LTCBillCodeCrosswalk 100109

LTC Bill Code Crosswalk
Texas LTC Local Codes
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
201
202
203
204
205
206
207
208
209
210
211
212
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
REVENUE
POS
CODE
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
CLAIM FIL IND
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CPT
CODE
MODIFIER 4
Page 1 of 67
NF - TILE 201
NF - TILE 202
NF - TILE 203
NF - TILE 204
NF - TILE 205
NF - TILE 206
NF - TILE 207
NF - TILE 208
NF - TILE 209
NF - TILE 210
NF - TILE 211
NF - TILE 212
NF - RAD
NF - RAC
NF - RAB
NF - RAA
NF - SE3
NF - SE2
NF - SE1
NF - SSC
NF - SSB
NF - SSA
NF - CC2
NF - CC1
NF - CB2
NF - CB1
NF - CA2
NF - CA1
NF - IB2
NF - IB1
NF - IA2
NF - IA1
NF - BB2
NF - BB1
NF - BA2
NF - BA1
NF - PE2
NF - PE1
NF - PD2
NF - PD1
NF - PC2
NF - PC1
NF - PB2
NF - PB1
NF - PA2
NF - PA1
NF - BC1
NF - PCE
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
N0201
N0202
N0203
N0204
N0205
N0206
N0207
N0208
N0209
N0210
N0211
N0212
RG001
RG002
RG003
RG004
RG005
RG006
RG007
RG008
RG009
RG010
RG011
RG012
RG013
RG014
RG015
RG016
RG017
RG018
RG019
RG020
RG021
RG022
RG023
RG024
RG025
RG026
RG027
RG028
RG029
RG030
RG031
RG032
RG033
RG034
RG035
RG036
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
Last Update 10/01/2009

RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
201
202
203
204
205
206
207
208
209
210
211
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
I
I
I
I
I
I
I
I
I
I
I
REVENUE
POS
CODE
CLAIM FIL IND
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CPT
CODE
MODIFIER 4
Page 2 of 67
VA DAILY CARE - RAD

VA DAILY CARE - RAC
VA DAILY CARE - RAB
VA DAILY CARE - RAA
VA DAILY CARE - SE3
VA DAILY CARE - SE2
VA DAILY CARE - SE1
VA DAILY CARE - SSC
VA DAILY CARE - SSB
VA DAILY CARE - SSA
VA DAILY CARE - CC2
VA DAILY CARE - CC1
VA DAILY CARE - CB2
VA DAILY CARE - CB1
VA DAILY CARE - CA2
VA DAILY CARE - CA1
VA DAILY CARE - IB2
VA DAILY CARE - IB1
VA DAILY CARE - IA2
VA DAILY CARE - IA1
VA DAILY CARE - BB2
VA DAILY CARE - BB1
VA DAILY CARE - BA2
VA DAILY CARE - BA1
VA DAILY CARE - PE2
VA DAILY CARE - PE1
VA DAILY CARE - PD2
VA DAILY CARE - PD1
VA DAILY CARE - PC2
VA DAILY CARE - PC1
VA DAILY CARE - PB2
VA DAILY CARE - PB1
VA DAILY CARE - PA2
VA DAILY CARE - PA1
VA DAILY CARE - BC1
VA DAILY CARE - PCE
VA DAILY CARE WITH ADD ON
VA DAILY CARE - TILE 201
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
V0101
V0102
V0103
V0104
V0105
V0106
V0107
V0108
V0109
V0110
V0111
V0112
V0113
V0114
V0115
V0116
V0117
V0118
V0119
V0120
V0121
V0122
V0123
V0124
V0125
V0126
V0127
V0128
V0129
V0130
V0131
V0132
V0133
V0134
V0135
V0136
V0200
V0201
V0202
V0203
V0204
V0205
V0206
V0207
V0208
V0209
V0210
V0211
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
DESCRIPTION
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

N0600
1
1
N0600
N0600
N0600
1
1
N0600
N0600
N0600
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
N0600
N0600
N0700
N0701
N0702
N0703
N0704
N0705
N0706
N0707
N0708
G0446
G0447
G0452
G0453
G0458
G0467
Page 3 of 67
AD
D7230
05/27/1999
12/31/2199
AD
D7240
05/27/1999
12/31/2199
5
5
AD
AD
D7241
D7250
D
D
A
A
05/27/1999
05/27/1999
12/31/2199
12/31/2199
AD
D7510
05/27/1999
12/31/2199
5
5
AD
AD
D7520
D9215
D
D
A
A
05/27/1999
05/27/1999
12/31/2199
12/31/2199
AD
D9220
05/27/1999
12/31/2199
5
5
6
6
6
6
6
6
6
6
6
7
7
7
7
7
7
AD
AD
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
D9221
D7140
D
D
N
N
N
N
N
N
N
N
N
I
I
I
I
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
05/27/1999
01/01/2006
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
10/15/2003
10/15/2003
12/31/2199
12/31/2199
08/31/2003
12/31/2199
EMERGENCY DENTAL - PULL OF IMPACTED TOOTH - BONY

EMERGENCY DENTAL - REMOVAL OF IMPACTED TOOTH PULL BONY COMPLICATIONS
EMERGENCY DENTAL - PULL REMAINING TOOTH ROOTS
EMERGENCY DENTAL - CUT AND EVACUATE ABSCESS INTRAORAL
EMERGENCY DENTAL - CUT AND EVACUATE OF ABSCESS EXTRAORAL
EMERGENCY DENTAL - LOCAL NUMBING
EMERGENCY DENTAL - GENERAL NUMBING FIRST HALF
HOUR
EMERGENCY DENTAL - GENERAL NUMBING AND EACH
SUBSEQUENT 15 MINUTES
EXTRACTION ERUPTED TOOTH/EXR
NAT - TRAINING COURSE
NAT - SKILLS TEST - PASSED
NAT - SKILLS TEST - FAILED
NAT - WRITTEN TEST - PASSED
NAT - WRITTEN TEST - FAILED
NAT-ORAL TEST - PASSED
NAT-ORAL TEST - FAILED
NAT - TRAINING MATERIALS
NAT - INCOMPLETE TRAINING COURSE
OT-SPECIALIZED SERV
OT ASSESSMENT-SPECIALIZED SERV
OT-REHABILITATIVE SERV
OT ASSESSMENT-REHABILITATIVE SERV
OT HABILITATION (S)
OT-REHABILITATIVE SERVICE CONTRACTED
TI
212
HC
94657
94004
94657
94004
97039
97003
97039
97003
REVENUE
POS
CODE
0100
0100
0230
0230
0230
0230
VA
U7
U7
U8
U8
0431
0434
0431
0434
97039 0431
CLAIM FIL IND
N0600
D0140
D9110
D0220
D0230
D7110
D7120
D7130
D7210
D7220
1
3
4
4
4
4
5
5
5
5
5
5
5
5
5
CPT
CODE
MODIFIER 4
HC
HC
HC
HC
AD
AD
AD
AD
AD
AD
AD
AD
AD

