1. No category

CMS Manual System
Pub. 100-04 Medicare Claims
Processing
Transmittal 51
Department of Health & Human
Services (DHHS)
Centers for Medicare &
Medicaid Services (CMS)
Date: DECEMBER 19, 2003
CHANGE REQUEST 3027
I. SUMMARY OF CHANGES: January Medicare Outpatient Code Editor (OCE)
Specifications Version 19.1 For Bills From Hospitals That Are Not Paid Under the
Outpatient Prospective Payment System (OPPS)
NEW/REVISED MATERIAL - EFFECTIVE DATE:
Various dates as described in
the instruction
*IMPLEMENTATION DATE: January 5, 2004
Disclaimer for manual changes only: The revision date and transmittal number apply
only to red italicized material. Any other material was previously published and
remains unchanged.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.)
(R = REVISED, N = NEW, D = DELETED – (Only One Per Row.)
R/N/D
CHAPTER/SECTION/SUBSECTION/TITLE
N/A
*III. FUNDING:
These instructions should be implemented within your current operating budget.
IV. ATTACHMENTS:
Business Requirements
Manual Instruction
Confidential Requirements
One-Time Notification
X Recurring Update Notification
*Medicare contractors only
Recurring Update Notification
Pub. 100-04
Transmittal: 51
Date: December 19, 2003
Change Request 3027
SUBJECT: January Medicare Outpatient Code Editor (OCE) Specifications Version
19.1 For Bills From Hospitals That Are Not Paid Under the Outpatient Prospective
Payment System (OPPS)
I.
GENERAL INFORMATION
A.
Background:
This Change Request (CR) informs you that the OCE has been updated with new additions,
changes, and deletions to Healthcare Common Procedure Coding System/Current Procedural
Terminology, Fourth Edition (HCPCS/CPT-4) codes. CMS sent detailed information about
these changes in separate communications. See Program Memorandum AB-03-140, dated
September 12, 2003. This OCE is used to process bills from hospitals not paid under the
OPPS.
B.
Policy:
The following are changes made to version 19.1 of the non-OPPS OCE:
•
The new HCPCS/CPT codes as described in Appendix A have been added to the list
of valid codes for the non-OPPS OCE.
•
The HCPCS/CPT codes listed in Appendices B and C have been deleted from the
non- OPPS OCE.
•
The following ASC procedure codes have been added to the list of ASC procedures
and payment groups, effective January 1, 2004:
Code
1. 36555
2. 36556
3. 36557
4. 36558
5. 36560
6. 36561
7. 36563
8. 36565
9. 36566
10. 36568
11. 36569
12. 36570
13. 36571
Payment Group
1
1
2
2
3
3
3
3
3
1
1
3
3
2
14. 36575
15. 36576
16. 36578
17. 36580
18. 36581
19. 36582
20. 36583
21. 36584
22. 36585
23. 36589
24. 36590
•
The following new procedure codes have been added to the list of procedures
for Females Only, effective January 1, 2004:
1.
2.
3.
4.
5.
6.
•
57425
59070
59072
59074
59076
59897
Laparoscopy, surg, colpopexy
Transabdom amnioinfus w/ us
Umbilical cord occlud w/ us
Fetal fluid drainage w/ us
Fetal shunt placement, w/ us
Fetal invas px w/ us
The following codes have been added to the list of Non-Covered procedures,
effective January 1, 2004:
1.
2.
3.
4.
5.
•
2
2
2
1
2
3
3
1
3
1
1
A9280
J7303
V5362
V5363
V5364
The following codes have been removed from the list of Non-Covered
procedures, effective January 1, 2001:
1. E0740
2. E0760
•
The following code has been removed from the list of Non-Covered procedures,
effective January 1, 2004:
1. G0282
•
The codes as described in Appendix D have been added to the list of NonReportable procedures.
3
•
The codes as described in Appendix E which are billable only to the DMERC
have been added to the list of Non-Reportable procedures.
•
The following code has been removed from the list of Non-Reportable
procedures, effective January 1, 2003:
1. G0257
C.
Provider Education:
Intermediaries shall inform affected providers by posting either a summary or relevant
portions of this document on their Web site within two weeks of receiving this instruction.
Also, intermediaries shall publish this same information in their next regularly scheduled
bulletin. If they have a listserv that targets affected providers, they shall use it to notify
subscribers that information about Non-OPPS OCE HCPCS Updates is available on their
Web site.
II.
BUSINESS REQUIREMENTS
“Shall" denotes a mandatory requirement
"Should" denotes an optional requirement
Requirement #
3027.1
3027.2
Requirements
Shared Systems Maintainers (SSMs) shall
install OCE version 19.1 into their systems.
Fiscal Intermediaries (FIs) shall inform
providers of the OCE changes for 2004 detailed
in this recurring change notification.
Responsibility
SSMs
FIs
III. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS
A.
Other Instructions:
X-Ref Requirement # Instructions
B.
Design Considerations:
X-Ref Requirement #
Recommendation for Medicare System Requirements
C.
Interfaces: OCE
D.
Contractor Financial Reporting /Workload Impact: N/A
4
E.
Dependencies: N/A
F.
Testing Considerations: N/A
IV. SCHEDULE, CONTACTS, AND FUNDING
Effective Date: Various dates as described in the
instruction.
Implementation Date: January 5, 2004
Pre-Implementation Contact(s): Nicole Atkins
(410) 786-8278
Post-Implementation Contact(s): Regional Office
ATTACHMENTS
These instructions should be
implemented within your current
operating budget.
