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Utah Provider Manual for Primary Care Plan
Division of Health Care Financing
Updated April 2005
Primary Care Network
Table of Contents
SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 - 1 Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 SCOPE OF SERVICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 - 1 Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Limitations for Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Observation services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 - 4 Minor Surgery and Anesthesia in an Outpatient Setting . . . . . . . . . . . . . . . . . . . . . . . . 9 Laboratory and Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Durable Medical Equipment and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Preventive Services and Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2 - 10 Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 - 11 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 - 12 Transportation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 - 13 Interpretive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 - 14 Audiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Non Covered Services under the Primary Care Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 C Authorized Diagnoses for Emergency Department Reimbursement C CLIA Certificates, Excluded Codes and CLIA Waiver Kits C Approved Medical and Surgical Procedures for the Primary Care Plan with Pertinent Criteria C Example of Primary Care Network Identification Card Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2005
SERVICES
The Primary Care Plan serves a po pulation no t previously eligible for M edicaid. T he S cop e of S ervice is lim ited toba sic medical service of a general nature to provide preventive and palliative care in an outpatient, office setting.
Services in the office should comport with the definition of Primary Care found in Utah Administrative Code R414-100-2(3) . Verification
Qualified persons receive a yellow Primary Care Network Identification card.
Authority
The Primary Care Plan is authorized by a waiver of federal Medicaid requirements approved by the federal Centersfor Medicare and Medicaid Services and allowed under 42 CFR 4.35.1115, 2000-edition. This rule is authorized byTitle 26, Chap ter 18 , Utah Co de A nno tated . Definitions
“Clien t” means a person the Division or its duly constituted agent has determined to be eligible for assistanceunder the Medicaid program.
“CLIA” means the Clinical Laboratory Improvement Amendm ents of 1988.
“CMS” m eans the Centers for Medicare and Medicaid Services.
“Code of Federal Regulation” (CFR) means the publication by the Office of the Federal Re gis ter, sp ec ificallytitled 42, used to govern the administration of the Medicaid program.
“Division” means the Division of Health Care Financing within the Department of Health.
“Em erge nc y” m eans the su dden on set of a medical condition, traumatic injury or illness manifesting itself byacu te sym ptoms of sufficient severity (including severe pain) such that the absence of imm ediate medicalattention could reasonably be expected to result in: placing the client’s h ealth in serio us je opa rdy; serious dysfunction of any bodily organ or part; or “E mergency Department Service” means service provided in a designated acute care general hospitalem erge ncy depa rtm ent.
Attention provided within 24 hours of the onset of symptom s or within 24 hours of mak ing a diagnosis; A condition that requires acute care, and is not chronic; It is reimbursed only until the condition is stabilized sufficient that the patient can leave the hospitalemergency department; and It is not related to an organ transplant procedure.
“O utpa tient” means a client who is not admitted to a facility, but receives services in a private office or clinic.
10. “Outpatient setting” means the physician’s office.
Utah Provider Manual for Primary Care Plan
Division of Health Care Financing
Issued July 2002
11. “Prima ry Ca re” m ea ns servic es to d iagno se and trea t illness and injury as well as preventive health care services. Primary care promotes early ide ntif ication a nd tre atm ent o f hea lth prob lem s, wh ich can h elp toredu ce u nne ces sary com plication s of illnes s or injury and m aintain or im prov e overall he alth sta tus. 12. “Prima ry Care Provider System” means those services provided directly by the physician or by his staff, under 13. “Provider” means any person , ind ividua l, corporation, institution or organization, qualified to perform services available und er the Me dicaid program and who has entered into a written contract with the Medicaid program.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated July 2003
SCOPE OF SERVICE
Physician Services
Physician services provide for the basic m edical needs of eligible individuals and must be provided within theparameters of accepted medical practice. Physician services may be provided directly by the physician or by otherprofes sio na ls – licensed certified nurse practitioners, or physician assistants, authorized to serve the health care needsof the prac tice po pulation thro ugh an a ppro ved sco pe o f ser vice u nde r the p hysician’s supe rvision . Providers of Primary care service are limited to those physicians who are prepared in: Fam ily Practice,General Practice,Internal Medicine,Obstetrics and Gynecology, and Pediatrics.
In addition, providers of phys ician s ervices in F ede rally Qu alified H ealth C ente rs, R ural H ealth C linics, Lo cal H ealthDepartment clinics, an d H ea lth C linics of Utah can provide service based on the Scope of Service and codesdeveloped for the Primary Care Network program.
Physician services include those that can be performed in an outpatient setting.
The CPT M anual is the standard for defining and coding physician services. Under the provisions of this Plan,not all procedures are acceptable, e.g., experimental, cosmetic, or those not reasonable, medically necessary orcost effective. Nonspecific or unlisted codes require physician review because of the potential for use to coverothe rwise non -covere d se rvices. The Approved Medical and Surgical Procedures for the Primary Care Plan with Pertinent Criteria (“PCN - CPT Code List”) is im plem en ted into this pro gram . This list serves as a guide as well as a safe gua rd to ina ppro priateutilization. The list outlines those procedures which are excluded because they are experimental, ineffective,cos m etic, or n ot rea son able and m edically nece ssa ry. (List attac hed .) The CPT office visit, Evaluation and Management codes (99201 - 99215) for either new or established patien tsare appropriate for the office services claims under this plan.