MEDICARE SKILLED
VENTILATOR - FULL
VENTILATOR - FULL
VENTILATOR - PARTIAL
EMERGENCY DENTAL - ORAL
EMERGENCY DENTAL - PALLIATIVE
EMERGENCY DENTAL - INITIAL X-RAY
EMERGENCY DENTAL - SUBSEQUENCE X-RAYS
EMERGENCY DENTAL - FIRST EXTRACTION
EMERGENCY DENTAL - 2ND EXTRACTION
EMERGENCY DENTAL - REMOVAL OF ROOT TOOTH
EMERGENCY DENTAL - PULL OF TOOTH DAMAGED
EMERGENCY DENTAL - PULL IMPACTED TOOTH
EMERGENCY DENTAL - PULL OF IMPACTED SLIGHTLY
TOOTH - BONY
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
V0212
N0400
N0500
N0500
N0501
N0501
N0600
N0600
N0600
N0600
N0600
N0600
N0600
N0600
N0600
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
DESCRIPTION
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
D
D
D
D
D
D
D
D
D
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
GO
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
10/16/2003
01/01/1900
01/01/1900
02/01/2008
01/01/1900
02/01/2008
05/27/1999
05/27/1999
05/27/1999
05/27/1999
05/27/1999
05/27/1999
05/27/1999
05/27/1999
05/27/1999
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2006
12/31/2006
12/31/2006
12/31/2199
12/31/2199
ACTIVE

REVENUE
POS
CODE
CLAIM FIL IND
CPT
CODE
MODIFIER 4
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
10/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/01/2008
12/31/2199
10/15/2003
10/15/2003
12/31/2199
12/31/2199
08/31/2003
12/31/2199
10/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/01/2008
12/31/2199
10/15/2003
10/15/2003
10/15/2003
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
ACTIVE
1
1
1
1
1
1
1
G0468
G0448
G0449
G0454
G0455
G0459
G0469
OT-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED

PT-SPECIALIZED SERV
PT ASSESSMENT-SPECIALIZED SERV
PT-REHABILITATIVE SERV
PT ASSESSMENT-REHABILITATIVE SERV
PT HABILITATION (S)
PT-REHABILITATIVE SERVICE CONTRACTED
7
8
8
8
8
8
8
HC
HC
HC
HC
HC
97003
97039
97001
97039
97001
0434
0421
0424
0421
0424
GO
I
I
I
I
I
HC
97039 0421
GP
1
1
1
1
1
1
1
1
1
G0470
G0450
G0451
G0451
G0456
G0457
G0457
G0460
G0471
PT-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED

ST-SPECIALIZED SERV
ST ASSESSMENT-SPECIALIZED SERV
ST-REHABILITATIVE SERV
ST ASSESSMENT-REHABILITATIVE SERV
ST HABILITATION (S)
ST-REHABILITATIVE SERVICE CONTRACTED
8
9
9
9
9
9
9
9
9
HC
HC
HC
HC
HC
HC
HC
97001 0424
92507 0441
92506 0444
0444
92507 0441
92506 0444
0444
GP
I
I
I
I
I
I
I
HC
92507 0441
GN
A
A
A
A
A
A
A
A
A
G0472
ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED
HC
92506 0444
GN
10/01/2008
12/31/2199
1
1
1
1
1
1
1
G0472
G0500
G0500
G0500
G0500
G0500
G0500
ST-ASSESSMENT-REHABILITATIVE SERVICE CONTRACTED

DME - ROLLABOUT CHAIR
DME - STANDARD WHEELCHAIR
DME/ADAPTIVE AIDS
DME/ADAPTIVE AIDS - COMMUNICATION OTHER
DME/ADAPTIVE AIDS - COMMUNICATION DEVICE
DME - MISCELLANEOUS (HOSPITAL BEDS VENTILATOR)
9
15
15
15
15
15
15
HC
HC
HC
V5364
E1031
E1130
0444
0290
0290
GN
I
I
I
HC
HC
HC
E1902
E1900
E1399
0290
0290
0290
I
I
I
A
A
A
A
A
A
A
10/01/2008
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
12/31/2199
12/31/2199
12/31/2199
09/30/2003
12/31/2199
12/31/2199
12/31/2199
1
1
1
1
1
1
1
1
G0500
N0502
G0955
G0958
G0959
N0401
G0461
G0462
DME/ADAPTIVE AIDS - OTHER (IN HOME/NON-VEHICLE LIFT)

CHILD TRACHEOSTOMY CARE
CUSTOMIZED POWER WHEELCHAIR
CPWC MODIFICATION
CPWC ADJUSTMENTS
SNF PART A FULL MEDICARE
OT - NF SPECIALIZED SERVICES
OT - NF ASSESSMENT-SPECIALIZED SERV
15
24
15A
15B
15C
3A
7A
7A
HC
HC
HC
HC
HC
ZZ
HC
HC
E0636
0290
I
P
I
I
I
P
I
I
A
A
A
A
A
A
A
A
05/19/1998
01/01/1900
01/01/2008
01/01/2008
01/01/2008
05/01/2008
10/16/2003
10/16/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
G0473
7A
HC
97039 0431
GO
10/01/2008
12/31/2199
1
1
1
1
1
G0474
G0479
G0956
G0463
G0464
OT-SPECIALIZED REHABILITATIVE SERVICE CONTRACTED

OT-SPECIALIZED ASSESSMENT-REHAB SERVICE
CONTRACTED
CPWC ASSESSEMENTS BY PT SERVICE CONTRACTED.
CPWC ASSESSMENTS BY OT
PT - NF SPECIALIZED SERVICES
PT - NF ASSESSMENT-SPECIALIZED SERV
7A
7B
7B
8A
8A
HC
HC
HC
HC
HC
97003
97542
97542
97039
97001
0434
0434
0434
0421
0424
GO
GO
I
I
I
I
I
A
A
A
A
A
10/01/2008
10/01/2008
01/01/2008
10/16/2003
10/16/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
G0475
PT- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED
8A
HC
97039 0421
GP
10/01/2008
12/31/2199
Page 4 of 67
V5364
V5364
99199
K0898
K0898
K0898
0290
0294
0299
97039 0431
97003 0434

G0476
G0480
G0957
G0465
G0466
G0466
PT- SPECIALIZED ASSESSMENT-REHAB SERVICE

CONTRACTED
CPWC ASSESSEMENTS BY OT SERVICE CONTRACTED.
CPWC ASSESSMENTS BY PT
ST - NF SPECIALIZED SERVICES - TREATMENT
ST - NF ASSESSMENT-SPECIALIZED SERV
8A
8B
8B
9A
9A
9A
HC
HC
HC
HC
HC
HC
G0477
ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED
9A
G0478
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
G0478
G0400
G0401
G0402
S0100
S0101
S0102
S0103
S0104
S0124
G0100
G0101
G0102
G0171
G0200
G0201
G0300
ST- SPECIALIZED REHABILITATIVE SERVICE CONTRACTED

ST- SPECIALIZED ASSESSMENT-REHAB SERVICE
CONTRACTED
OCCUPATIONAL THERAPY
PHYSICAL THERAPY
SPEECH THERAPY
HABILITATION - TRAINING
HABILITATION - ADL'S
HABILITATION - DELEGATED NURSING
HABILITATION - SUPPORTIVE EMPLOY EMPLOYMENT
HABILITATION - PREVOCATIONAL
AGENCY ADMIN - HABILITATION CDS
RESPITE-IN HOME RESPITE-DSA
RESPITE - IN-HOME CDS-INDIVIDUAL
RESPITE - OUT-OF-HOME
AGENCY ADMIN - IN HOME RESPITE CDS
CASE MANAGEMENT
CASE MANAGEMENT - FIXED RATE
NURSING CARE - RN-SKILLED CARE PROVIDED IN THE
CLIENT'S HOME
G0300
RN-NURSING ASSESSMENT/EVALUATION (ANNUAL