Appendix A
Code
A4570
Description
Splint
Eff Date
20011001
S9150
Evaluation by ocularist
20020401
S9484
S9490
S9900
Crisis intervention per hour
HIT corticosteroid/diem
Christian Sci Pract visit
20020701
20020701
20020701
S0104
S0201
S0207
S0315
S0316
S0320
S1040
S2262
S2265
S2266
S2267
S3655
Zidovudine, oral, 100 mg
Partial hospitalization serv
Paramedicintercep nonhospals
Disease management program
Follow-up/reassessment
RN telephone calls to DMP
Cranial remolding orthosis
Abortion maternal indic>=25w
Abortion 25-28wks fetal indi
Abortion 29-31wks fetal indi
Abortion >=32wks fetal indic
Antisperm antibodies test
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
A4580
S5100
S5101
S5102
S5105
S5110
S5111
S5115
S5116
S5120
S5121
S5125
S5126
S5130
S5131
S5135
S5136
S5140
S5141
S5145
S5146
S5150
S5151
S5160
S5161
S5162
S5165
S5170
S5175
S5180
Cast supplies (plaster)
Adult daycare services 15min
Adult day care per half day
Adult day care per diem
Centerbased day care perdiem
Family homecare training 15m
Family homecare train/sessio
Nonfamily homecare train/15m
Nonfamily HC train/session
Chore services per 15 min
Chore services per diem
Attendant care service /15m
Attendant care service /diem
Homaker service nos per 15m
Homemaker service nos /diem
Adult companioncare per 15m
Adult companioncare per diem
Adult foster care per diem
Adult foster care per month
Child fostercare th per diem
Ther fostercare child /month
Unskilled respite care /15m
Unskilled respitecare /diem
Emer response sys instal&tst
Emer rspns sys serv permonth
Emer rspns system purchase
Home modifications per serv
Homedelivered prepared meal
Laundry serv,ext,prof,/order
HH respiratory thrpy in eval
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
1
12/22/2003
Appendix A
S5181
S5185
S5190
S5199
S8004
HH respiratory thrpy nos/day
Med reminder serv per month
Wellness assessment by nonph
Personal care item nos each
Wholebody radiopharm trgcell
20030101
20030101
20030101
20030101
20030101
H2010
H2011
H2012
H2013
H2014
H2015
H2016
H2017
H2018
H2019
H2020
H2021
H2022
H2023
H2024
H2025
H2026
H2027
H2028
H2029
H2030
H2031
H2032
H2033
H2034
H2035
H2036
H2037
S0136
S0137
S0138
S0139
S0140
S0141
S2090
S2091
S3000
S3820
S3822
S3823
S3828
S3829
S3833
S3834
S5108
S5109
Comprehensive med svc 15 min
Crisis interven svc, 15 min
Behav hlth day treat, per hr
Psych hlth fac svc, per diem
Skills train and dev, 15 min
Comp comm supp svc, 15 min
Comp comm supp svc, per diem
Psysoc rehab svc, per 15 min
Psysoc rehab svc, per diem
Ther behav svc, per 15 min
Ther behav svc, per diem
Com wrap-around sv, 15 min
Com wrap-around sv, per diem
Supported employ, per 15 min
Supported employ, per diem
Supp maint employ, 15 min
Supp maint employ, per diem
Psychoed svc, per 15 min
Sex offend tx svc, 15 min
Sex offend tx svc, per diem
MH clubhouse svc, per 15 min
MH clubhouse svc, per diem
Activity therapy, per 15 min
Multisys ther/juvenile 15min
A/D halfway house, per diem
A/D tx program, per hour
A/D tx program, per diem
Dev delay prev dp ch, 15 min
Clozapine, 25 mg
Didanosine, 25 mg
Finasteride, 5 mg
Minoxidil, 10 mg
Saquinavir, 200 mg
Zalcitabine, 0.375 mg
Open cryosurg renal
Perc cryosurg renal
Bilat dil retinal exam
Comp BRCA1/BRCA2
Sing mutation brst/ovar
3 mutation brst/ovar
Comp MLH1 gene
Comp MLH2 gene
Comp APC sequence
Sing mutation APC
Homecare train pt 15 min
Homecare train pt session
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
2
12/22/2003
Appendix A
S8460
S8990
S9434
T2010
T2011
Camisole post-mast
Pt or manip for maint
Mod solid food suppl
PASRR Level I
PASRR Level II
20030401
20030401
20030401
20030401
20030401
S0317
S3625
S3840
S3841
S3842
S3843
S3844
S3845
S3846
S3847
S3848
S3849
S3850
S3851
S3852
S9335
Disease mgmt per diem
Maternal triple screen test
DNA analysis RET-oncogene
Gene test retinoblastoma
Gene test Hippel-Lindau
DNA analysis factor v
DNA analysis deafness
Gene test alpha-thalassemia
Gene test beta-thalassemia
Gene test Tay-Sachs
Gene test Gaucher
Gene test Niemann-Pick
Gene test sickle cell
Gene test canavan
DNA analysis APOE alzheimer
HT hemodialysis diem
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
C9207
G0027
K0622
K0623
K0624
K0625
K0626
S2070
S2213
S2230
S2235
S5550
S5551
S5552
S5553
S5560
S5561
S5565
S5566
S5570
S5571
S8120
S8121
S9476
T2012
T2013
T2014
T2015
T2016
Injection, bortezomib
Semen analysis
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
Cysto laser tx ureteral calc
Implant gastric stim
Implant semi-imp hear
Implant auditory brain imp
Insulin rapid 5 u
Insulin most rapid 5 u
Insulin intermed 5 u
Insulin long acting 5 u
Insulin reuse pen 1.5 ml
Insulin reuse pen 3 ml
Insulin cartridge 150 u
Insulin cartridge 300 u
Insulin dispos pen 1.5 ml
Insulin dispos pen 3 ml
O2 contents gas cubic ft
O2 contents liquid lb
Vestibular rehab per diem
Habil ed waiver, per diem
Habil ed waiver per hour
Habil prevoc waiver, per d
Habil prevoc waiver per hr
Habil res waiver per diem
3
12/22/2003
Appendix A
T2017
T2018
T2019
T2020
T2021
T2022
T2023
T2024
T2025
T2026
T2027
T2028
T2029
T2030
T2031
T2032
T2033
T2034
T2035
T2036
T2037
T2038
T2039
T2040
T2041
T2042
T2043
T2044
T2045
T2046
T2048
Habil res waiver 15 min
Habil sup empl waiver/diem
Habil sup empl waiver 15min
Day habil waiver per diem
Day habil waiver per 15 min
Case management, per month
Targeted case mgmt per month
Serv asmnt/care plan waiver
Waiver service, nos
Special childcare waiver/d
Spec childcare waiver 15 min
Special supply, nos waiver
Special med equip, noswaiver
Assist living waiver/month
Assist living waiver/diem
Res care, nos waiver/month
Res, nos waiver per diem
Crisis interven waiver/diem
Utility services waiver
Camp overnite waiver/session
Camp day waiver/session
Comm trans waiver/service
Vehicle mod waiver/service
Financial mgt waiver/15min
Support broker waiver/15 min
Hospice routine home care
Hospice continuous home care
Hospice respite care
Hospice general care
Hospice long term care, r&b
Bh ltc res r&b, per diem
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
00529
01173
01958
20982
21685
22532
22533
22534
31632
31633
34805
35510
35512
35522
35525
35697
36555
36556
36557
36558
Anesth, chest partition view
Anesth, fx repair, pelvis
Anesth, antepartum manipul
Ablate, bone tumor(s) perq