In general, both office visit and service codes will not pay for same dates of service.
Lic en se d certified fa m ily or p ed iatric nurse pra ctitio ne rs are lim ited , un de r this Medicaid Scope of Practice, to acooperative, ambulatory, office type, wo rking relationsh ip with a physician. W hen employed by the physician, thephysician bills for the service.
Physician assistants work under the supervision of a physician to provide service to patients within the practicepopulation.
Physicians providing service in the Emergency Department will use CPT Codes 99281 - 99285 to bill for services.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated January 2004
Limitations for Physician Services
The CPT M anual is the standard for defining and coding physician services. However, not all procedu res arecovered under this plan, e.g., experimental, ineffective, cosmetic, or those not cost effective, reasonable orm ed ica lly nece ss ary.
Use of nonspecific or unlisted codes to cover pro ce du res not o the rwise liste d in the CP T Man ua l req uire M ed ica idphysician consultant review and approval because of the potential for use to cover otherwise non-coveredservices.
Services are limited to those included in the “PCN - CPT Code List” with criteria.
Evaluation/Management office visit codes (CPT) for new and a (99201 - 99215) must be used appropriately onclaim s for serv ice. Of fice vis it code s (E /M) and serv ice code s (10 060 - 699 90) w ill not be pa id on th e sa m e da te of s ervice. Services identified by the 9000 0 series of c od es are spec ialty m ed ica l servic es and w ill be limited only to thosethat can be safely provided in the physician’s office.
After-hours office visit codes cannot be used in a hospital setting, including emergency department, by private orstaff physicians. They cannot be used for standby for surgery, delivery, or other similar circumstances, and theycan not b e us ed w hen see ing a n ew p atient. Cogn itive services are limited to one se rvice per day by the same provider.
Modifier 25 will not be recognized as a stand-alone entity to override the one service per day limitation.
10. Laboratory services provided by a physician in the office are limited to the approved kits, waived tests or those laboratory tes ts id en tified by CMS for which an individual physician is CLIA certified to provide and listed in the“PC N -C PT Co de L ist.” 11. Unspecified laboratory codes will no longer be accepted when there is a specific test available. The specific test must be ordered to receive reimbursem ent. For example: The cod e 87 660 –T richo m ona s vaginalis, direct probe, must be used; the code 87797–Infectious agent nototherwise specified; direct probe technique will no longer be accepted when the test completed is Trichomonasvaginalis, direct prob e. Th is also app lies to the Affirm Te st. The code 87800–Infectious agent detection, directprobe technique will no longer be accepted when the test is Chlamydia trachomatis, direct probe. The code87490–Chlamydia trachomatis, direct probe must be used.
12. A specim en collection fee is limited only to venipuncture specimens drawn under the supervision of a physician to be sent outside of the office for processing. Any blood test obtained by hee l or finger stic k w ill post a m utu allyexclusive edit with 36415 –venipuncture. The following codes have been added as mutually exclusive to 36415:82948–blood glucose, reagent strip, 85013–spun hematocrit, 85014–hematocrit, 85610–Prothrombin time,83036–glycated hemoglobin, and 86318 –imm unoassay for infectious agent by reagent strip when sub m itted withthe m odifier QW . 13. Over-the-counter drugs and medications are limited to those on the list of covered OTC drugs estab lished for this plan. Refer to Chapter 2 - 6, Pharmacy Services.
14. Vitamins are lim ited to coverage for pre gn an t wo m en . Vita m in B -12 is limited to patients with pernicious anemia.
15. Drugs and biologicals are limited to those approved by the Food and Drug A dm inis tration or the local Drug Utilization Review Board which has the authority to approve off label use of drugs.
The pneumovax vaccine must be separated by more than five years. W hen given sooner than five years, there
are adverse reactions which may occur from this vaccine. For updates on adult vaccination visit the Centers forDisease Control and Prevention web site at http://www.cdc.gov/nip/recs/adult-schedule.pdf 16. Additional paym ent fo r services is limited to those cases where the circumstances are so unusual and severe that excess time is required to safely monitor and treat the patient. Docum entation in the medical rec ord m us t cle arlyshow the extenuating circumstances and the unusual time com mitment to warrant medical review andcon sideration for ad ditiona l reim burs em ent.
17. Medical and Surgical Procedures identified by CPT code m ay only be provided by the physician or osteopath.
Procedures may not be completed by ancillary personnel including nurse practitioners and physician assistants.
18. Medical serv ices prov ided by oph thalm ologists or opto m etrists are limited to codes 92002, 92004, 92012, 92014, 92020, 92083, 92135, 99201- 99205, 99211-99215 Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2004
Hospital Services
The Primary Care Plan does not cover inpatient or outpatient hospital services except for emergency services in a
des ignated a cute care gen eral hosp ital em erge ncy depa rtm ent.
Revenue Codes and ICD.9.CM diagnosis codes are the main means of documentation for these services. RevenueCodes appropriate to be covered for emergency service are: All other revenue codes are non-covered.
