36470	36471
37785	37788	38242	42820	42821	42825	42826	42842
42844	42845	42860	42870	43257	43644	43645	43842
43845	43846	43847	43848	43850	43855	43860	43865
48155	50320	50340	50360	50365	50370	50380	51925
54360	54400	54415	54416	54417	55400	57335	58150
58152	58180	58260	58262	58263	58267	58270	58275
58280	58290	58291	58292	58293	58294	58345	58541
58542	58543	58544	58550	58552	58553	58554	58570
58571	58572	58573	58672	58673	58750	58752	59135
59840	59841	59850	59851	59852	59855	59856	59857
61850	61860	61870	61875	61880	61885	61888	63650
63655	63660	63685	64555	64573	64809	64818	65710
65730	65750	65755	65756	67900	69300	69310	69320
69714	69715	69717	69718	69930	87901	87903	87904

92607

92608

Procedure Code	Modifier	Description
Z1930	Non-emergency hysterectomy following c-section

Notes

016.06.11 Ark. Code R. 022

6/15/2011