Hyoid myotomy & suspension
Lat thorax spine fusion
Lat lumbar spine fusion
Lat thor/lumb, addl seg
Bronchoscopy/lung bx, addl
Bronchoscopy/needle bx addl
Endovasc abdo repair w/pros
Artery bypass graft
Artery bypass graft
Artery bypass graft
Artery bypass graft
Reimplant artery each
Insert non-tunnel cv cath
Insert non-tunnel cv cath
Insert tunneled cv cath
Insert tunneled cv cath
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
4
12/22/2003
Appendix A
36560
36561
36563
36565
36566
36568
36569
36570
36571
36575
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36595
36596
36597
36838
37765
37766
43237
43238
47140
47141
47142
53500
57425
59070
59072
59074
59076
59897
61537
61540
61566
61567
61863
61864
61867
61868
63101
63102
63103
64449
64517
64681
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Insert tunneled cv cath
Repair tunneled cv cath
Repair tunneled cv cath
Replace tunneled cv cath
Replace tunneled cv cath
Replace tunneled cv cath
Replace tunneled cv cath
Replace tunneled cv cath
Replace tunneled cv cath
Replace tunneled cv cath
Removal tunneled cv cath
Removal tunneled cv cath
Mech remov tunneled cv cath
Mech remov tunneled cv cath
Reposition venous catheter
Dist revas ligation, hemo
Phleb veins - extrem - to 20
Phleb veins - extrem 20+
Endoscopic us exam, esoph
Uppr gi endoscopy w/us fn bx
Partial removal, donor liver
Partial removal, donor liver
Partial removal, donor liver
Urethrlys, transvag w/ scope
Laparoscopy, surg, colpopexy
Transabdom amnioinfus w/ us
Umbilical cord occlud w/ us
Fetal fluid drainage w/ us
Fetal shunt placement, w/ us
Fetal invas px w/ us
Removal of brain tissue
Removal of brain tissue
Removal of brain tissue
Incision of brain tissue
Implant neuroelectrode
Implant neuroelectrde, addl
Implant neuroelectrode
Implant neuroelectrde, addl
Removal of vertebral body
Removal of vertebral body
Remove vertebral body add-on
N block inj, lumbar plexus
N block inj, hypogas plxs
Injection treatment of nerve
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
5
12/22/2003
Appendix A
65780
65781
65782
67912
68371
70557
70558
70559
75998
76082
76083
76514
76937
76940
78804
79403
84156
84157
85055
85396
87269
87329
87660
88112
88361
89220
89225
89230
89235
89240
89268
89272
89280
89281
89290
89291
89335
89342
89343
89344
89346
89352
89353
89354
89356
90655
90698
90715
90734
91110
95991
97755
Ocular reconst, transplant
Ocular reconst, transplant
Ocular reconst, transplant
Correction eyelid w/ implant
Harvest eye tissue, alograft
Mri brain w/o dye
Mri brain w/ dye
Mri brain w/o & w/ dye
Fluoroguide for vein device
Computer mammogram add-on
Computer mammogram add-on
Echo exam of eye, thickness
Us guide, vascular access
Us guide, tissue ablation
Tumor imaging, whole body
Hematopoetic nuclear therapy
Assay of protein, urine
Assay of protein, other
Reticulated platelet assay
Clotting assay, whole blood
Giardia ag, if
Giardia ag, eia
Trichomonas vagin, dir probe
Cytopath, cell enhance tech
Immunohistochemistry, tumor
Sputum specimen collection
Starch granules, feces
Collect sweat for test
Water load test
Pathology lab procedure
Insemination of oocytes
Extended culture of oocytes
Assist oocyte fertilization
Assist oocyte fertilization
Biopsy, oocyte polar body
Biopsy, oocyte polar body
Cryopreserve testicular tiss
Storage/year; embryo(s)
Storage/year; sperm/semen
Storage/year; reprod tissue
Storage/year; oocyte
Thawing cryopresrved; embryo
Thawing cryopresrved; sperm
Thaw cryoprsvrd; reprod tiss
Thawing cryopresrved; oocyte
Flu vaccine, 6-35 mo, im
Dtap-hib-ip vaccine, im
Tdap vaccine >7 im
Meningococcal vaccine, im
Gi tract capsule endoscopy
Spin/brain pump refil & main
Assistive technology assess
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
6
12/22/2003
Appendix A
99601
99602
0001F
0002F
0003F
0004F
0005F
0006F
0007F
0008F
0009F
0010F
0011F
0045T
0046T
0047T
0048T
0049T
0050T
0051T
0052T
0053T
0054T
0055T
0056T
0057T
0058T
0059T
0060T
0061T
A0800
A4216
A4217
A4248
A4366
A4416
A4417
A4418
A4419
A4420
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
A4432
A4433
A4434
Home infusion/visit, 2 hrs
Home infusion, each addtl hr
Blood pressure, measured
Tobacco use, smoking, assess
Tobacco use, non-smoking
Tobacco use txmnt counseling
Tobacco use txmnt, pharmacol
Statin therapy, prescribed
Beta-blocker thx prescribed
Ace inhibitor thx prescribed
Assess anginal symptom/level
Assess anginal symptom/level
Oral antiplat thx prescribed
Whole body photography
Cath lavage, mammary duct(s
Cath lavage, mammary duct(s)
Implant ventricular device
External circulation assist
Removal circulation assist
Implant total heart system
Replace component heart syst
Replace component heart syst
Bone surgery using computer
Bone surgery using computer
Bone surgery using computer
Uppr gi scope w/ thrml txmnt
Cryopreservation, ovary tiss
Cryopreservation, oocyte
Electrical impedance scan
Destruction of tumor, breast
Amb trans 7pm-7am
Sterile water/saline, 10 ml
Sterile water/saline, 500 ml
Chlorhexidine antisept
Ostomy vent
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin conv
Ost pch urine w barrier/tapv
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
7
12/22/2003
Appendix A
A4638
A4671
A4672
A4673
A4674
A4728
A6407
A6441
A6442
A6443
A6444
A6445
A6446
A6447
A6448
A6449
A6450
A6451
A6452
A6453
A6454
A6455
A6456
A6550
A6551
A7046
A7520
A7521
A7522
A7523
A7524
A7525
A7526
A9280
A9525
A9526
A9528
A9529
A9530
A9531
A9532
A9533
A9534
A9999
C1080
C1081
C1082
C1083
C1713
C1714
C1715
C1717
Repl batt pulse gen sys
Disposable cycler set
Drainage ext line, dialysis
Ext line w easy lock connect
Chem/antisept solution, 8oz
Dialysate solution, non-dex
Packing strips, non-impreg
Pad band w>=3" <5"/yd
Conform band n/s w<3"/yd
Conform band n/s w>=3"<5"/yd
Conform band n/s w>=5"/yd
Conform band s w <3"/yd
Conform band s w>=3" <5"/yd
Conform band s w >=5"/yd
Lt compres band <3"/yd
Lt compres band >=3" <5"/yd
Lt compres band >=5"/yd
Mod compres band w>=3"<5"/yd
High compres band w>=3"<5"yd
Self-adher band w <3"/yd
Self-adher band w>=3" <5"/yd
Self-adher band >=5"/yd
Zinc paste band w >=3"<5"/yd
Neg pres wound ther drsg set
Neg press wound ther canistr
Repl water chamber, PAP dev
Trach/laryn tube non-cuffed
Trach/laryn tube cuffed
Trach/laryn tube stainless