In addition, the current Medicaid Authorized Diagnoses for Emergency Department Reimbursement list is incorporated as approved emergency department care. Any code other than one of those listed would be a non-covered serviceresulting in no paym en t be ing m ad e. If the determ ination is m ad e th at th e visit is not for a bonafide emergency, andno service is provided, revenue code 458 (Triage fee) can be billed and a nominal payment can be made to thehospital for the evaluatio n and determ ination . The diagn os es in the A uth orized Em erge nc y Dep artm en t list areICD.9.CM codes. (List Attached.) Physicians providing service in the Emergency Department will use CPT Codes 99281 - 99285 to bill for services.
Observation services are limited to cases where time is needed for observation and evaluation to establish adiagnos is and /or the app ropr iatene ss o f an inpatien t adm ission . Observation services are defined as use of a bed and periodic patient monitoring, on the hospital’s premises, byhospital nursing or other appropriate staff. O bs ervation servic es are cons idered re as on ab le and m ed ica llynecessary when needed to evaluate an outpatient’s condition and assess the need for possible inpatientadmission. Observation services are covered only under physician’s written orders.
[Ta ke n from UB -92 B illing In struc tion M anu al.] Observation Services, under Medicaid, are limited to 24 hours or less.
A patient arrives at the facility in an unstable condition with vague symptoms which do not point to adefinitive diagnosis. Observation and testing are indicated to identify the nature of the complaint andestablish a treatment plan.
An unusual reaction follows an outpatient surgical procedure and requires monitoring or treatment beyondthat custo m arily pro vided in the imm ediate post operative period, i.e., a drug reaction; delayed recoveryfrom ane sthe sia; or acu te pa in unreso lved b y usual m edication a dm inistration . A significant, adverse reaction, above and beyond the usual response expected as a result of a scheduleddiagnostic test or outpatient therapeutic services.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2004
Ob servation Service m ust b e m edically nece ssa ry, and the fo llowing criteria a nd g uidelines m ust b e m et: Reason for observation must be stated in the physician’s orders for observation Pa tien t’s c on ditio n is clinica lly unsta ble as charac terized by: T Variance from generally accepted, safe laboratory values, or1.
Clinical signs and symptoms above or below those of normal range which indicates need forevaluation and monitoring, or 2. Uncertain severity of illness or condition exists. Change in status is anticipated and imm ediate medical intervention may be needed.
La bo ratory, radiologic, or other testing is necessary in order to assess the patient’s need forhospitalization.
Diagnosis and treatment plan are undefined until further evaluation is completed.
Docum entation in the medical record must support the m edical nec ess ity of observation services and justify theam oun t of tim e sp ent in o bse rvation . Doc um enta tion m ust inc lude, but is not lim ited to: The written physician’s orderThe differential diagnosis(es)Signs and symptoms; vital signs; lab values, etc.
Docum ented complicationsReco rded obs ervations and interventions (tests, x-rays, EKG, etc.),Findings/Response to interventionsInterval assessments and chartingStatus change - improvem ent/deteriorationRecorded time in and time out Observation services mus t be p atient spe cific an d no t part of stan dard ope rating proc edu re or facilityprotocol for a given diagnosis or service.
Use of observation status to submit ancillary charges associated with outpatient surgery, other outpatientdiagnos tic services , or other ou tpatien t stays fo r any re aso n is ex cluded from reim burs em ent. Observation services are limited only to those provided under orders specifically written by the physicianor othe r provider a utho rized to a dm it patients to the hospital or to order outpatient tests. Reason for theobservation service m ust be clearly stated in the order.
Observation services are not co vered fo r the con venienc e of the hos pita l, ph ysic ians, p atie nts , or patien t’sfam ilies or w hile aw aitin g plac em en t in ano the r he alth care fac ility.
Observation services are limited to 24 hours or less total time. An outpatient procedure -- surgical and/ordiagnostic, which becomes an observation because of a complication or an adverse reaction must meetthe 24 hour limitation. As the 24 time limit approaches, the need for admission or discharge must bedetermined throu gh use of the M ed ica id ag en cy standard criteria, if applicable, or through severity ofillness and intensity of service criteria.
W hen a patie nt is admitted to the hospital at the end of the observation period, observation services arerolled into the admission DRG.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2004
Observation services can not be covered or billed for routine preoperative preparation associated with anoutpatient surgery. These services are included as part of the surgical procedure and do not warrantadd itional pa ym ent.
Observation services can not be covered or billed for the routine preparation time before a scheduledinvasive outp atient diagnostic procedure or the recovery period following the procedure. For mostprocedu res, this tim e is included in the procedure itself.
Scheduled ongoing therapeutic services associated with a known medical condition include a requiredperiod of tim e to evaluate response to the service. This period of evaluation is not a separate observationservice and must not be billed as such.
Outpatient administration of blood or IV fluids associated with no other medical treatment does not qualifyas an o bse rvation serv ice. T he u se o f the h osp ital facilities, including staff time, is inherent in theadministration of the blood or fluids and is included in the payment for the administration of the blood orfluids.