REASSESSMENTS/HEALTH AND SAFETY/AND POSTHOSPITALIZATION)
G0300
2
2
G0301
G0301
2
2
2
2
2
2
2
G0403
G0403
G0403
G0403
G0403
G0403
G0403
Page 5 of 67
NURSING SERVICES - RN TRAINING/RN

DELEGATION/MONITORING AND SUPERVISION PARTIAL UNIT
NURSING CARE - LVN-SKILLED CARE PROVIDED IN THE
CLIENT'S HOME
LVN-NURSING SERVICES PARTIAL UNIT
PSYCHOLOGICAL SERVICES INITIAL NEEDS
ASSESSMENT/EVALUATION
PSYCHOLOGICAL SERVICES
97001
97542
97542
92507
92506
REVENUE
POS
CODE
CLAIM FIL IND
1
1
1
1
1
1
CPT
CODE
MODIFIER 4
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
0424
0424
0424
0441
0444
0444
GP
GP
I
I
I
I
I
I
A
A
A
A
A
A
10/01/2008
10/01/2008
01/01/2008
10/16/2003
10/16/2003
10/16/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
HC
92507 0441
GN
10/01/2008
12/31/2199
9A
HC
92506 0444
GN
10/01/2008
12/31/2199
9A
7
8
9
10
10
10
10
10
10
11
11
11
11
12
12
HC
HC
HC
HC
HC
HC
0444
GN
GO
GP
GN
U3
U5
I
P
P
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
10/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
08/31/2003
12/31/2199
V5364
V5364
G0152
G0151
G0153
T2016
T2021
ZZ
ZZ
ZZ
P
P
P
ZZ
HC
T2022
13
HC
S9123
TD
01/01/1900
12/31/2199
13
HC
T1001
TD
01/01/1900
12/31/2199
13
HC
T1002
TD
01/01/1900
12/31/2199
13
13
HC
HC
S9124
T1003
TE
TE
P
P
A
A
01/01/1900
01/01/1900
12/31/2199
12/31/2199
14
14
14
14
14
14
14
HC
HC
HC
HC
HC
HC
HC
P
P
P
P
P
P
P
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
90801
90812
90814
90821
90823
90826
90828

REVENUE
POS
CODE
CLAIM FIL IND
CPT
CODE
MODIFIER 4
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
G0403
PSYCHOLOGICAL SERVICES 1 TO 1 COUNSELING/THERAPY30 MINUTES INCREMENTS
14
HC
90810
01/01/1900
12/31/2199
G0403
PSYCHOLOGICAL SERVICES BEHAVIORAL MANAGEMENT

PROGRAM DEVELOPMENT AND INSERVICE TRAINING WITH
CLIENT
14
HC
90816
01/01/1900
12/31/2199
14
HC
90818
01/01/1900
12/31/2199
14
HC
90845
01/01/1900
12/31/2199
14
HC
90862
01/01/1900
12/31/2199
14
HC
96100
01/01/1900
12/31/2199
14
15
15
15
15
15
HC
AD
HC
HC
HC
HC
90847
D9999
T2003
T2039
E1031
E1400
P
D
P
P
P
A
A
A
A
A
A
01/01/1900
05/19/1998
05/19/1998
10/01/2003
05/19/1998
05/19/1998
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
09/30/2003
15
HC
E1900
05/19/1998
12/31/2199
15
15
15
HC
HC
HC
E1902
T2029
T2028
P
P
P
A
A
A
05/19/1998
10/01/2003
10/01/2003
12/31/2199
12/31/2199
12/31/2199
15
HC
S5199
01/01/2003
12/31/2199
HC
HC
HC
HC
E0636
E1130
E1399
S5165
P
P
P
P
A
A
A
A
05/19/1998
05/19/1998
05/19/1998
01/01/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
11/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/31/2003
08/31/2003
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
G0403
G0403
G0403
G0403
2
2
2
2
2
2
G0403
G0500
G0500
G0500
G0500
G0500
G0500
2
2
2
G0500
G0500
G0500
G0500
PSYCHOLOGICAL SERVICES MONITOR BMP WITH

CLIENT/COUNSELING WITH CLIENT AND SERVICE
PROVIDERS
PSYCHOLOGICAL SERVICES-ONGOING COUNSELING WITH
FAMILY/FRIENDS/SERVICE PROVIDERS AND CLIENT
PSYCHOLOGICAL SERVICES PSYCHIATRIC
THERAPY/COUNSELING
PSYCHOLOGICAL SERVICES PROFESSIONAL ASSESSMENT ABL
PSYCHOLOGICAL SERVICES 1 TO 1 INDIVIDUAL
THERAPY/COUNSELING
ADAPTIVE AIDS - UNSPECIFIED PROCEDURE (DENTAL)
ADAPTIVE AIDS - TRANSPORTATION
DME - VEHICLE MODIFICATIONS TO INCLUDE LIFT
DME - ROLLING CHAIR
DME - ADAPTIVE AIDS
DME/ADAPTIVE AIDS - ELECTRONIC AUGMENTIVE
COMMUNICATION DEVICES/AIDS/EQUIPMENT
DME/ADAPTIVE AIDS - NON-ELECTRONIC AUGMENTIVE
COMMUNICATIONS AIDS AND EQUIPMENT
DME - MEDICAL EQUIPMENT (NOT OTHERWISE SPECIFIED)
MEDICAL SUPPLIES - (NOT OTHERWISE SPECIFIED)
ADAPTIVE AIDS - PERSONAL CARE ITEMS (CONSUMERABLE
SUPPLIES/DIAPER/BED PAD/ENSURE)
2
2
2
2
G0500
G0500
G0500
G0608

DME - WHEELCHAIR/STROLLERS
DME - MISCELLANEOUS (HOSPITAL BEDS/VENTILATOR)
HOME MODIFICATIONS
15
15
15
16
2
2
2
2
2
2
2
2
2
2
2
2
2
G0720
G0721
H2025
G0202
G0203
G0203
G0204
G0205
G0605
G0515
G0516
G0517
G0518
CONSUMER MANAGED PERSONAL ATTENDANT SERVICES

CLIENT MANAGED ATTENDANT SERVICES - VOUCHER
CLASS SUPPORTED EMPLOYMENT
PRE-ASSESSMENT
CASE MANAGEMENT PARTIAL ASSESSMENT
CASE MANAGEMENT FULL ASSESSMENT
DSA FULL ASSESSMENT FEE
ANNUAL ASSESSMENT
SPECIFICATIONS HM MODS
ADP AIDES/REQUISITION FEES 0.00 - 499.99
27
27
37
40
40
40
40
40
40
41
41
41
41
Page 6 of 67
HC
H2024
HC
HC
HC
T1023
T1001
T1023
ZZ
ZZ
ZZ
ZZ
P
U8
U8
U7
P
P
P
P
P
P
P

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
S0105
S0105
S0106
S0107
G0128
G0170
G0196
G0197
G0302
G0302
G0305
G0303
G0303
G0303
G0304
S9800
T1002
G0306
T1003
Page 7 of 67
REVENUE
POS
CODE
CLAIM FIL IND
G0404
T2038
S5145
CPT
CODE
MODIFIER 4
2
2
2