Tracheostomy shower protect
Tracheostoma stent/stud/bttn
Tracheostomy mask
Tracheostomy tube collar
Alert device, noc
Low/iso-osmolar contrast mat
Ammonia N-13, per dose
Dx I131 so iodide cap millic
Dx I131 so iodide sol millic
Th I131 so iodide sol millic
Dx I131 so iodide microcurie
I-125 serum albumin micro
I-131 tositumomab diagnostic
I-131 tositumomab therapeut
DME supply or accessory, nos
I-131 tositumomab, dx
I-131 tositumomab, tx
In-111 ibritumomab tiuxetan
Yttrium 90 ibritumomab tiuxe
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
8
12/22/2003
Appendix A
C1721
C1722
C1724
C1725
C1726
C1727
C1728
C1729
C1730
C1731
C1732
C1733
C1750
C1751
C1752
C1753
C1754
C1755
C1756
C1757
C1758
C1759
C1760
C1762
C1763
C1764
C1766
C1767
C1768
C1769
C1770
C1771
C1772
C1773
C1776
C1777
C1778
C1779
C1780
C1781
C1782
C1784
C1785
C1786
C1787
C1788
C1789
C1813
C1815
C1816
C1817
C1874
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
9
12/22/2003
Appendix A
C1875
C1876
C1877
C1878
C1879
C1880
C1881
C1882
C1883
C1885
C1887
C1891
C1892
C1893
C1894
C1895
C1896
C1897
C1898
C1899
C2615
C2617
C2619
C2620
C2621
C2622
C2625
C2626
C2627
C2628
C2629
C2630
C2631
C9210
C9211
C9212
E0118
E0140
E0190
E0240
E0247
E0248
E0300
E0301
E0302
E0303
E0304
E0470
E0471
E0472
E0561
E0562
Injection, palonosetron HCL
Inj, alefacept, IV
Inj, alefacept, IM
Crutch substitute
Walker w trunk support
Positioning cushion
Bath/shower chair
Trans bench w/wo comm open
HDtrans bench w/wo comm open
Enclosed ped crib hosp grade
HD hosp bed, 350-600 lbs
Ex hd hosp bed > 600 lbs
Hosp bed hvy dty xtra wide
Hosp bed xtra hvy dty x wide
RAD w/o backup non-inv intfc
RAD w/backup non inv intrfc
RAD w backup invasive intrfc
Humidifier nonheated w PAP
Humidifier heated used w PAP
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
10
12/22/2003
Appendix A
E0637
E0638
E0675
E0955
E0956
E0957
E0960
E0981
E0982
E0983
E0984
E0985
E0986
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010
E1019
E1021
E1028
E1029
E1030
E1391
E1634
E2120
E2201
E2202
E2203
E2204
E2300
E2301
E2310
E2311
E2320
E2321
E2322
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2331
E2340
E2341
Sit-stand w seatlift
Standing frame sys
Pneumatic compression device
Cushioned headrest
W/c lateral trunk/hip suppor
W/c medial thigh support
W/c shoulder harness/straps
Seat upholstery, replacement
Back upholstery, replacement
Add pwr joystick
Add pwr tiller
W/c seat lift mechanism
Man w/c push-rim pow assist
Pwr seat tilt
Pwr seat recline
Pwr seat recline mech
Pwr seat recline pwr
Pwr seat combo w/o shear
Pwr seat combo w/shear
Pwr seat combo pwr shear
Add mech leg elevation
Add pwr leg elevation
HD feature power seat
Ex hd feature power seat
W/c manual swingaway
W/c vent tray fixed
W/c vent tray gimbaled
Oxygen concentrator, dual
Peritoneal dialysis clamp
Pulse gen sys tx endolymp fl
Man w/ch acc seat w>=20"<24"
Seat width 24-27 in
Frame depth less than 22 in
Frame depth 22 to 25 in
Pwr seat elevation sys
Pwr standing
Electro connect btw control
Electro connect btw 2 sys
Hand chin control
Hand interface joystick
Mult mech switches
Special joystick handle
Chin cup interface
Sip and puff interface
Breath tube kit
Head control interface mech
Head/extremity control inter
Head control nonproportional
Head control proximity switc
Attendant control
W/c wdth 20-23 in seat frame
W/c wdth 24-27 in seat frame
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
11
12/22/2003
Appendix A
E2342
E2343
E2350
E2351
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2399
E2402
E2500
E2502
E2504
E2506
E2508
E2510
E2511
E2512
E2599
G0302
G0303
G0304
G0305
G0306
G0307
G0308
G0309
G0310
G0311
G0312
G0313
G0314
G0315
G0316
G0317
G0318
G0319
G0320
G0321
G0322
G0323
G0324
G0325
G0326
G0327
G0328
W/c dpth 20-21 in seat frame
W/c dpth 22-25 in seat frame
W/c hd pt wt >250 lbs
Electronic SGD interface
22nf nonsealed leadacid
22nf sealed leadacid battery
Gr24 nonsealed leadacid
Gr24 sealed leadacid battery
U1nonsealed leadacid battery
U1 sealed leadacid battery
Battery charger, single mode
Battery charger, dual mode
Noc interface
Neg press wound therapy pump
SGD digitized pre-rec <=8min
SGD prerec msg >8min <=20min
SGD prerec msg>20min <=40min
SGD prerec msg > 40 min
SGD spelling phys contact
SGD w multi methods msg/accs
SGD sftwre prgrm for PC/PDA
SGD accessory, mounting sys
SGD accessory noc
Pre-op service LVRS complete
Pre-op service LVRS 10-15dos
Pre-op service LVRS 1-9 dos
Post op service LVRS min 6
CBC/diffwbc w/o platelet
CBC without platelet
G0338
Linear accelerator stero pln
ESRD related svs home mo 20+
ESRD related svs home/dy/2y
ESRD relate home/dy 2-11yr
ESRD relate home/dy 12-19y
ESRD relate home/dy 20+yrs
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040102
20040103
20040104
20040105
20040106
20040107
20040108
20040109
20040110
20040111
20040112
20040113
20040114
20040115
20040101
20040101
20040101
20040101
20040101
20040101
20040101
12
12/22/2003
Appendix A
G0339
G0340
J0152
J0215
J0583
J0595
J1335
J1595
J2001
J2185
J2280
J2353
J2354
J2505
J2783
J3411
J3415
J3465
J3486
J7303
J7621
J9098
J9178
J9263
J9395
L0112
L0861
L1831
L1907
L1951
L1971
L3031
L3917
L5673
L5679
L5681
L5683
L8511
L8512
L8513
L8514
L8631
L8659
P9051
P9052
P9053
P9054
P9055
P9056
P9057
P9058
P9059
Robot lin-radsurg com, first
Robot lin-radsurg fractx 2-5
Adenosine injection
Alefacept
Bivalirudin
Butorphanol tartrate 1 mg
Ertapenem injection
Injection glatiramer acetate
Lidocaine injection
Meropenem
Inj, moxifloxacin 100 mg
Octreotide injection, depot
Octreotide inj, non-depot
Injection, pegfilgrastim 6mg
Rasburicase
Thiamine hcl 100 mg
Pyridoxine hcl 100 mg
Injection, voriconazole
Ziprasidone mesylate
Contraceptive vaginal ring
(Levo)albuterol/Ipra-bromide
Cytarabine liposome
Inj, epirubicin hcl, 2 mg
Oxaliplatin
Injection, Fulvestrant
Cranial cervical orthosis
Halo repl liner/interface
Knee orth pos locking joint
AFO supramalleolar custom
AFO spiral prefabricated
AFO w/ankle joint, prefab
Foot lamin/prepreg composite
Prefab metacarpl fx orthosis
Socket insert w lock mech
Socket insert w/o lock mech
Intl custm cong/latyp insert
Initial custom socket insert
Indwelling trach insert
Gel cap for trach voice pros
Trach pros cleaning device
Repl trach puncture dilator
MCP joint repl 2 pc or more