Outpatient servic es for dre ss ing chan ge s, IV adm inistration or m ed ica tion adm inistration as follow-up ca rerelated to a surgical procedure and within the normal recovery period following surgery (42days) are therespon sibility of the surgeon, and do not qualify as separate hospital observation or treatment services.
Un its are not required for billing or payme nt of observation services. The important parameters are aclear reco rding of ad m ission time an d disc harg e tim e alon g with detailed recording of services providedduring the observation time.
Under no circumstances can an observation stay be extended to more than 24 hours. It is not expectedthat a patient would be discharged in the event the 24 hour time limit would be reached after midnight orinto the early m orning hou rs, bu t the additio na l tim e doe s not w arrant a n add ition al day stay.
The re are circ um sta nc es in whic h a patien t is admitted to inpatient service with the intent of rem aining mo rethan 24 hours and later improves to the point discharge is indicated. The stay may be covered and billed asObservation providing all criteria for observation admission are met, including the hospital adm ission order,and documentation in the medical record is consistent with that noted above as justification and support ofmedical necessity for observation.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated July 2003
Minor Surgery and Anesthesia in an Outpatient Setting
For the purposes of this program, outpatient setting m ea ns only in the phys ician’s office. Only those procedures thatcan be safely provided in the physician’s office can be covered.
Laboratory and Radiology Services
Professional and technical laboratory and radiology services are furnished by certified providers with use of the 70000and 80000 series of codes.
For this pro gram , lab orato ry an d ra diology pro ce du res w ill be limited to those which can be provided through the“Primary Care Provider system,” i.e., in the physician’s office.
Laboratory services are limited und er federa l CLIA regu lations . All laboratory testing sites providing services musthave either a Clinical Laboratory Improvement Amendm ents (CLIA) certificate of waiver or a certificate ofregistration along with a C LIA identification number. Only laboratories CLIA certified can com plete c ertain testsand rece ive pa ym ent. (P CN CL IA List attached .) Som e laboratory and radiology procedures are non-covered because they relate to otherwise non-coveredservices. The “PCN -CPT Code List” indicates covered service.
CPT code 80074, acute hepatitis panel, includes four other cod es: 8 6709, 86705, 87340, and 86803. W henthree of the fou r codes are billed, th ey w ill be reb un dled into th e acu te h ep atitis panel code 800 74 fo r paym ent.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2005
Pharmacy Services
The Medicaid Pharmacy Policy as set forth in the Utah Provider Manual for Pharmacy Services is hereby adopted forthe Primary Care group of clients with the following changes. Coverage is more restrictive for units and time.
Pharmacy services include prescribed drugs and preparations provided by a licen sed pha rm acy. T he fa ct tha t aprovider may prescribe, order, or approve a prescription drug, service, or supply does not m ak e it an e ligible ben efit,even tho ug h it is not sp ec ifically listed as an exclu sio n. T he follo win g pha rm ac y benefits and restrictions areincorporated into this program.
This program is limited to four prescriptions per month, per client with no overrides or exceptions in thenumber of prescriptions.
OT C p rescription s co unt a gainst the 4R X/m onth limit.
C. A patient paid prescription is not counted as one of the four prescriptions per month.
D. Th e co pay is p rodu ct de pen den t: (1) $5.0 0 co pay fo r any gene ric pro duc t.
(2) $5.0 0 co pay fo r the p refe rred drug s on the attach ed list.
(4) 25% of the Medicaid payment for any name brand drug not on the preferred list where a generic product (5) 25 % of the Med ica id paym en t for an y pro du ct th at is in the same therapeutic class as a product on the W hen a generic product is available and the name brand is requested and the name brand is NOT on thepref erre d list, the total paym ent m ust b e m ade by the c lient.
Prior app rova l and th e criteria govern ing su ch a re the sam e as the re gular Medicaid progra m . G. Generic drugs with an A B rating are mandated for dispensing.
H. N am e brand drugs where generics are available will require full payment by the c lient. No physic ian DA W is Over-the-counter products . The ex tent of thes e pro duc ts is m ore lim ited tha n reg ular M edicaid. Produ ctscovered are: Insulin 1 0cc vials; Ins ulin syring es; g lucose b lood test strips; lancets; contraceptive creams,foams, tablets, sponges, and condoms.
OTC products that are covered require a written pre sc ription jus t like legen d drugs in order for the pharmacyto fill them . No duplicate pre sc ription will be paid by Me dicaid for los t, stolen, spilled or otherwise non usable medications.
No injectable products are available for payment by Medicaid except for 10 ml vials of Insulin.
C. Com pounded prescriptions are not covered.
D. Drugs are covered fo r lab eled indic atio ns only.
Rap idly dissolving tablets, lozenges, suckers, pellets, patches, or other unique form ulations or deliverymethodologies are NO T available, except where the s pecific me dication is unavailable in any other form(Duragesic and Actiq - see chapter 2-6.3, Cumulative amounts). Patches are NOT reimbursable.
Cosm etics, weight gain or loss products are not covered.
G. No vitamins or minerals are covered, except for pregnant women.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2005
3. Cum ulative monthly amounts are determined for the following drugs: Morphine long acting formulations, any strength - 90 PPIs - 31 with prior approval for override.
m . Tryptans (for m igraine headache ) - 9n.
