April 2007 Professional Providers Provider Bulletin Number 738b Quarterly HCPCS Updates The following Healthcare Common Procedure Coding System (HCPCS) codes are covered with an effective date of January 1, 2007. Q4083 Q4084 Q4085 Q4086 These codes are subject to the same intra-articular injection limitations currently in place. Coverage of procedure code J7319, which was added with the 2007 annual HCPCS updates was inactivated as of January 1, 2007. Information about the Kansas Medical Assistance Program as well as provider manuals and other publications are on the KMAP Web site at https://www.kmap-state-ks.us. For the changes resulting from this provider bulletin, please view the Professional Provider Manual, pages AI-11 through AI-16. If you have any questions, please contact the Customer Service Center at 1-800-933-6593 (in-state providers) or (785) 274-5990 between 7:30 a.m. and 5:30 p.m., Monday through Friday. EDS is the fiscal agent and administrator of the Kansas Medical Assistance Program for the Kansas Health Policy Authority. Page 1 of 7
90746 Hepatitis B Vaccine; standard vial Adult Dosage 90747 Hepatitis B Vaccine; dialysis or - - - - - - immunosuppressed patient, any age (4 dose schedule) J7319 Hyaluronan (sodium hyaluronate) or derivative, intra-articular injection per 20 to 25 mg Q4083 Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose Q4084 Hyaluronan or derivative, synvisc, for intra-articular injection, per dose Q4085 Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose Q4086 Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose J3470 Hyaluronidase up to 150 1 cc J3473 Hyaluronidase, recombinant 1 usp unit C9232 Idursulfase 1mg J3471 Injection, Hyaluronidase, ovine, up to 999 usp Preservative free, per usp unit J3472 Injection, Hyaluronidase, ovine, per 1000 usp Preservative free J0360 Hydralazine HCL up to 20 mg amp J1700 Hydrocortisone Acetate, up to 25 mg 1 cc J1720 Hydrocortisone Sodium Succinate up to 100 mg 2 cc J1710 Hydrocortisone Sodium Phosphate up to 50 mg 1 cc J1170 Hydromorphone up to 4 mg 1 cc J3410 Hydroxyzine HCL up to 25 mg 1 cc *Second series requires prior authorization J1740 Ibandronate sodium 1 mg MCD J9211 Idarubicin Hydrochloride 5 mg vial J9208 Ifosfomide per gm 1 gm vial MCD J1785 Imiglucerase - - - unit J1562 Immune Globulin. Subcutaneous 100 mg PA J1745 Infliximab (Remicade) 10 mg vial 90657 Influenza Virus Vaccine, Split Virus 6-36 Months Dosage, For Intramuscular or Jet Injection Use 90658 Influenza Virus Vaccine, Split Virus 3 Years and Above Dosage, For Intramuscular or Jet Injection Use J9213 Interferon, Alfa-2A, Recombinant 3 mill. vial J9214 Interferon, Alfa-2B, Recombinant 1 mill. - - - J9215 Interferon, Alfa-N3 (Human 250,000 - - - Leukocyte Derived) J9212 Interferon, Alfacon-1, Recombinant 1 mcg AI-11
J1825 Interferon Beta-1A 33 mcg MCD J1830 Interferon Beta 1-B 0.25 mg - - - J9216 Interferon, Gamma 1-B 3 mill. vial J7645 Ipratropium Bromide, inhalation solution, compounded product administered through DME, unit does form J9206 Irinotecan HCI 20 mg/ml 1 ml J1751 Iron Dextran 50 mg J1752 Iron Dextran 50 mg J1756 Iron Sucrose 21 mg J7647 Isoetharine HCL, inhalation solution, DME, concentrated form J7650 Isoetharine HCL, inhalation solution, DME, unit dose form J7657 Isoproterenol HCL, inhalation solution, DME, concentrated form J7658 