Interphalangeal joint repl
Blood, l/r, cmv-neg
Platelets, hla-m, l/r, unit
Plt, pher, l/r cmv-neg, irr
Blood, l/r, froz/degly/wash
Plt, aph/pher, l/r, cmv-neg
Blood, l/r, irradiated
RBC, frz/deg/wsh, l/r, irrad
RBC, l/r, cmv-neg, irrad
Plasma, frz between 8-24hour
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
13
12/22/2003
Appendix A
P9060
Q0137
Q0182
Q4054
Q4055
S0107
S0115
S2085
S2095
S2113
S2135
S2225
S2362
S2363
S3853
S8075
S8948
T2101
T5001
T5999
V2121
V2221
V2321
V2745
V2756
V2761
V2762
V2782
V2783
V2784
V2786
V2797
Fr frz plasma donor retested
Darbepoetin alfa, non-esrd
Nonmetabolic act d/e tissue
Darbepoetin alfa, esrd use
Epoetin alfa, esrd use
Inj, omalizumab 25 mg
Bortezomib 3.5 mg
Laparoscop gastric bypass
Transcath emboliz microspher
Arthro chondrocyte implant
Neurolysis interspace foot
Myringotomy laser-assist
Kyphoplasty, first vertebra
Kyphoplasty, each addl
Gene test myo musclr dyst
CAD of digital mammogr
Low-level laser trmt 15 min
Breast milk proc/store/dist
Special position seat/vehicl
Supply, nos
Lenticular lens, single
Lenticular lens, bifocal
Lenticular lens, trifocal
Tint, any color/solid/grad
Eye glass case
Mirror coating
Polarization, any lens
Lens, 1.54-1.65 p/1.60-1.79g
Lens, >= 1.66 p/>=1.80 g
Lens polycarb or equal
Occupational multifocal lens
Vis item/svc in other code
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
14
12/22/2003
Appendix B
Code
A9527
Description
A6020
Eff Date TermDate
20000801
20010101
S8945
S9524
T1008
T1011
PT phonophoresis 30 mins
Nursing services related to
Day Treatment for Individual
Alcohol/Substance Abuse NOC
20030401
20030401
20030401
20030401
S9802
S9803
HT nursing visit
HT nursing addl hr
20030701 20030630
20030701 20030630
S9546
Home inf blood prod nurs ser
20031001 20030930
76085
A9518
A9603
C9111
C9116
C9119
C9120
C9204
E1091
G0236
G0256
G0261
G0273
G0274
J0151
J2352
Q4053
Computer mammogram add-on
I-131 sodium iodide solution
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
Inj, bivalirudin, 250mg vial
Ertapenem sodium, per 1 gm
Injection, fulvestrant
Ziprasidone mesylate
Wheelchair youth
Digital film convert diag ma
Prostate Brachy w palladium
Prostate brachy w iodine see
Pretx planning, non-Hodgkins
Radiopharm tx, non-Hodgkins
Adenosine injection
Octreotide acetate injection
Pegfilgrastim, 1 mg
1
20030331
20030331
20030331
20030331
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
12/22/2003
Appendix C
Code
36488
36489
36490
36491
36493
36530
36531
36532
36533
36534
36535
36536
36537
47134
61862
76490
89252
89256
89350
89355
89360
89365
89399
90659
99025
99551
99552
99553
99554
99555
99556
99557
99558
99559
99560
99561
99562
99563
99564
99565
99566
99567
99568
99569
0002T
0025T
00544
A4214
A4319
A4323
A4621
Description
Insertion of catheter, vein
Insertion of catheter, vein
Insertion of catheter, vein
Insertion of catheter, vein
Repositioning of cvc
Insertion of infusion pump
Revision of infusion pump
Removal of infusion pump
Insertion of access device
Revision of access device
Removal of access device
Remove cva device obstruct
Remove cva lumen obstruct
Partial removal, donor liver
Implant neurostimul, subcort
Us for tissue ablation
Assist oocyte fertilization
Prepare cryopreserved embryo
Sputum specimen collection
Exam feces for starch
Collect sweat for test
Water load test
Pathology lab procedure
Flu vaccine, whole, im
Initial surgical evaluation
Home infus, pain mgmt, iv/sc
Hm infus pain mgmt, epid/ith
Home infuse, tocolytic tx
Home infus, hormone/platelet
Home infuse, chemotheraphy
Home infus, antibio/fung/vir
Home infuse, anticoagulant
Home infuse, immunotherapy
Home infus, periton dialysis
Home infus, entero nutrition
Home infuse, hydration tx
Home infus, parent nutrition
Home admin, pentamidine
Hme infus, antihemophil agnt
Home infus, proteinase inhib
Home infuse, iv therapy
Home infuse, sympath agent
Home infus, misc drug, daily
Home infuse, each addl tx
endo repair abd aa aorto uni
Ultrasonic pachymetry
Anesth, chest lining removal
30 CC sterile water/saline
Sterile H2O irrigation solut
Saline irrigation solution
Tracheotomy mask or collar
Eff Date
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
1
TermDate
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
12/22/2003
Appendix C
A4622
A4631
A4644
A4645
A4646
A4712
A6421
A6422
A6424
A6426
A6428
A6430
A6432
A6434
A6436
A6438
A6440
A7019
A7020
C1010
C1011
C1015
C1016
C1017
C1018
C1020
C1021
C1022
C1166
C1167
C1774
C9010
C9503
C9711
E0142
E0145
E0146
E0165
E0943
E0975
E0976
E0979
E0991
E0993
E1066
E1069
G0110
G0111
G0112
G0113
G0114
G0115
Tracheostomy or larngectomy
Wheelchair battery
Contrast 100-199 MGs iodine
Contrast 200-299 MGs iodine
Contrast 300-399 MGs iodine
Sterile water inj per 10 ml
Pad bandage >=3 <5in w /roll
Conf bandage ns >=3<5"w/roll
Conf bandage ns >=5"w /roll
Conf bandage s >=3<5" w/roll
Conf bandage s >=5" w /roll
Lt compres bdg >=3<5"w /roll
Lt compres bdg >=5"w /roll
Mo compres bdg >=3<5"w /roll
Hi compres bdg >=3<5"w /roll
Self-adher bdg >=3<5"w /roll
Zinc paste bdg >=3<5"w /roll
Saline solution dispenser
Sterile H2O or NSS w lgv neb
Blood, L/R, CMV-NEG
Platelets, HLA-m, L/R, unit
Plt, pher,L/R,CMV, irrad
BLOOD,L/R,FROZ/DEGLY/Washed
Plt, APH/PHER,L/R,CMV-NEG
Blood, L/R, IRRADIATED
RBC, frz/deg/wsh, L/R, irrad
RBC, L/R, CMV neg, irrad
Plasma, frz within 24 hour
CYTARABINE LIPOSOMAL, 10 mg
EPIRUBICIN HCL, 2 mg
Darbepoetin alfa, non-esrd
Baclofen Refill Kit--4000mcg
Fresh frozen plasma, ea unit
Walker rigid wheeled with se
Walker whled seat/crutch att
Folding walker wheels w seat
Commode chair stationry det
Cervical pillow
Wheelchair reinforced seat u
Wheelchair reinforced back u
Wheelchair belt with velcro
Wheelchair upholstry seat
Wheelchair back upholstery
Wheelchair battery charger
Wheelchair deep cycle batter
Nett pulm-rehab educ; ind
Nett pulm-rehab educ; group
Nett;nutrition guid, initial
Nett;nutrition guid,subseqnt
Nett; psychosocial consult
Nett; psychological testing
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
2
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
12/22/2003
Appendix C
G0116
G0167
G0262
G0272
J1910
J2000
J7508
J9180
K0016
K0022
K0025
K0026
K0027
K0028
K0029
K0030
K0031
K0032
K0033
K0035
K0036
K0048
K0049
K0054
K0055
K0057
K0058
K0062
K0063
K0079