Ultracet 1 80 (focu s on AP AP , there fore includ ed in o ral AP AP /narc otic 18 0 cu m ulative lim it) Drugs on the current PCN Drug Criteria and Limits List require prior approval. List attached.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated January 2005
Durable Medical Equipment and Supplies
Equipment and app liance s are nec ess ary to as sist the patien t’s m ed ica l recovery, including both durable and non-du rable medical supplies and equipment. However, the Primary Care Plan waiver notes that “The fact that a providermay prescribe, order, recomm end, or approve a service or supply does not, of itself, make it an eligible benefit, eventhough it is not specifically listed as an e xclusion.” Th e follow ing co des represe nt covered equ ipm ent a nd s upp lies un der th is plan : A4259; A4565; A4490 - A4510; A4253; E0114; E0135 LL; A4570; A4614; E1390RR; K0001 LL; L0120; S8490.
Preventive Services and Health Education
The Primary Care Plan includes preventive screening services, including routine physical examinations andimm unizations, and educational methods and materials for promoting wellness, disease prevention and m ana gem ent.
These services are ass um ed unde r the general Evaluation and M anagem ent care provided to patients by the physicianduring m edical visits. T he s ervices inc lude cou nse ling, anticipatory guida nce , and /or risk factor reduction interventions.
Except for imm unization codes, no special programs or codes are covered. The intent is that these services be billedunder the general evaluation and managem ent codes and a co-pay should be collected.
Diabetes: Effective January 1, 2004 using code S9455 – Diabetes Self-Management Training Program will be
available for use by authorized diabetes self-ma nagem ent providers. Patient preauthorization is required to receive
diabetes self-managem ent training.
Patient Preauthorization:
A newly diagnosed patient with Type I, Type II, or gestational diabetes or a patient previously diagnosed with Type I
or Type II diabetes, is eligible to receive diabetes self-managem ent training through Medicaid when:
!
The physician provides a referral for the patient who has never had a diabetes self-managem ent training course.
Th e co urse is lim ited to ten se ssio ns. The patient completed the diabetes training at least 12 months ago, and the physician refers the patient for aspecified number of refresher diabetes training sessions because:" The patien t has prog ressed in diabetes illness to requ ire furth er m ana gem ent tra ining o r the p atient h asindica tions th ey are non com pliant w ith treatm ent.
Patient has complications of diabetes requiring two or more visits to the emergency room during the last sixm onth s or a hos pital adm ission related to diab etes within the last year. At preauthorization the following patient information should be provided:! Patient is informed of the importance of completing the series of classes and agrees to sign a contract agreementto m ak e every attem pt to fo llow thro ugh with ed uca tion se ssio ns. The patien t is inform ed th at if they do not c om plete the classes there is a one year waiting period before furtherclasses will be authorized.
Diab etes self-m ana gem ent tra ining m ust b e pro vided throu gh a state or na tionally rec ogn ized progra m . " As required by CMS, the Diabetes Self-Management Program must be taught by a state licensed RN, certifieddietician, and registered pharmacist. At least two of the three provider types are required to a pp ly to M ed ica idas a Diabetes Self-Management program and obtain a provider group practice number. Providers who maybecom e recogn ized fo r reim burs em ent inc lude an A DA certified diabe tes e duc ator (C DE ) or a U tah S tateDepa rtmen t of Health certified instructor.
A Utah State Department of Health certified instructor mus t have com pleted a m inimum of 24 hours of recentapproved diabetes spec ific continuing educa tion which covers the AD A 15 co re curriculum content areas. Atleast 6 hours of diabetic specific continuing education must be completed each year following the completionof the initial 24 hours by each instructor or certified diabetes educator in the program.
Each instructor (RN, pharmacist, or dietician) must be qualified to teach all of the 15 core content areas.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated July 2004
Immun izations:
Hepatitis B vaccine for imm unocomprom ised adult or adult dialysis patient Hep atitis A a nd He pa titis B com binatio n fo r ad ult Influenza virus vaccine, split virus, 3 yrs+, intram uscular Tetanus and diphth eria to xo ids (T d) Th is sho uld be m ain choic e bec au se of res urge nc e of dip hth eriain Eu rope . Va ricella for subcutaneous use for a varicella-exposed person who is not imm une, but not for use inim m uno com prom ised patien t.
Pneumococcal polysaccharide 23-valent vaccine adult or imm unosuppressed patient Lyme disease only if known exposure.
Family Planning Services
This serv ice inc ludes dissem inating inform ation, tre atm ent, m edications , sup plies, device s, an d re lated counselingin family planning methods to prevent or delay pregnancy. All services must be provided or authorized by a physician,or nurse practitioner and must be provided in con cert with U tah law . Refer to Chapter 2 - 17, Non Covered Servicesunder the Primary Care Plan.
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Division of Health Care Financing
Page Updated April 2004
2 - 10V ision C are
Services provided by licensed ophthalmologists or licensed optometrists, within their scope of practice. Coveredservices are limited to: Exam inations and refractions. No glasses will be covered.
The following codes are covered: 92002, 92004, 92012, 92014. The examination fee includes the refraction (glassesprescription).