Isoproterenol Hydrochloride conc. form J7659 Isoproterenol Hydrochloride unit dose form (NDC and product name/description must be provided) J7660 Isoproterenol HCL, inhalation solution, DME, unit dose form J1835 Itraconazole 50 mg J1840 Kanamycin Sulfate up to 500 mg 2 cc J1850 Kanamycin Sulfate up to 75 mg 2 cc J1885 Ketorolac Tromethamine (NDC and product name/description must be provided) 15 mg ml J1931 Laronidase 0.1 mg J0640 Leucovorin Calcium 50 mg vial J1950 Leuprolide Acetate (For Depot) 3.75 mg - - - Suspension) J9218 Leuprolide Acetate 1 mg 1 ml J9217 Leuprolide Acetate, For Depot 7.5 mg/ml 1.5 ml Suspension J9219 Leuprolide Acetate Implant 65 mg (NDC and product name/description must be provided) J7607 Levalbuterol, inhalation solution, compounded product, concentrated form 0.5 mg J7615 Levalbuterol, inhalation solution, compounded product, unit dose 0.5 mg J1956 Levofloxacin 250 mg - - - AI-12
J2001 Lidocaine HCL (For intravenous infusion) 10 mg J2010 Lincomycin HCL up to 300 mg 1 cc MCD J2001 Lidocaine HCL 1-0.0005 per ml (Lidocaine HCL w/epinephrine) J2020 Linezolid 200 mg J7511 Lymphocyte Immune Globulin, 25 mg Antihymocyte Globulin, Rabbit, Parenteral J3475 Magnesium Sulfate 500 mg - - - J2150 Mannitol 25% 50 ml J2170 Mecasermin 1mg J9230 Mechlorethamine HCL (Nitrogen 10 mg 20 cc Mustard), HN2 J1051 Medroxyprogesterone Acetate 50 mg J1055 Medroxyprogesterone Acetate 150 mg 1 cc For Contraceptive Use J1056 Medroxyprogesterone Acetate/ Estradiol Cypionate, 5 mg/25 mg J2180 Meperidine and Promethazine HCL up to 50 mg 2 cc J2175 Meperidine 100 mg 1 cc J0670 Mepivacaine 1% 1 cc J2185 Meropenem 100 mg J9209 Mesna 200 mg vial J3490 Mesoridazine Besylate 25 mg 1 cc J7667 Metaproterenol sulfate, inhalation solution, compounded product, concentrated form per 10 mg J7670 Metaproterenol sulfate, inhalation solution, compounded product, unit dose form per 10 mg J0380 Metaraminol up to 10 mg 1 cc J2800 Methocarbamol up to 10 ml 10 cc J9250 Methotrexate 5 mg - - - J9260 Methotrexate Sodium Mix 50 mg 2 cc J2210 Methylergonovine Maleate up to 0.2 mg 1 cc J1020 Methylprednisolone Acetate 20 mg 1 cc J1040 Methylprednisolone Acetate 80 mg 2 cc J2920 Methylprednisolone Sodium up to 40 mg 1 cc Succinate J2930 Methylprednisolone Sodium up to 125 mg 2 cc Succinate J2765 Metoclopramide HCL up to 10 mg 2 cc S0030 Metronidazole up to 500 mg 100 ml J2248 Micafungin sodium 1 mg J2260 Milrinone Lactate 5 mg J9280 Mitomycin 5 mg - - - J9290 Mitomycin 20 mg - - - AI-13
J9291 Mitomycin 40 mg - - - J9293 Mitoxantrone HCL 5 mg 10 ml J2270 Morphine Sulfate up to 10 mg 1 cc J2271 Morphine Sulfate 100 mg - - - MCD J2275 Morphine Sulfate, preservative-free 10 mg ml sterile solution) J2280 Moxifloxacin 100 mg J2300 Nalbuphine HCL 10 mg 2 cc J2310 Naloxone HCL 1 mg 1 cc J2315 Naltrexone, depot form 1 mg J2320 Nandrolone Decanoate up to 50 mg 0.5 cc J2321 Nandrolone Decanoate up to 100 mg 1 cc J2322 Nandrolone Decanoate up to 200 mg 2 cc J9261 Nelarabine 50 mg J2710 Neostigmine Bromide 1:1000 (1 mg) 1 cc J2710 Neostigmine Methylsulfate up to 0.5 mg 1 cc J2353 Octreotride (Depot form) 1 mg J2354 Octreotride (non-depot form) 25 mg J2357 Omalizumab 5 mg MCD J2405 Ondansetron Hydrochloride 1 mg 0.5 ml J2355 Oprelvekin 5 mg J2700 Oxacillin Sodium up to 250 mg vial J9263 Oxaliplatin 0.5 mg J2410 Oxymorphone HCL up to 1 mg 1 cc J2460 