K0080
K0082
K0083
K0084
K0085
K0086
K0087
K0088
K0089
K0100
K0103
K0107
K0112
K0113
K0268
K0460
K0461
K0531
K0532
K0533
K0534
K0538
Nett; psychosocial counsel
Hyperbaric oz tx;no md reqrd
Sm intestinal image capsule
Naso/oro gastric tube pl MD
Kutapressin injection
Lidocaine injection
Tacrolimus oral per 5 MG
Epirubicin HCl injection
Detach adjust armrst cmplete
Reinforced back upholstery
Hook-on headrest extension
Back upholst lgtwt whlchr
Back upholst other whlchr
Manual fully reclining back
Reinforced seat upholstery
Solid plnr seat sngl dnsfoam
Safety belt/pelvic strap
Seat uphols lgtwt whlchr
Seat upholstery other whlchr
Heel loop with ankle strap
Toe loop each
Elevate legrest complete
Calf pad each
Seat wdth 10-12/15/17/20 wc
Seat dpth 15/17/18 ltwt wc
Seat wdth 19/20 hvy dty wc
Seat dpth 17/18 power wc
Handrim 8-10 vert/obliq proj
Hndrm 12-16 vert/obliq proj
Wheel lock extension pair
Anti-rollback device pair
22 nf nonsealed leadacid
22nf sealed leadacid battery
Gr24 nonsealed leadacid
Gr24 sealed leadacid battery
U1nonsealed leadacid battery
U1 sealed leadacid battery
Battery charger, single mode
Battery charger, dual mode
Amputee adapter pair
Transfer board < 25"
Wheelchair tray
Trunk vest supprt innr frame
Trunk vest suprt w/o inr frm
Humidifier nonheated w PAP
WC power add-on joystick
WC power add-on tiller cntrl
Heated humidifier used w pap
Noninvasive assist wo backup
Noninvasive assist w backup
Invasive assist w backup
Neg pressure wnd thrpy pump
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
3
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
12/22/2003
Appendix C
K0539
K0540
K0541
K0542
K0543
K0544
K0545
K0546
K0547
K0549
K0550
K0556
K0557
K0558
K0559
K0560
K0581
K0582
K0583
K0584
K0585
K0586
K0587
K0588
K0589
K0590
K0591
K0592
K0593
K0594
K0595
K0596
K0597
K0610
K0611
K0612
K0613
K0614
K0615
K0616
K0617
K0621
L1885
K0622
K0623
K0624
K0625
K0626
L2102
L2104
L2122
L2124
Neg pres wnd thrpy dsg set
Neg pres wnd thrp canister
SGD prerecorded msg <= 8 min
SGD prerecorded msg > 8 min
SGD msg formed by spelling
SGD w multi methods msg/accs
SGD sftwre prgrm for PC/PDA
SGD accessory,mounting systm
SGD accessory NOC
Hosp bed hvy dty xtra wide
Hosp bed xtra hvy dty x wide
Socket insert w lock mech
Socket insert w/o lock mech
Intl custm cong/atyp insert
Initial custom socket insert
MCP joint 2-piece for implnt
Ost pch clsd w barrier/filtr
Ost pch w bar/bltinconv/fltr
Ost pch clsd w/o bar w filtr
Ost pch for bar w flange/flt
Ost pch clsd for bar w lk fl
Ost pch for bar w lk fl/fltr
Ost pch drain w bar & filter
Ost pch drain for barrier fl
Ost pch drain 2 piece system
Ost pch drain/barr lk flng/f
Urine ost pouch w faucet/tap
Urine ost pouch w bltinconv
Ost urine pch w b/bltin conv
Ost pch urine w barrier/tapv
Os pch urine w bar/fange/tap
Urine ost pch bar w lock fln
Ost pch urine w lock flng/ft
Peritoneal dialysis clamp
Disposable cycler set
Drainage ext line, dialysis
Ext line w easy lock connect
Chem/antisept solution, 8oz
SGD prerec mes >8min <=20min
SGD prerec mes>20min <=40min
SGD prerec mes > 40min
Gauze, non-impreg pack strip
Knee upright w/resistance
Afo tibial fx cast plstr mol
Afo tib fx cast synthetic mo
Kafo fem fx cast plaster mol
Kafo fem fx cast synthet mol
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
4
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
12/22/2003
Appendix C
Q0086
Q2010
Q4052
Q4078
Q9920
Q9921
Q9922
Q9923
Q9924
Q9925
Q9926
Q9927
Q9928
Q9929
Q9930
Q9931
Q9932
Q9933
Q9934
Q9935
Q9936
Q9937
Q9938
Q9939
Q9940
S0009
S0079
S0124
S0130
S8180
S8181
V2116
V2117
V2216
V2217
V2316
V2317
V2740
V2741
V2742
V2743
Physical therapy evaluation/
Glatiramer acetate, per dose
Octreotide injection, depot
Ammonia N-13, per dose
Epoetin with hct <= 20
Epoetin with hct = 21
Epoetin with hct = 22
Epoetin with hct = 23
Epoetin with hct = 24
Epoetin with hct = 25
Epoetin with hct = 26
Epoetin with hct = 27
Epoetin with hct = 28
Epoetin with hct = 29
Epoetin with hct = 30
Epoetin with hct = 31
Epoetin with hct = 32
Epoetin with hct = 33
Epoetin with hct = 34
Epoetin with hct = 35
Epoetin with hct = 36
Epoetin with hct = 37
Epoetin with hct = 38
Epoetin with hct = 39
Epoetin with hct >= 40
Injection, butorphanol tartr
Octreotide 100 mcg
Inj urofollitropin 75 iu
Inj c gonadotropin 5000 iu
Trach shower protector
Trach tube holder
Nonaspheric lens bifocal
Aspheric lens bifocal
Lens lenticular nonaspheric
Lens lenticular aspheric bif
Lens lenticular nonaspheric
Lens lenticular aspheric tri
Rose tint plastic
Non-rose tint plastic
Rose tint glass
Non-rose tint glass
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
20040401
5
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
20031231
12/22/2003
Appendix D
Code
S9150
Description
Evaluation by ocularist
Eff Date
20020401
S9484
S9490
S9900
Crisis intervention per hour
HIT corticosteroid/diem
Christian Sci Pract visit
20020701
20020701
20020701
S0104
S0201
S0207
S0315
S0316
S0320
S1040
S2262
S2265
S2266
S2267
S3655
Zidovudine, oral, 100 mg
Partial hospitalization serv
Paramedicintercep nonhospals
Disease management program
Follow-up/reassessment
RN telephone calls to DMP
Cranial remolding orthosis
Abortion maternal indic>=25w
Abortion 25-28wks fetal indi
Abortion 29-31wks fetal indi
Abortion >=32wks fetal indic
Antisperm antibodies test
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
20021001
S5100
S5101
S5102
S5105
S5110
S5111
S5115
S5116
S5120
S5121
S5125
S5126
S5130
S5131
S5135
S5136
S5140
S5141
S5145
S5146
S5150
S5151
S5160
S5161
S5162
S5165
S5170
S5175
S5180
S5181
S5185
S5190
Adult daycare services 15min
Adult day care per half day
Adult day care per diem
Centerbased day care perdiem
Family homecare training 15m
Family homecare train/sessio
Nonfamily homecare train/15m
Nonfamily HC train/session
Chore services per 15 min
Chore services per diem
Attendant care service /15m
Attendant care service /diem
Homaker service nos per 15m
Homemaker service nos /diem
Adult companioncare per 15m
Adult companioncare per diem
Adult foster care per diem
Adult foster care per month
Child fostercare th per diem
Ther fostercare child /month
Unskilled respite care /15m
Unskilled respitecare /diem
Emer response sys instal&tst
Emer rspns sys serv permonth
Emer rspns system purchase