Dental Services
Services include relief of pain and infection for dental emergenc ies limited to an emergency examination, anemergency x-ray, an d em erge nc y extractio n w he n th e service is pro vided by a dentis t in the office. Only the followingdental codes are covered: D0120 Periodic exam - 2 per year, no sooner than 6 m onths apartD0140 Limited exam, focused problem (emergency examination)D0150 Com prehensive oral exam, one per providerD0210 Intr a oral com plete s eries - inc luding bite win gs , total of 8 o r m ore film sD0220 Pe riapic al x-ra y 1 filmD0230 Pe riapic al x-ra y additio na l filmD0270 Bite win g singleD0272 Bite win g 2 film sD0274 Bite win g 4 film sD1110 Adult prophyD1205 Topical fluoride applicationD4355 Debridement for diagnosis - instead of prophy, one per yearD2140 Am algam 1 surface permanentD2150 Am algam 2 surface permanentD2160 Am algam 3 surface permanentD2161 Am algam 4+ surface permanent D2330 Resin 1 surface anteriorD2331 Resin 2 surface anteriorD2332 Resin 3 surface anteriorD2335 Resin 4+ s urface anterior D714 0, Extraction, erupted tooth or expose d root (elevation and/or forceps rem oval).
D7210 Extraction su rgica l, docu m ent n eed to lay flap, section tooth Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2004
Transportation Services
Am bu lance (grou nd and air) s ervice fo r m ed ica l em erge nc ies only.
Interpretive Services
Services pro vid ed by e ntitie s un der contra ct to M edicaid to provide m edical trans lation service for peo ple with
lim ited English proficiency and interpretive services for the deaf.
No specific codes are identified. W hen providers use the Medicaid authorized interpretive services, payment is madeto the entity under terms of the signed contract. Me dical providers ma y use their own interpreters. However,independent interpreters cannot bill nor be paid by Med icaid. If independen t interpreters are used, payment remainsthe responsibility of the provider who secured their services.
Audiology Services
Au diology servic es are lim ited to o ne hearing tes t for he aring loss ann ually.
V5010, assessment of hearing aid.
He aring aids a re no t a co vere d be nefit.
Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated July 2004
No n-C ov ered Serv ices u nd er the Prim ary Ca re Ne tw ork
Inpatient or outpatient hospital diagnostic, therapeutic, or surgical services, except for those in the emergencydep artm ent o r thos e very m inor procedu res whic h ca n be prov ided in the p hysician’s of fice. Procedures tha t are cos m etic , ex pe rim en tal, in vestig ationa l, ineffective or not within the limits of acceptedm edical practice. Health screenings or services to rule out familial diseases or conditions without manifest symptom s.
Medical or psychological evaluations or testing for legal purposes such as paternity suits, custodial rights, orfor insurance or employment examinations.
Non-emergency ambulance service through comm on or private aviation services.
Trans po rtation servic e fo r the con venienc e of the patie nt o r fa m ily.
Norplant: CPT procedure codes 11975, 11976, 11977 Infertility studies and reversal of sterilization: ICD.9.CM D iagnosis Codes: Male - 606.0 - 606.96CPT Procedure Codes: 54240, 54250, 54900, 54901, 55200, 55300, 55400.
ICD .9. CM Diag nos is Co des : Fem ale - 25 6.0 - 2 56.9 ; 628 .0 - 62 8.9CPT Procedure Codes: 58345, 58350, 58750, 58752, 58760, 58770 Assisted Reproductive Technologies (ART’s) (in-Vitro)ICD.9.CM diagnosis code: V26.1 and above infertility diagnosis codes.
ICD .9.CM p rocedu re co des : 66.1, 66.8, 6 9.92 , 87.82, 87 .83. CPT procedure codes are: 58321, 58322, 58323, 58970, 58974, 58976, 89250, 89251, 89253, 89254,89255, 89257, 89258, 89259, 89260, 89261, 89264, 89321 Genetic CounselingICD.9.CM diagnosis code: V26.3, V65.40, V25.09CPT Procedure codes for cytogenetic studies: 88230 - 88299 12. Office visit for allergy injections or other repetitive injections - Non-covered: Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated April 2004
17. Podiatric (podiatry) Services - Rou tine foot care 19. Medical and surgical services of a dentist 21. Charges incurred as an organ or tissue donor This exclusion applies regardless of whether services are recomm ended by a provider and includes thefollowing: Skilled Nursing ServiceSupportive maintenancePrivate duty nursingHom e health aideCustod ial careResp ite CareTravel or transportation expenses, escort services, or food services 24. Substance abuse and dependency services 28. Hom e and Comm unity-based W aiver services 30. Other outsid e m ed ica l servic es in free sta nd ing centers – Emergency centers (Insta-Care type), surgical Note: Any ICD.9.CM diagnosis or procedure codes related to any of the services in the preceding PCN Plan No n-C ove red S ervices List will also be no n-cove red. P aym ent o f suc h se rvices will be d enied. Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated July 2004
59050 - 59051 Fetal monitoring during labor 59150 - 59151 Ec top ic pregn an cy (La pa rosc op y) Vaginal Delivery, Antepartum , and Postpartum care 59 51 0, 5 95 14 , 59 51 5, a nd 5952 5 hyste recto m y follo win g delivery (em erge nc y) Other pregnancy related medical procedures 59899 Unlisted services/procedures76805 - 76828 Ultrasounds 59400 (22 m odifier) Global (v ag inal)59510 (22 modifier) Global (C-section)59410 (22 m odifier) De livery an d P os tpa rtum care only59515 (22 m odifier) C-se ctio n and Po stp artum care only Utah Provider Manual for Primary Care Network
Division of Health Care Financing
Page Updated October 2004
Enhanced Services - **These a re the servic es adde d und er the “Bab y Your Ba by” Program and are non- T1017, H1004, S9446, S9470, H0046Single Visits 99204-SB and 99212-SB CN M se rvices are not covered in PCN. W ell-W om an Ca re and C ontraceptive Man agem ent areonly covered when provided by a participating prim ary care provider.