Oxytetracycline HCL up to 50 mg 1 ml J2460 Oxytetracycline HCL 500 mg 10 cc J2590 Oxytocin up to 10 1 cc J9264 Injection, paclitaxel protein-bound 1 mg particles J9265 Paclitaxel 30 mg 5 ml KBH,PA 90378 Palivizumab (Synagis) up to 50 mg vial J2469 Palonosetron HCL 25 mcg J2430 Pamidronate Dissodium 30 mg vial C9235 Panitumumab 10 mg J2440 Papaverine HCL up to 60 mg 2 cc J2501 Paricalacitol 1 mcg J2505 Pegfilgrastim 6 mg J9305 Pemetrexed 10 mg J0530 Penicillin G Benzathine & Penicillin up to 600,000 1 cc G Procaine J0540 Penicillin G Benzathine & Penicillin up to 1,200,000 2 cc G Procaine J0550 Penicillin G Benzathine & Penicillin up to 2,400,000 4 cc G Procaine AI-14
J0560 Penicillin G Benzathine up to 600,000 1 cc J0570 Penicillin G Benzathine up to 1,200,000 2 cc J0580 Penicillin G Benzathine up to 2,400,000 4 cc J2540 Penicillin G Potassium up to 600,000 1 cc J2510 Penicillin G Procaine, Aqueous up to 600,000 1 cc 94642 Pentamidine, aerosol inhalation 300 mg vial J3070 Pentazocine HCL up to 30 mg 1 cc J2515 Pentobarbital Sodium 50 mg 1 cc J3310 Perphenazine up to 5 mg 1 cc J2560 Phenobarbital Sodium up to 120 mg 2 cc J1165 Phenytoin Sodium 100 mg 2 cc J2543 Piperacillin Sodium/Tazobactum Sodium 1 gm/0.125 gm vial J9270 Plicamycin (Mithramycin) 2.5 mg 90732 Pneumococcal Vaccine, Polysaccharide - - - 0.5cc 23-Valent, adult or immunosuppressed Patient, for subcutaneous or intramuscular use 90712 Poliovirus Vaccine, Live, (any types); - - - - - - Oral Immunization, Active Z2069 Polymyxin B Sulfate 500,000 vial J9600 Porfimer Sodium 75 mg - - - J3480 Potassium Chloride 2 meq - - - J2650 Prednisolone Acetate up to 1 ml - - - J0743 Primaxin 250 mg - - - J2690 Procainamide HCL up to 1 gm 2 cc J0780 Prochlorperazine up to 10 mg 2 cc J3490 Prolixin Enanthate 25 mg 1 cc J2550 Promethazine HCL up to 50 mg 1 cc J1800 Propranolol HCL up to 1 mg 1 cc J2720 Protamine Sulfate 10 mg - - - J3415 Pyridoxine 100 mg 90675 Rabies Vaccine For Intramuscular Use 90676 Rabies Vaccine For Intradermal Use 90375 Rabies Immune Globulin (RIG), Human For Intramuscular and/or Subcutaneous Use 90376 Rabies Immune Globulin, Heat-Treated (RIG-HT), Human For Intramuscular and/or Subcutaneous Use C9233 Ranibizumab 0.5 mg J2780 Ranitidine HCL 25 mg AI-15
J2783 Rasburicase 0.5 mg J1565 Resp Sync Vir Immug (Respigam) 50 mg/ml 1 ml 90378 Resp Sync Vir Immug (RSV-IGIM) for intramuscular use * Administration only J2993 Reteplase 18.1 mg (two single use vials) 90384 RHO (D) Immune Globulin (RHIG), Human, Full-Dose For Intramuscular Use J2788 RHO (D) Immune Globulin, Human, Mini-Dose 50 mg 90385 RHO (D) Immune Globulin (RHIG), Human, Mini-Dose For Intramuscular Use 90386 RHO (D) Immune Globulin (RHIGIV), Human, For Intravenous Use J2792 RHO D Immune Globulin, Human 100 IU Solvent Detergent J2794 Risperidone, long acting 0.5 mg J9310 Rituximab 100 mg MCD J2820 Sargramostin (GM-CSF) 50mcg vial J2916 Sodium Ferric Gluconate 12.5 mg PA,KBH J2940 Somatrem 1 mg J2941 Somatropin 1 mg J3320 Spectinomycin Dihydrochloride up to 2 gm 3.2 cc J0697 Sterile Cefuroxime Sodium 750 mg vial S0040 Sterile Ticarcillin Disodium and 3.1 gm vial Clavulanate J2995 Streptokinase 250,000 unit vial J0330 Succinycholine Chloride up to 20 mg vial J3030 Sumatriptan Succinate 6 mg - - - J7525 Tacrolimus, Parenteral 5 mg J3100 Tenecteplase 50 mg Q2017 Teniposide - - - 1 ml AI-16