ADP AIDES/REQUISITION FEES 5000.00 - OVER
MH MODS/REQUISITION FEES 0 - 499.00
MH MODS/REQUISITION FEES 500.00 - 999.99
MH MODS/REQUISITION FEES 6500.00 - OVER
SPECIALIZED THERAPIES
SPECIALIZED THERAPIES - AT HOME
SPECIALIZED THERAPIES - IN COMMUNITY-FUTURE USE
SPECIALIZED THERAPIES - ACTIVITY THERAPY - FUTURE
USE
TRANSITION ASSISTANCE SERVICES (TAS)
SUPPORT FAMILY SERVICES
HABILITATION ATTENDANT CARE SERVICES - DELEGATED
NURSING
HABILITATION PERSONAL CARE SERVICES - NURSING
AGENCY ADMIN - OUT OF HOME RESPITE CDS
CDS RESPITE OUT-OF-HOME
CDS RESPITE IN-HOME
NURSING SERVICES BY LPN/LVN
NURSING CARE - LVN
CDS NURSING LVN
NURSING SERVICES - RN
NURSING SERVICES IN THE HOME - RN
NURSING SERVICES - RN - ASSESSMENT/EVALUATION
CDS NURSING RN
NURSING SERVICES - HIGHLY TECH RN PER HOUR
SPECIALIZED NURSING RN
CDS SPECIALIZED NURSING RN
LPN/LVN SERVICES
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0519
G0520
G0521
G0522
G0523
G0524
G0525
G0609
G0610
G0611
G0612
G0613
G0614
G0615
G0616
G0617
G0618
G0619
G0620
G0621
G0622
G0404
G0404
G0404
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
BEGIN
DATE
END
DATE
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
10/15/2003
12/31/2199
12/31/2199
ACTIVE
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
42
42
42
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
Q0082
42
53
55
HC
HC
HC
H2032
T2038
S5145
P
P
P
A
A
A
10/16/2003
09/01/2004
09/01/2004
12/31/2199
12/31/2199
12/31/2199
10A
10A
10B
10B
11A
11A
11AV
11PV
13A
13A
13AV
13B
13B
13B
13BV
13C
13C
13CV
13D
HC
HC
HC
HC
HC
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5125
T1019
T2019
T2015
S5151
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
10/16/2003
01/01/1900
01/01/1900
01/01/1900
03/01/2008
03/01/2008
01/01/1900
10/16/2003
08/01/2009
01/01/1900
10/16/2003
10/16/2003
08/01/2009
01/01/1900
01/01/2008
08/01/2009
01/01/1900
12/31/2199
12/31/2199
10/31/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2008
12/31/2199
12/31/2199
12/31/2008
12/31/2008
12/31/2199
05/01/2005
12/31/2199
12/31/2199
05/01/2005
97535
97537
S5151
S9125
T1003
S9124
T1003
T1002
S9123
T1001
T1002
S9800
T1002
T1002
T1003
U4
TG
TG
TG
TG
UC
TE
UC
TD
UC
TD
TD

HC
HC
ZZ
ZZ
ZZ
ZZ
HC
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
ZZ
T1003
T1003
REVENUE
POS
CODE
TG
TG
UC
TE
TE
CLAIM FIL IND
13D
13DV
17A
17B
19E
19F
27A
27A
40A
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41C
41D
41F
41F
41F
41F
41F
41F
41F
41F
41F
41F
41F
53A
57V
5A
62V
63V
7V
8V
9V
7
8
9
11
CPT
CODE
MODIFIER 4
Page 8 of 67
SPECIALIZED NURSING LVN

CDS SPECIALIZED NURSING LVN
PAS DELEGATED (FOR FUTURE USE)
PAS PROTECTIVE SUPERVISION (FOR FUTURE USE)
ASSISTED LIVING - HABILITATION 24 HR
ASSISTED LIVING - HABILITATION LESS THAN 24 HR
CMPAS - CLIENT DIRECTED SERVICES
CMPAS - CLIENT DIRECTED SERVICES - AGENCY
DSA-PARTIAL ASSESSMENT
MH MODS/REQUISITION FEES 0-499.99
SPECIFICATIONS ADAPTIVE AIDS
SPECIALIZED THERAPIES/REQ FEES 0 - 499.99
SPECIALIZED THERAPIES/REQ FEES 500.00 - 999.99
SPECIALIZED THERAPIES/REQ FEES 5000 - OVER
TAS FEES
CDS SUPPORT CONSULTATION
EMERGENCY DENTAL
CDS - CLASS ORIENTATION FEE
CDS CLASS MONTHLY ADMINISTRATION FEE
OCCUPATIONAL THERAPY - CDS
PHYSICAL THERAPY - CDS
SPEECH/LANGUAGE PATHOLOGY THERAPY - CDS
PHYSICAL THERAPY
SPEECH THERAPY
RESPITE - IN-HOME
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
T1003
G0307
G0705
G0706
G0937
G0938
G0722
G0723
G0207
G0623
G0624
G0625
G0626
G0627
G0628
G0629
G0630
G0631
G0632
G0633
G0634
G0635
G0636
G0607
G0604
G0648
G0649
G0650
G0651
G0652
G0653
G0654
G0655
G0656
G0657
G0658
G0239
G0757
N0600
G0222
G0226
G0408
G0409
G0410
G0400
G0401
G0402
G0101
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
T2024
P
P
G0152
G0151
G0153
G0152
G0151
G0153
UC
UC
UC
GO
GP
GN
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/2008
08/01/2009
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2004
01/01/2009
01/01/1900
09/01/2007
09/01/2007
08/01/2009
08/01/2009
08/01/2009
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

REVENUE
POS
CODE
ZZ
HC
HC
HC
HC
HC
AD
HC
HC
HC
HC
CLAIM FIL IND
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
11
12
13
13
13
13
13
15
15
15
15
15
15
CPT
CODE
MODIFIER 4
Page 9 of 67
RESPITE - ADULT FOSTER CARE - LEVEL 1

RESPITE - ASSISTED LIVING - APT (LEVEL 6)
RESPITE - RESIDENTIAL CARE - APT (LEVEL 6)
RESPITE - RESIDENTIAL CARE - NON APT (LEVEL 6)
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
RESPITE - IN-HOME
VENTILATOR - FULL
CASE MANAGEMENT
Nursing Care - RN
Nursing Assessment/Evaluation
Nursing Services - RN partial unit
Nursing Care - LVN
Nursing Services - LVN/LPN partial unit
ADAPTIVE AIDS - UNSPECIFIED PROCEDURE
DME/ADP AIDS - VEHICLE MODIFICATIONS
DME/ADP AIDS - POSITIONING DEVICE
DME/ADP AIDS - ROLLING CHAIR
DME/ADP AIDS - STANDARD WHEELCHAIR
DME/ADAPTIVE AIDS
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0103
G0104
G0105
G0106
G0107
G0109
G0171
G1105
G1106
G1107
G2105
G2106
G2107
G3105
G3106
G3107
G4105
G4106
G4107
G5105
G5106
G5107
N0201
N0202
N0203
N0204
N0205
N0206
N0207
N0208
N0209
N0210
N0211
N0212
N0500
N0501
G0200
G0300
G0300
G0300
G0301
G0301
G0500
G0500
G0500
G0500
G0500
G0500
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
S9123
T1001
T1002
S9124
T1003
D9999
T2039
E0636
E1031
E1130
TD
TD
TD
TE
TE
P
P
P
P
P
D
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
05/19/1998
10/01/2003
05/19/1998
05/19/1998
05/19/1998
05/19/1998
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
09/30/2003

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
G0700
G0701
G0800
G0801
G0802
G0900
G0900
G0901
G0902
G0905
G1900
G1900
G1901
G1902
G2900
G2900
G2901
G2902
G3900
G3900
G3901
G3902
G4900
G4900
G4900
G4900
G4900
G4900
G4901
G4902
G5900
G5900
G5900
G5900
G5900
G5900
G5900
G5900
Page 10 of 67
REVENUE
POS
CODE
CLAIM FIL IND
G0500
G0608
99999
CPT
CODE
MODIFIER 4
3
3
3
DME/ADAPTIVE AIDS - COMMUNICATION-ELECTRONIC