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Division of Health Care Financing
Page Updated April 2004
Abortions and Sterilizations . . . . . . . . . . . . . . . . . . . 18 Durable Medical Equipment and Supplies . . . . . . . . 12 Additional payment for services . . . . . . . . . . . . . . . . . 5 Emergency . . . . . . . . . . . . . . . . 1, 2, 4-6, 12, 14, 16-18 After-hours office visit . . . . . . . . . . . . . . . . . . . . . . . . . 5 Emergency Centers . . . . . . . . . . . . . . . . . . . . . . . . . 17 Ambulance (ground and air) . . . . . . . . . . . . . . . . . . . 15 Emergency centers (Insta-Care type) . . . . . . . . . . . 17 Amniocentesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Emergency department . . . . . . . . . . . . . . 1, 2, 4-6, 16 Antepartum, and Postpartum care . . . . . . . . . . . . . . 18 Emergency Department Reimbursement . . . . . . . . 1, 6 Assisted Reproductive Technologies . . . . . . . . . . . . 16 Emergency Department Service . . . . . . . . . . . . . . . . 2 Audiology services . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Emergency Service . . . . . . . . . . . . . . . . . . . . . . . . 2, 6 Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 5 Enhanced Services . . . . . . . . . . . . . . . . . . . . . . . . . 19 Authorized Diagnoses for Emergency Department Equipment and appliances . . . . . . . . . . . . . . . . . . . . 12 Reimbursement . . . . . . . . . . . . . . . . . . . . 1, 6 Equipment and supplies . . . . . . . . . . . . . . . . . . . . . . 12 Aviation services . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Escort services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Benefit Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Established patients . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Biofeedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Evaluation and Management codes . . . . . . . . . . . 4, 12 Biologicals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Evaluation/Management office visit codes . . . . . . . . . 5 Blood Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 10 Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Centers for Medicare and Medicaid Services . . . . . . 2 Examinations . . . . . . . . . . . . . . . . . . . . . . . . 12, 14, 16 Certified family or pediatric nurse practitioners . . . . . 4 Experimental . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 5, 16 Certified Nurse Midwife . . . . . . . . . . . . . . . . . . . . . . 19 Experimental, investigational, ineffective . . . . . . . . . 16 Cesarean Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Extenuating circumstances . . . . . . . . . . . . . . . . . . . . 5 Charges incurred as an organ or tissue donor . . . . . 17 Family Planning Services . . . . . . . . . . . . . . . . . . 13, 16 Chiropractic Services . . . . . . . . . . . . . . . . . . . . . . . . 17 Family planning services - Non-covered: . . . . . . . . . 16 CLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1, 2, 5, 9 Food services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 CLIA Certificates, Excluded C odes & CLIA W aiver Kits Foot care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Free standing centers . . . . . . . . . . . . . . . . . . . . . . . . 17 Clinical Laboratory Improvem ent Amendments . . . 2, 9 Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . 16 CMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 5, 12 Glasses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Code of Federal Regulation . . . . . . . . . . . . . . . . . . . . 2 Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Cognitive services . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Health screenings . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Cosmetic, experimental, investigational . . . . . . . . . . 16 Hearing aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 CPT Procedure Code . . . . . . . . . . . . . . . . . . . . . . . . 17 Hearing test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Custodial care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 High Risk Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Cytogenetic studies . . . . . . . . . . . . . . . . . . . . . . . . . 16 HIV Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 C-section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Home and Com munity-based Waiver services . . . . 17 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Hom e Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Home Health Aide . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Home Health and Hospice Services . . . . . . . . . . . . 17 Diabetes Education . . . . . . . . . . . . . . . . . . . . . . . . . 12 Hospice Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Diabetes Self-Management . . . . . . . . . . . . . . . . . . . 12 Hospital diagnostic, therapeutic, or surgical services Diagnostic services . . . . . . . . . . . . . . . . . . . . . . . . . . 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Dialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13, 17 Hospital facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Division of Health Care Financing . . . . . . . . . . . . . . . 2 Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Documentation in the medical record . . . . . . . . . 5, 7, 8 Hypnotherapy or Biofeedback . . . . . . . . . . . . . . . . . 17 Donor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Drug Criteria and Limits List . . . . . . . . . . . . . . . . . . . 11 Immunization codes . . . . . . . . . . . . . . . . . . . . . . . . . 12 Drug Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . 12, 13 Drugs and biologicals . . . . . . . . . . . . . . . . . . . . . . . . . 5 Infertility studies and reversal of sterilization . . . . . . 16 Durable Medical Equipment . . . . . . . . . . . . . . . . . . . 12 Injectable products . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Utah Provider Manual for Primary Care Network