Home modifications per serv
Homedelivered prepared meal
Laundry serv,ext,prof,/order
HH respiratory thrpy in eval
HH respiratory thrpy nos/day
Med reminder serv per month
Wellness assessment by nonph
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
20030101
1
12/22/2003
Appendix D
S5199
S8004
Personal care item nos each
Wholebody radiopharm trgcell
20030101
20030101
H2010
H2011
H2012
H2013
H2014
H2015
H2016
H2017
H2018
H2019
H2020
H2021
H2022
H2023
H2024
H2025
H2026
H2027
H2028
H2029
H2030
H2031
H2032
H2033
H2034
H2035
H2036
H2037
S0136
S0137
S0138
S0139
S0140
S0141
S2090
S2091
S3000
S3820
S3822
S3823
S3828
S3829
S3833
S3834
S5108
S5109
S8460
S8990
S9434
Comprehensive med svc 15 min
Crisis interven svc, 15 min
Behav hlth day treat, per hr
Psych hlth fac svc, per diem
Skills train and dev, 15 min
Comp comm supp svc, 15 min
Comp comm supp svc, per diem
Psysoc rehab svc, per 15 min
Psysoc rehab svc, per diem
Ther behav svc, per 15 min
Ther behav svc, per diem
Com wrap-around sv, 15 min
Com wrap-around sv, per diem
Supported employ, per 15 min
Supported employ, per diem
Supp maint employ, 15 min
Supp maint employ, per diem
Psychoed svc, per 15 min
Sex offend tx svc, 15 min
Sex offend tx svc, per diem
MH clubhouse svc, per 15 min
MH clubhouse svc, per diem
Activity therapy, per 15 min
Multisys ther/juvenile 15min
A/D halfway house, per diem
A/D tx program, per hour
A/D tx program, per diem
Dev delay prev dp ch, 15 min
Clozapine, 25 mg
Didanosine, 25 mg
Finasteride, 5 mg
Minoxidil, 10 mg
Saquinavir, 200 mg
Zalcitabine, 0.375 mg
Open cryosurg renal
Perc cryosurg renal
Bilat dil retinal exam
Comp BRCA1/BRCA2
Sing mutation brst/ovar
3 mutation brst/ovar
Comp MLH1 gene
Comp MLH2 gene
Comp APC sequence
Sing mutation APC
Homecare train pt 15 min
Homecare train pt session
Camisole post-mast
Pt or manip for maint
Mod solid food suppl
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
20030401
2
12/22/2003
Appendix D
T2010
T2011
PASRR Level I
PASRR Level II
20030401
20030401
S0317
S3625
S3840
S3841
S3842
S3843
S3844
S3845
S3846
S3847
S3848
S3849
S3850
S3851
S3852
S9335
Disease mgmt per diem
Maternal triple screen test
DNA analysis RET-oncogene
Gene test retinoblastoma
Gene test Hippel-Lindau
DNA analysis factor v
DNA analysis deafness
Gene test alpha-thalassemia
Gene test beta-thalassemia
Gene test Tay-Sachs
Gene test Gaucher
Gene test Niemann-Pick
Gene test sickle cell
Gene test canavan
DNA analysis APOE alzheimer
HT hemodialysis diem
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
20030701
C9207
S2070
S2213
S2230
S2235
S5550
S5551
S5552
S5553
S5560
S5561
S5565
S5566
S5570
S5571
S8120
S8121
S9476
T2012
T2013
T2014
T2015
T2016
T2017
T2018
T2019
T2020
T2021
T2022
T2023
T2024
T2025
Injection, bortezomib
Cysto laser tx ureteral calc
Implant gastric stim
Implant semi-imp hear
Implant auditory brain imp
Insulin rapid 5 u
Insulin most rapid 5 u
Insulin intermed 5 u
Insulin long acting 5 u
Insulin reuse pen 1.5 ml
Insulin reuse pen 3 ml
Insulin cartridge 150 u
Insulin cartridge 300 u
Insulin dispos pen 1.5 ml
Insulin dispos pen 3 ml
O2 contents gas cubic ft
O2 contents liquid lb
Vestibular rehab per diem
Habil ed waiver, per diem
Habil ed waiver per hour
Habil prevoc waiver, per d
Habil prevoc waiver per hr
Habil res waiver per diem
Habil res waiver 15 min
Habil sup empl waiver/diem
Habil sup empl waiver 15min
Day habil waiver per diem
Day habil waiver per 15 min
Case management, per month
Targeted case mgmt per month
Serv asmnt/care plan waiver
Waiver service, nos
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
3
12/22/2003
Appendix D
T2026
T2027
T2028
T2029
T2030
T2031
T2032
T2033
T2034
T2035
T2036
T2037
T2038
T2039
T2040
T2041
T2042
T2043
T2044
T2045
T2046
T2048
90918
90925
A4570
A4580
A4590
C1080
C1081
C1082
C1083
C1713
C1714
C1715
C1717
C1721
C1722
C1724
C1725
C1726
C1727
C1728
C1729
C1730
C1731
C1732
C1733
C1750
C1751
C1752
C1753
Special childcare waiver/d
Spec childcare waiver 15 min
Special supply, nos waiver
Special med equip, noswaiver
Assist living waiver/month
Assist living waiver/diem
Res care, nos waiver/month
Res, nos waiver per diem
Crisis interven waiver/diem
Utility services waiver
Camp overnite waiver/session
Camp day waiver/session
Comm trans waiver/service
Vehicle mod waiver/service
Financial mgt waiver/15min
Support broker waiver/15 min
Hospice routine home care
Hospice continuous home care
Hospice respite care
Hospice general care
Hospice long term care, r&b
Bh ltc res r&b, per diem
I-131 tositumomab, dx
I-131 tositumomab, tx
In-111 ibritumomab tiuxetan
Yttrium 90 ibritumomab tiuxe
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20031001
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
4
12/22/2003
Appendix D
C1754
C1755
C1756
C1757
C1758
C1759
C1760
C1762
C1763
C1764
C1766
C1767
C1768
C1769
C1770
C1771
C1772
C1773
C1776
C1777
C1778
C1779
C1780
C1781
C1782
C1784
C1785
C1786
C1787
C1788
C1789
C1813
C1815
C1816
C1817
C1874
C1875
C1876
C1877
C1878
C1879
C1880
C1881
C1882
C1883
C1885
C1887
C1891
C1892
C1893
C1894
C1895
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
5
12/22/2003
Appendix D
C1896
C1897
C1898
C1899
C2615
C2617
C2619
C2620
C2621
C2622
C2625
C2626
C2627
C2628
C2629
C2630
C2631
C9210
C9211
C9212
S0107
S0115
S2085
S2095
S2113
S2135
S2225
S2362
S2363
S3853
S8075
S8948
T2101
T5001
T5999
Injection, palonosetron HCL
Inj, alefacept, IV
Inj, alefacept, IM
Inj, omalizumab 25 mg
Bortezomib 3.5 mg
Laparoscop gastric bypass
Transcath emboliz microspher
Arthro chondrocyte implant
Neurolysis interspace foot
Myringotomy laser-assist
Kyphoplasty, first vertebra
Kyphoplasty, each addl
Gene test myo musclr dyst
CAD of digital mammogr
Low-level laser trmt 15 min
Breast milk proc/store/dist
Special position seat/vehicl
Supply, nos
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
0001F
0002F
0003F
0004F
0005F
0006F
0007F
0008F
0009F
0010F
0011F
Blood pressure, measured
Tobacco use, smoking, assess
Tobacco use, non-smoking
Tobacco use txmnt counseling
Tobacco use txmnt, pharmacol
Statin therapy, prescribed
Beta-blocker thx prescribed
Ace inhibitor thx prescribed
Assess anginal symptom/level
Assess anginal symptom/level
Oral antiplat thx prescribed
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
20040101
6
12/22/2003
Appendix E
Code