DEVICE
DME/ADAPTIVE AIDS - COMMUNICATION-OTHER
DME - MEDICAL EQUIPMENT
MEDICAL SUPPLIES - SPECIALIZED SUPPLIES
DME/ADP AIDS - MISCELLANEOUS (HOSPITAL
BEDS/VENTILATOR)
HOME MODIFICATIONS
EXPEDITED PAYMENT
PERSONAL ASSISTANCE SERVICES - LEVEL 3 - (RESERVED
FOR DELEGATED FUTURE USE)
PERSONAL ASSISTANCE SERVICES - LEVEL 2 - PRIORITY
ADULT FOSTER CARE - LEVEL 1
ASSISTED LIVING - APT (LEVEL 6)
RESIDENTIAL CARE - APT (LEVEL 6)
RESIDENTIAL CARE - NON APT (LEVEL 6)
ASSISTED LIVING/RESIDENTIAL CARE - PERSONAL CARE
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0500
G0500
G0500
G0500
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
15
15
15
15
HC
HC
HC
HC
E1900
E1902
T2029
T2028
P
P
P
P
A
A
A
A
05/19/1998
05/19/1998
10/01/2003
10/01/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
15
16
17
HC
HC
ZZ
E1399
S5165
P
P
E
A
A
A
05/19/1998
01/01/2003
01/01/1900
12/31/2199
12/31/2199
04/30/2009
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
08/31/2003
08/31/2003
08/31/2003
11/30/2009
11/30/2009
08/31/2003
08/31/2003
11/30/2009
11/30/2009
08/31/2003
08/31/2003
11/30/2009
11/30/2009
08/31/2003
08/31/2003
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
08/31/2003
08/31/2003
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
17
17
18
18
18
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
PR
AL
AL
AL
CT
CT
2
1
2
3
211
211
HC
HC
HC
HC
HC
HC
S5125
S5140
S5140
S5140
T2031
T2031
CT
CT
210 HC
210 HC
T2031
T2031
CT
CT
209 HC
209 HC
T2031
T2031
CT
CT
208 HC
208 HC
T2031
T2031
CT
CT
CT
CT
CT
CT
202
206
207
202
206
207
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
CT
CT
CT
CT
CT
CT
CT
CT
201
203
204
205
201
203
204
205
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
0240
U1
U1
U1
U1
P
I
I
I
P
I
0240
U1
U1
U1
U1
P
I
U1
U1
U1
U1
I
P
0240
U1
U1
U1
U1
P
I
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
P
P
P
I
I
I
0240
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
P
P
P
P
I
I
I
I
3105
3105
3105
0240

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
BA2
IA1
IA2
BA2
IA1
IA2
PA2
PA2
PA1
PA1
BA1
BA1
PB1
CA1
PB2
PB1
CA1
PB2
SSA
PC2
BB2
IB2
PD1
SSA
PC2
BB2
IB2
PD1
CA2
PC1
BB1
IB1
CA2
PC1
BB1
IB1
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
RAA
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
CPT
CODE
MODIFIER 4
Page 11 of 67

ASSISTED LIVING - APT (LEVEL 6) BA2
ASSISTED LIVING - APT (LEVEL 6) IA1
ASSISTED LIVING - APT (LEVEL 6) PA2
ASSISTED LIVING - APT(LEVEL 6) PA2
ASSISTED LIVING - APT (LEVEL 5) PB1
ASSISTED LIVING - APT (LEVEL 5) CA1
ASSISTED LIVING - APT (LEVEL 4) SSA
ASSISTED LIVING - APT (LEVEL 4) PC2
ASSISTED LIVING - APT (LEVEL 4) BB2
ASSISTED LIVING - APT (LEVEL 4) IB2
ASSISTED LIVING - APT (LEVEL 4) PD1
ASSISTED LIVING - APT (LEVEL 4) SSA
ASSISTED LIVING - APT (LEVEL 2) RAA
ASSISTED LIVING - APT (LEVEL 2) RAB
ASSISTED LIVING - APT (LEVEL 2) CB1
ASSISTED LIVING - APT (LEVEL 2) RAC
ASSISTED LIVING - APT (LEVEL 2) SE2
ASSISTED LIVING - APT (LEVEL 2) PE1
ASSISTED LIVING - APT (LEVEL 2) SSB
ASSISTED LIVING - APT (LEVEL 2) RAA
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G5901
G5902
R0009
R0009
R0009
R0009
R0009
R0009
R0009
R0009
R0009
R0009
R0009
R0009
R0019
R0019
R0019
R0019
R0019
R0019
R0029
R0029
R0029
R0029
R0029
R0029
R0029
R0029
R0029
R0029
R0039
R0039
R0039
R0039
R0039
R0039
R0039
R0039
R0049
R0049
R0049
R0049
R0049
R0049
R0049
R0049
R0049
R0049
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
I
I
I
P
I
P
I
P
I
P
P
P
I
I
I
P
P
P
P
P
I
I
I
I
I
P
P
P
P
I
I
I
I
P
P
P
P
P
P
P
P
P
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SE1
SE3
PE2
CC2
RAD
CC1
SSC
SE1
SE3
PE2
CC2
RAD
CC1
SSC
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
19
20
20
20
21
22
22
25
25
40
40
40
40
41
41
41
41
41
41
41
41
41
41
41
41
41
41
CPT
CODE
MODIFIER 4
Page 12 of 67
ASSISTED LIVING - APT (LEVEL 2) RAB

ASSISTED LIVING - APT (LEVEL 2) RAC
ASSISTED LIVING - APT (LEVEL 2) SSB
ASSISTED LIVING - APT (LEVEL 1) CC2
ASSISTED LIVING - APT (LEVEL 1) RAD
ASSISTED LIVING - APT (LEVEL 1) RAD
ASSISTED LIVING - APT (LEVEL 1) SSC
EMERGENCY RESPONSE SERVICES - INITIAL MONTH
EMERGENCY RESPONSE SERVICES - ONGOING MONTH
EMERGENCY RESPONSE SERVICES-ALL SERVICES
PRESCRIPTIONS - DISCONTINUED
MEDICAL SUPPLIES - OTHER
MEDICAL SUPPLIES-SPECIALIZED SUPPLIES
HOME DELIVERED MEALS
HOME DELIVERED MEALS - PREPARATION/DELIVERY
PRE-ASSESSMENT
ANNUAL ASSESSMENT
ASSESSMENT-MDS HOME
ADP AIDES/REQUISITION FEES 0 - 499.99
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
R0049
R0049
R0049
R0049
R0049
R0049
R0049
R0049
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
R0059
G1000
G1000
G1000
G1100
G1200
G1200
C0100
C0101
G0202
G0205
G0206
G0605
G0515
G0516
G0517
G0518
G0519
G0520
G0521
G0522
G0523
G0524
G0525
G0609
G0610
G0611
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
P
P
P
P
P
P
P
P
P
P
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
S5160
S5161
S5162
HC
HC
S5199
T2028
P
P
HC
S5170
P
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2003
10/01/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
08/31/2003
12/31/2199
08/31/2003
08/31/2003
05/01/2005
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003