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Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Physician assistants . . . . . . . . . . . . . . . . . . . . . . . . 4, 5 Inpatient or outpatient hospital . . . . . . . . . . . . . . . 6, 16 Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . 4, 5 Interpretive Services . . . . . . . . . . . . . . . . . . . . . . . . 15 Pneumovax Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . 5 Interpretive services for the deaf . . . . . . . . . . . . . . . 15 Podiatric (podiatry) Services . . . . . . . . . . . . . . . . . . 17 Investigational, ineffective . . . . . . . . . . . . . . . . . . . . 16 Postpartum care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 In-Vitro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Preferred Drug List . . . . . . . . . . . . . . . . . . . . . . . . 1, 10 Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 5-7, 9 Pregnancy Related Services . . . . . . . . . . . . . . . . . . 18 Laboratory and Radiology Services . . . . . . . . . . . . . . 9 Prenatal Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Laboratory codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . 12 LIMITATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 7, 10 Primary Care . . . . . . . . . . . . . . . . 1-4, 6, 9, 10, 13, 16 Limitations for Physician Services . . . . . . . . . . . . . . . 5 Primary Care Provider System . . . . . . . . . . . . . . . . 3, 9 Long term care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Private duty nursing . . . . . . . . . . . . . . . . . . . . . . . . . 17 Massage therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Provider . . . . . . . . . . . . . . 3, 5, 7, 9, 10, 12, 14, 15, 17 Medical and Surgical Procedures . . . . . . . . . . . 1, 4, 5 Psychological evaluations . . . . . . . . . . . . . . . . . . . . 16 Medical and surgical services of a dentist . . . . . . . . 17 Radiology Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Medical Equipment and Supplies . . . . . . . . . . . . . . . 12 Reproductive Technologies . . . . . . . . . . . . . . . . . . . 16 Medical or psychological evaluations . . . . . . . . . . . . 16 Respite care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Medical translation . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Revenue Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Reversal of sterilization . . . . . . . . . . . . . . . . . . . . . . 16 Midwife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Routine drug screening . . . . . . . . . . . . . . . . . . . . . . 16 Minerals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 SCOPE OF SERVICE . . . . . . . . . . . . . . . . . . . . . . 2, 4 Minor procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . 2-10, 12-19 Minor Surgery and Anesthesia . . . . . . . . . . . . . . . . . . 9 Services to children (CHEC) . . . . . . . . . . . . . . . . . . 17 Modifier 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Skilled Nursing Service . . . . . . . . . . . . . . . . . . . . . . 17 New or Established patients . . . . . . . . . . . . . . . . . . . . 4 Specimen collection fee . . . . . . . . . . . . . . . . . . . . . . . 5 NON COVER ED SERVICES . . . . . . . . . . . . . . . 13, 16 Speech Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Non-emergency ambulance service . . . . . . . . . . . . . 16 Stage Renal Disease (Dialysis) . . . . . . . . . . . . . . . . 17 Norplant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Nurse Midwife . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 17 Substance abuse and dependency services . . . . . . 17 Observation services . . . . . . . . . . . . . . . . . . . . . . . 6-8 Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6, 12, 13 Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . 17 Supportive maintenance . . . . . . . . . . . . . . . . . . . . . . 17 Office visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 5, 16 Surgical Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Office visit for allergy injections . . . . . . . . . . . . . . . . 16 Targeted case Management . . . . . . . . . . . . . . . . . . 17 Ophthalmologists . . . . . . . . . . . . . . . . . . . . . . . . . 5, 14 Therapy services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Optom etrists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 14 Tissue donor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Organ or tissue donor . . . . . . . . . . . . . . . . . . . . . . . . 17 Transportation service . . . . . . . . . . . . . . . . . . . . . . . 16 Organ Transplant Services . . . . . . . . . . . . . . . . . . . 17 Transportation Services . . . . . . . . . . . . . . . . . . . . . . 15 Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . 2, 4, 6-9, 16 Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Outpatient setting . . . . . . . . . . . . . . . . . . . . . . . . 2, 4, 9 Travel or transportation expenses, escort services . 17 Outside medical services in free standing centers . . 17 Unlisted codes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 5 Overrides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Over-the-Counter drugs . . . . . . . . . . . . . . . . . . . . . . . 5 Venipuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Patches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 PCN -CPT Code List . . . . . . . . . . . . . . . . . . . . . . . 5, 9 Vitamin B-12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Pediatric nurse practitioners . . . . . . . . . . . . . . . . . . . . 4 Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 10, 16 Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . 5, 10 Vitamins - prescription or injection . . . . . . . . . . . . . . 16 Physical examinations . . . . . . . . . . . . . . . . . . . . . . . 12 W eight loss programs . . . . . . . . . . . . . . . . . . . . . . . 16 Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Source: http://www.health.state.ut.us/medicaid/pdfs/pcn.pdf