A4221
A4222
A4230
A4231
A4232
A4253
A4254
A4255
A4256
A4258
A4259
A4265
A4556
A4557
A4558
A4595
A4611
A4612
A4613
A4615
A4616
A4617
A4618
A4619
A4620
A4621
A4624
A4628
A4630
A4631
A4635
A4636
A4637
A4640
A7000
A7001
A7002
A7003
A7004
A7005
A7006
A7007
A7008
A7009
A7010
A7011
A7012
A7013
A7014
A7015
A7016
EffDate
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
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8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
1
12/22/2003
Appendix E
A7017
E0100
E0105
E0110
E0111
E0112
E0113
E0114
E0116
E0130
E0135
E0141
E0142
E0143
E0144
E0145
E0146
E0147
E0153
E0154
E0155
E0156
E0157
E0158
E0159
E0160
E0161
E0162
E0163
E0164
E0165
E0166
E0167
E0175
E0176
E0177
E0178
E0179
E0180
E0181
E0182
E0184
E0185
E0186
E0187
E0188
E0189
E0191
E0192
E0193
E0194
E0196
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
2
12/22/2003
Appendix E
E0197
E0198
E0199
E0200
E0202
E0205
E0210
E0215
E0217
E0218
E0220
E0225
E0230
E0235
E0236
E0238
E0239
E0249
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0271
E0272
E0275
E0276
E0277
E0280
E0290
E0291
E0292
E0293
E0294
E0295
E0296
E0297
E0305
E0310
E0325
E0326
E0371
E0372
E0373
E0424
E0431
E0434
E0439
E0441
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
3
12/22/2003
Appendix E
E0442
E0443
E0444
E0450
E0455
E0457
E0459
E0460
E0462
E0480
E0500
E0550
E0555
E0560
E0565
E0570
E0575
E0580
E0585
E0590
E0600
E0601
E0602
E0605
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
E0606
E0607
E0608
E0609
E0610
E0615
E0621
E0627
E0628
E0629
E0630
E0635
E0650
E0651
E0652
E0655
E0660
E0665
E0666
E0667
E0668
E0669
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
4
12/22/2003
Appendix E
E0671
E0672
E0673
E0690
E0720
E0730
E0731
E0740
E0744
E0745
E0747
E0748
E0760
E0776
E0779
E0780
E0781
E0784
E0791
E0840
E0850
E0855
E0860
E0870
E0880
E0890
E0900
E0910
E0920
E0930
E0935
E0940
E0941
E0942
E0943
E0944
E0945
E0946
E0947
E0948
E0962
E0963
E0964
E0965
E0967
E0968
E0969
E0977
E0980
E0994
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
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8/1/2000
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8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
5
12/22/2003
Appendix E
E0997
E0998
E0999
E1001
E1031
E1065
E1210
E1211
E1225
E1227
E1228
E1230
E1296
E1297
E1298
E1310
E1340
E1353
E1355
E1372
E1375
E1377
E1378
E1379
E1380
E1381
E1382
E1383
E1384
E1385
E1390
E1399
E1405
E1406
E1700
E1701
E1702
E1800
E1805
E1810
E1815
E1820
E1825
E1830
J2545
J7608
J7618
J7619
J7628
J7629
J7631
J7635
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
6
12/22/2003
Appendix E
J7636
J7637
J7638
J7639
J7642
J7643
J7644
J7648
J7649
J7658
J7659
J7668
J7669
J7680
J7681
J7682
J7683
J7684
J7699
J7799
K0001
K0002
K0003
K0004
K0005
K0006
K0007
K0009
K0010
K0011
K0012
K0014
K0015
K0016
K0017
K0018
K0019
K0020
K0021
K0022
K0023
K0024
K0025
K0026
K0027
K0028
K0029
K0030
K0031
K0032
K0033
K0034
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
7
12/22/2003
Appendix E
K0035
K0036
K0037
K0038
K0039
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0048
K0049
K0050
K0051
K0052
K0053
K0054
K0055
K0056
K0057
K0058
K0059
K0060
K0061
K0062
K0063
K0064
K0065
K0066
K0067
K0068
K0069
K0070
K0071
K0072
K0073
K0074
K0075
K0076
K0077
K0078
K0079
K0080
K0081
K0082
K0083
K0084
K0085
K0086
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8
12/22/2003
Appendix E
K0087
K0088
K0089
K0090
K0091
K0092
K0093
K0094
K0095
K0096
K0097
K0098
K0099
K0100
K0101
K0102
K0103
K0104
K0105
K0106
K0107
K0108
K0114
K0115
K0116
K0182
K0183
K0184
K0185
K0186
K0187
K0188
K0189
K0195
K0268
K0269
K0270
K0283
K0452
K0455
K0456
K0457
K0458
K0459
K0460
K0461
K0462
K0501
K0529
K0531
K0532
K0533
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
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8/1/2000
8/1/2000
8/1/2000
8/1/2000
9
12/22/2003
Appendix E
K0534
L3964
L3965
L3966
L3968
L3969
L3970
L3972
L3974
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
8/1/2000
A4608
A7018
A7019
A7020
E0148
E0149
E0168
E0571
E0572
E0574
E0617
E0765
E1035
K0538
K0539
K0540
K0541
K0542
K0543
K0544
K0545
K0546
K0547
1/1/2001
1/1/2001
1/1/2001
1/1/2001
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1/1/2001
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1/1/2001
1/1/2001
1/1/2001
1/1/2001
1/1/2001
1/1/2001
1/1/2001
1/1/2001
1/1/2001
K0549
K0550
4/1/2001
4/1/2001
K0551
7/1/2001
A4257
E0169
E0221
E0316
E0482
E0620
E1801
E1806
E1811
E1816
E1818
E1821
E1840
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
4/1/2002
10
12/22/2003
Appendix E
E2000
E2100
E2101
4/1/2002
4/1/2002
4/1/2002
A4609
A4610
A4632
A4633
A4639
A7025
A7026
A7030
A7031
A7032
A7033
A7034
A7035
A7036
A7037
A7038
A7039
A7044
E0117
E0454
E0461
E0483
E0484
E0636
E0691
E0692
E0693
E0694
E0701
E1011
E1012
E1013
E1014
E1015
E1016
E1017
E1018
E1020
E1025
E1026
E1027
E1037
E1038
E1231
E1232
E1233
E1234
E1235
1/1/2003
1/1/2003
1/1/2003
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1/1/2003
1/1/2003
1/1/2003
1/1/2003
11
12/22/2003
Appendix E
E1236
E1237
E1238
E1802
1/1/2003
1/1/2003
1/1/2003
1/1/2003
A4638
A6550
A6551
A7046
A9999
E0140
E0300
E0301
E0302
E0303
E0304
E0470
E0471
E0472
E0561
E0562
E0637
E0638
E0675
E0955
E0956
E0957
E0960
E0981
E0982
E0983
E0984
E0985
E0986
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010
E1019
E1021
E1028
E1029
E1030
E1391
E2120
E2201
E2202
1/1/2004
1/1/2004
1/1/2004
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1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
12
12/22/2003
Appendix E
E2203
E2204
E2300
E2301
E2310
E2311
E2320
E2321
E2322
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2331
E2340
E2341
E2342
E2343
E2350
E2351
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2367
E2399
E2402
E2500
E2502
E2504
E2506
E2508
E2510
E2511
E2512
E2599
J7621
K0552
K0600
K0601
K0602
K0603
K0604
K0605
K0606
1/1/2004
1/1/2004
1/1/2004
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1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
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Appendix E
K0607
K0608
K0609
K0610
K0611
K0612
K0613
K0614
K0615
K0616
K0617
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
1/1/2004
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