HC
ZZ
T2038
HC
HC
HC
HC
HC
HC
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
REVENUE
POS
CODE
CLAIM FIL IND
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
41
52
53
65
11A
11B
11B
11B
11B
11B
11B
11B
11BVW
11BVW
11BVW
11BVY
11BVY
11BVY
11BW
11BW
11BW
11BW
11BW
11BW
11BY
11BY
CPT
CODE
MODIFIER 4
Page 13 of 67

PRESCRIPTIONS/REQUESITION FEES
MEDICAL S/REQUISITION FEES 0 - 499.99
MEDICAL S/REQUISITION FEES 500.00 - 999.99
MEDICAL S/REQUISITION FEES 5000.00 - OVER
COMMUNITY SUPPORT SERVICES
OVERNIGHT SUPPORT SERVICES
CDS ADULT FOSTER CARE RESPITE - AGENCY
CDS/ICM/MAO RESPITE ADULT FOSTER CARE LEVEL 1
CDS/ICM RESPITE ADULT FOSTER CARE LEVEL 1
ICM/MAO-RESPITE - ADULT FOSTER CARE LEVEL 1
ICM - RESPITE - FOSTER CARE - LEVEL 1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0612
G0613
G0614
G0615
G0616
G0617
G0618
G0619
G0620
G0621
G0622
G1101
G1201
G1202
G1203
G1204
G1205
G1206
G1207
G1208
G1209
G1210
G1211
G0237
T2038
G0817
G0128
G0132
G0132
G0133
G0133
G0134
G0134
G0172
W0155
W0156
W0157
Y0155
Y0156
Y0157
W0132
W0132
W0133
W0133
W0134
W0134
Y0132
Y0133
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
0660
0660
0660
0660
0660
0660
U3
U3
U4
U4
U5
U5
U2
U3
U4
U2
U3
U4
U3
U3
U4
U4
U5
U5
U3
U4
UB
UB
UB
UB
UB
UB
P
I
P
I
P
I
P
P
P
P
P
P
P
P
I
P
I
P
I
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2004
01/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
REVENUE
POS
CODE
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
U3
U4
U5
U5
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U8
U8
U7
U7
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
11BY
11BY
11BY
11BY
11C
11C
11C
11C
11C
11C
11C
11C
11C
11C
11C
11C
11CV
11CV
11CVW
11CVY
11CW
11CW
11CW
11CW
11CW
11CW
11CW
11CW
11CW
11CW
11CW
11CW
11CY
11CY
11CY
11CY
11CY
11CY
11CY
11CY
11CY
11CY
11CY
11CY
11D
11D
11D
11D
CPT
CODE
MODIFIER 4
Page 14 of 67

CDS ASSISTED LIVING APT RESPITE - IND
CDS - ASSISTED LIVING APT RESPITE - AGENCY
CDS/ICM/MAO- RESPITE - ASST
CDS/ICM- RESPITE - ASST
ICM/MAO - RESPITE - ASSISTED LIVING APT LEVEL 6
ICM/MAO RESPITE - ASSISTED LIVING APT LEVEL 3
ICM - RESPITE - ASSISTED LIVING APT (LEVEL 6)
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
Y0133
Y0133
Y0134
Y0134
G0135
G0135
G0136
G0136
G0137
G0137
G0138
G0138
G0139
G0139
G0140
G0140
G0173
G0174
W0159
Y0159
W0135
W0135
W0136
W0136
W0137
W0137
W0138
W0138
W0139
W0139
W0140
W0140
Y0135
Y0135
Y0136
Y0136
Y0137
Y0137
Y0138
Y0138
Y0139
Y0139
Y0140
Y0140
G0142
G0142
G0143
G0143
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
P
I
I
P
I
P
I
P
I
P
I
P
I
P
P
P
P
P
P
I
P
I
P
I
P
I
P
I
P
I
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
07/01/2007
07/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
REVENUE
POS
CODE
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
U6
U6
U5
U5
U4
U4
U3
U3
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
CLAIM FIL IND
11D
11D
11D
11D
11D
11D
11D
11D
11DV
11DV
11DVW
11DVY
11DW
11DW
11DW
11DW
11DW
11DW
11DW
11DW
11DW
11DW
11DW
11DW
11DY
11DY
11DY
11DY
11DY
11DY
11DY
11DY
11DY
11DY
11DY
11DY
11E
11E
11E
11E
11E
11E
11E
11E
11E
11E
11E
11E
CPT
CODE
MODIFIER 4
Page 15 of 67

CDS RESIDENTIAL CARE APT RESPITE - IND
CDS RESIDENTIAL CARE APT RESPITE - AGENCY
CDS/ICM/MAO- RESPITE - ASST
CDS/ICM- RESPITE - ASST
ICM/MAO RESPITE - RESIDENTIAL CARE APT LEVEL 6
ICM - RESPITE - ASST LIV RC APT (LEVEL 6)
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0144
G0144
G0145
G0145
G0146
G0146
G0147
G0147
G0175
G0176
W0160
Y0160
W0142
W0142
W0143
W0143
W0144
W0144
W0145
W0145
W0146
W0146
W0147
W0147
Y0142
Y0142
Y0143
Y0143
Y0144
Y0144
Y0145
Y0145
Y0146
Y0146
Y0147
Y0147
G0149
G0149
G0150
G0150
G0151
G0151
G0152
G0152
G0153
G0153
G0154
G0154
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
P
I
P
I
P
I
P
P
P
P
P
P
I
P
I
P
I
P
I
P
I
P
I
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
201
202
203
204
205
206
207
208
209
210
211
212
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
REVENUE
POS
CODE
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0660
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U8
U8
U7
U7
U6
U6
U5
U5
U4
U4
U3
U3
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
CLAIM FIL IND
11EV
11EV
11EVW
11EVY
11EW
11EW
11EW
11EW
11EW
11EW
11EW
11EW
11EW
11EW
11EW
11EW
11EY
11EY
11EY
11EY
11EY
11EY
11EY
11EY
11EY
11EY
11EY
11EY
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
CPT
CODE
MODIFIER 4
Page 16 of 67
CDS RESIDENTIAL CARE NON APT RESPITE - IND

CDS RESIDENTIAL CARE NON APT RESPITE - AGENCY
CDS/ICM/MAO - RESPITE - ASST
CDS/ICM - RESPITE - ASST
ICM/MAO RESPITE-RESIDENTIAL CARE NON APT LEVEL 6
ICM RESPITE - ASST LIV NON-APT (LEVEL 6)
RESPITE NF - TILE 201
RESPTIE NF - TILE 208
NF DAILY CARE RAD
NF DAILY CARE RAC
NF DAILY CARE RAB
RESPITE NF - RAA
RESPITE NF - SE3
RESPITE NF - SE2
RESPITE NF - SE1
RESPITE NF - SSC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0177
G0178
W0161
Y0161
W0149
W0149
W0150
W0150
W0151
W0151
W0152
W0152
W0153
W0153
W0154
W0154
Y0149
Y0149
Y0150
Y0150
Y0151
Y0151
Y0152
Y0152
Y0153
Y0153
Y0154
Y0154
N1201
N1202
N1203
N1204
N1205
N1206
N1207
N1208
N1209
N1210
N1211
N1212
RG101
RG102
RG103
RG104
RG105
RG106
RG107
RG108
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
I
P
I
P
I
P
I
P
I
P
I
I
P
I
P
I
P
I
P
I
P
I
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CA1
CB2
CB1
CA2
CA1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
REVENUE
POS
CODE
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
CLAIM FIL IND
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11FV
11FV
11FVW
11FVY
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
CPT
CODE
MODIFIER 4
Page 17 of 67
RESPITE NF - SSB
RESPITE NF - SSA
RESPITE NF - CC2
RESPITE NF - CC1
RESPITE NF - CB2
RESPITE NF - CB1
RESPITE NF - CA2
RESPITE NF - CA1
RESPITE NF - IB2
RESPITE NF - IB1
RESPITE NF - IA2
RESPITE NF - IA1
RESPITE NF - BB2
RESPITE NF - BB1
RESPITE NF - BA2
RESPITE NF - BA1
RESPITE NF - PE2
RESPITE NF - PE1
RESPITE NF - PD2
RESPITE NF - PD1
RESPITE NF - PC2
RESPITE NF - PC1
RESPITE NF - PB2
RESPITE NF - PB1
RESPITE NF - PA2
RESPITE NF - PA1
RESPITE NF - BC1
RESPITE NF - PCE
CDS-RESPITE NURSING FACILITY - IND
CDS-RESPITE NURSING FACILITY - AGENCY
CDS/ICM/MAO - RESPITE - NURSING FACILITY
CDS/ICM - RESPITE - NURSING FACILITY
ICM/MAO - RESPITE NF RAD
ICM/MAO - RESPITE NF RAC
ICM/MAO - RESPITE NF RAB
ICM/MAO - RESPITE NF RAA
ICM/MAO - RESPITE NF SE3
ICM/MAO - RESPITE NF SSC
ICM/MAO - RESPITE NF SSB
ICM/MAO - RESPITE NF SSA
ICM/MAO - RESPITE NF CC2
ICM/MAO - RESPITE NF CA1
ICM/MAO - RESPITE NF CB2
ICM/MAO - RESPITE NF CB1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG109
RG110
RG111
RG112
RG113
RG114
RG115
RG116
RG117
RG118
RG119
RG120
RG121
RG122
RG123
RG124
RG125
RG126
RG127
RG128
RG129
RG130
RG131
RG132
RG133
RG134
RG135
RG136
G0179
G0180
W0162
Y0162
RW101
RW102
RW103
RW104
RW105
RW106
RW107
RW108
RW109
RW110
RW111
RW112
RW113
RW114
RW115
RW116
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
P
P
P
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
201
202
203
204
205
206
207
208
209
210
211
212
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
REVENUE
POS
CODE
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
CLAIM FIL IND
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FW
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
CPT
CODE
MODIFIER 4
Page 18 of 67
ICM/MAO - RESPITE NF IB2

ICM/MAO - RESPITE NF IB1
ICM/MAO - RESPITE NF IA2
ICM/MAO - RESPITE NF IA1
ICM/MAO - RESPITE NF BB2
ICM/MAO - RESPITE NF BB1
ICM/MAO - RESPITE NF BA2
ICM/MAO - RESPITE NF BA1
ICM/MAO - RESPITE NF PE2
ICM/MAO - RESPITE NF PE1
ICM/MAO - RESPITE NF PD2
ICM/MAO - RESPITE NF PD1
ICM/MAO - RESPITE NF PC2
ICM/MAO - RESPITE NF PC1
ICM/MAO - RESPITE NF PB2
ICM/MAO - RESPITE NF PB1
ICM/MAO - RESPITE NF PA2
ICM/MAO - RESPITE NF PA1
ICM/MAO - RESPITE NF BC1
ICM/MAO - RESPITE NF PCE
ICM/MAO - RESPITE - NURSING FACILITY TILE 201
ICM - RESPITE NF RAD
ICM - RESPITE NF RAC
ICM - RESPITE NF RAB
ICM - RESPITE NF RAA
ICM - RESPITE NF SE3
ICM - RESPITE NF SSC
ICM - RESPITE NF SSB
ICM - RESPITE NF SSA
ICM - RESPITE NF CC2
ICM - RESPITE NF CC1
ICM - RESPITE NF CB2
ICM - RESPITE NF CB1
ICM - RESPITE NF CA2
ICM - RESPITE NF CA1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RW117
RW118
RW119
RW120
RW121
RW122
RW123
RW124
RW125
RW126
RW127
RW128
RW129
RW130
RW131
RW132
RW133
RW134
RW135
RW136
W1201
W1202
W1203
W1204
W1205
W1206
W1207
W1208
W1209
W1210
W1211
W1212
RY101
RY102
RY103
RY104
RY105
RY106
RY107
RY108
RY109
RY110
RY111
RY112
RY113
RY114
RY115
RY116
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
201
202
203
204
205
206
207
208
209
210
211
212
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5150
S5150
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S9124
T1003
S9124
T1003
S9124
T1003
S9123
T1001
T1002
S9123
REVENUE
POS
CODE
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
UC
UC
CLAIM FIL IND
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11FY
11PVW
11PVY
11W
11Y
12A
13A
13A
13AW
13AW
13AY
13AY
13B
13B
13B
13BW
CPT
CODE
MODIFIER 4
Page 19 of 67
ICM - RESPITE NF IB2

ICM - RESPITE NF IB1
ICM - RESPITE NF IA2
ICM - RESPITE NF IA1
ICM - RESPITE NF BB2
ICM - RESPITE NF BB1
ICM - RESPITE NF BA2
ICM - RESPITE NF BA1
ICM - RESPITE NF PE2
ICM - RESPITE NF PE1
ICM - RESPITE NF PD2
ICM - RESPITE NF PD1
ICM - RESPITE NF PC2
ICM - RESPITE NF PC1
ICM - RESPITE NF PB2
ICM - RESPITE NF PB1
ICM - RESPITE NF PA2
ICM - RESPITE NF PA1
ICM - RESPITE NF BC1
ICM - RESPITE NF PCE
ICM - RESPITE - NURSING FACILITY TILE 201
CDS/ICM/MAO - RESPITE-IN-HOME
CDS/ICM - RESPITE-IN-HOME
ICM/MAO - RESPITE - IN-HOME
ICM - RESPITE IN HOME
TARGETED CASE MANAGEMENT
NURSING SERVICES - LVN
ICM/MAO NURSING SERVICES - LVN
ICM/MAO NURSING SERVICES - LVN
ICM NURSING CARE - LVN
ICM NURSING SERVICES BY LPN/LVN
Nursing Services in the Home - RN
Nursing Services - RN - Assessment/evaluation
Nursing Services - RN
ICM/MAONURSING SERVICES IN THE HOME - RN
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RY117
RY118
RY119
RY120
RY121
RY122
RY123
RY124
RY125
RY126
RY127
RY128
RY129
RY130
RY131
RY132
RY133
RY134
RY135
RY136
Y1201
Y1202
Y1203
Y1204
Y1205
Y1206
Y1207
Y1208
Y1209
Y1210
Y1211
Y1212
W0158
Y0158
W0101
Y0101
G0216
G0302
G0302
W0302
W0302
Y0302
Y0302
G0303
G0303
G0303
W0303
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
09/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Y0303
Y0303
S9800
T1002
G0815
W0815
G0815
W1002
Y1002
T1003
T1003
G0816
W0816
Y0816
W1003
Y1003
G0304
G0305
G0317
W0304
W0305
W0317
Y0304
Y0305
Y0317
W0300
W0300
W0300
W0301
W0301
Y0300
Y0300
Y0300
Y0301
Y0301
W0500
W0500
W0500
W0500
W0500
W0500
W0500
ICM NURSING SERVICES - RN - ASSESSMENT/EVALUATION

ICM NURSING SERVICES - RN
CDS SPECIALIZED NURSING RN
ICM/MAO CDS SPECIALIZED NURSING LVN
ICM CDS SPECIALIZED NURSING RN
ICM/MAO SPECIALIZED NURSING RN
ICM SPECIALIZED NURSING RN
CDS SPECIALIZED NURSING LVN
ICM/MAO CDS SPECIALIZED NURSING LVN
ICM CDS SPECIALIZED NURSING LVN
ICM/MAO SPECIALIZED NURSING LVN
ICM SPECIALIZED NURSING LVN
CDS NURSING RN
CDS NURSING LVN
CDS NURSING ASSESSMENT RN
CDS/ICM/MAO NURSING RN
CDS/ICM/MAO NURSING LVN
CDS/ICM/MAO NURSING ASSESSMENT RN
CDS/ICM/SSI NURSING RN
CDS/ICM/SSI NURSING LVN
CDS/ICM/SSI NURSING ASSESSMENT RN
ICM/MAO NURSING CARE - RN
ICM/MAO NURSING ASSESSMENT/EVALUATION
ICM/MAO NURSING SERVICES - RN PARTIAL UNIT
ICM/MAO NURSING CARE - LVN
ICM/MAO NURSING SERVICES - LVN/LPN PARTIAL UNIT
ICM NURSING CARE - RN
ICM NURSING ASSESSMENT/EVALUATION
ICM NURSING SERVICES - RN PARTIAL UNIT
ICM NURSING CARE - LVN
ICM NURSING SERVICES - LVN/LPN PARTIAL UNIT
ICM/MAO DME/ADP AIDS - VEHICLE MODIFICATIONS
ICM/MAO DME/ADP AIDS - POSITIONING DEVICE
ICM/MAO DME/ADP AIDS - ROLLING CHAIR
ICM/MAO DME/ADP AIDS - STANDARD WHEELCHAIR
ICM/MAO DME/ADAPTIVE AIDS - COMMUNICATION-OTHER
ICM/MAO DME - MEDICAL EQUIPMENT
ICM/MAO MEDICAL SUPPLIES - SPECIALIZED SUPPLIES
Page 20 of 67
REVENUE
POS
CODE
CLAIM FIL IND
ICM/MAO NURSING SERVICES - RN ASSESSMENT/EVALUATION

ICM/MAO NURSING SERVICES - RN
ICM NURSING SERVICES IN THE HOME - RN
CPT
CODE
MODIFIER 4
W0303
W0303
Y0303
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
3
3
3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
13BW
13BW
13BY
HC
HC
HC
T1001
T1002
S9123
P
P
P
A
A
A
09/01/2007
09/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
13BY
13BY
13C
13C
13CV
13CVW
13CVY
13CW
13CY
13D
13D
13DV
13DVW
13DVY
13DW
13DY
13V
13V
13V
13VW
13VW
13VW
13VY
13VY
13VY
13W
13W
13W
13W
13W
13Y
13Y
13Y
13Y
13Y
15W
15W
15W
15W
15W
15W
15W
HC
HC
HC
HC
ZZ
ZZ
ZZ
HC
HC
HC
HC
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T1001
T1002
S9800
T1002
TG
TG
T1002
T1002
T1003
T1003
TG
TG
TG
TG
TE
TE
T1003
T1003
T1002
T1003
T1001
T1002
T1003
T1001
T1002
T1003
T1001
S9123
T1001
T1002
S9124
T1003
S9123
T1001
T1002
S9124
T1003
T2039
E0636
E1031
E1130
E1902
T2029
T2028
TG
TG
TE
TE
TD
TE
TD
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
07/01/2007
07/01/2007
10/16/2003
01/01/2008
01/01/2008
01/01/2008
01/01/2008
01/01/2008
01/01/2008
10/16/2003
01/01/2008
01/01/2008
01/01/2008
01/01/2008
01/01/2008
01/01/2008
05/01/2008
05/01/2008
05/01/2008
05/01/2008
05/01/2008
05/01/2008
05/01/2008
05/01/2008
05/01/2008
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
12/31/2199
12/31/2199
12/31/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
TD
TE
TD
TE
TD
TD
TE
TD
TD
TD
TD
TE
TE
TD
TD
TD
TE
TE

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
W0500
Y0500
Y0500
Y0500
Y0500
3
3
3
3
Y0500
Y0500
Y0500
Y0500
3
3
3
3
3
REVENUE
POS
CODE
CLAIM FIL IND
G0719
3
3
3
3
3
CPT
CODE
MODIFIER 4
W0500
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
Y0500
W0608
Y0608
G0717
G0717
ICM/MAO DME/ADAPTIVE AIDS - COMMUNICATIONELECTRONIC DEVICE

ICM/MAO DME/ADP AIDS - MISCELLANEOUS (HOSPITAL
BEDS/VENTILATOR)
ICM DME/ADP AIDS - VEHICLE MODIFICATIONS
ICM DME/ADP AIDS - POSITIONING DEVICE
ICM DME/ADP AIDS - ROLLING CHAIR
ICM DME/ADP AIDS - STANDARD WHEELCHAIR
ICM DME/ADAPTIVE AIDS - COMMUNICATION-ELECTRONIC
DEVICE
ICM DME/ADAPTIVE AIDS - COMMUNICATION-OTHER
ICM DME - MEDICAL EQUIPMENT
ICM MEDICAL SUPPLIES - SPECIALIZED SUPPLIES
ICM DME/ADP AIDS - MISCELLANEOUS (HOSPITAL
BEDS/VENTILATOR)
ICM/MAO HOME MODIFICATIONS
ICM - HOME MODIFICATIONS
CDS-PERSONAL ASSISTANCE SERVICES (PAS) - IND
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
15W
HC
E1900
09/01/2007
01/31/2008
15W
15Y
15Y
15Y
15Y
HC
HC
HC
HC
HC
E1399
T2039
E0636
E1031
E1130
P
P
P
P
P
A
A
A
A
A
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
15Y
15Y
15Y
15Y
HC
HC
HC
HC
E1900
E1902
T2029
T2028
P
P
P
P
A
A
A
A
07/01/2007
07/01/2007
07/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
15Y
16W
16Y
17V
17V
HC
HC
HC
ZZ
HC
E1399
S5165
S5165
P
P
P
P
P
A
A
A
A
A
07/01/2007
09/01/2007
07/01/2007
01/01/1900
06/01/2005
12/31/2199
12/31/2199
12/31/2199
05/31/2005
12/31/2199
CDS-PERSONAL ASSISTANCE SERVICES (PAS) - AGENCY
17V
ZZ
01/01/1900
05/31/2005
G0719
W0163
Y0163

CDS/ICM/MAO-PERSONAL ASSISTANCE SERVICES (PAS)
CDS/ICM-PERSONAL ASSISTANCE SERVICES(PAS)
17V
17VW
17VY
HC
HC
HC
S5125
S5125
S5151
UC
UB
UB
P
P
P
A
A
A
06/01/2005
09/01/2007
09/01/2007
12/31/2199
12/31/2199
12/31/2199
W0701
Y0701
W0800
W0801
W0802
Y0800
Y0801
Y0802
G0921
G0921
G0922
G0922
G0923
G0923
G0924
G0924
G0925
G0925
G0925
G0925
G0925
G0925
ICM/MAO PERSONAL ASSISTANCE SRVS LEVEL 2 - PRIORITY

ICM PERSONAL ASSISTANCE SERVICES (PAS)
ICM/MAO ADULT FOSTER CARE - LEVEL 1
ICM/MAOADULT FOSTER CARE - LEVEL 2
ICM/MAO ADULT FOSTER CARE - LEVEL 3
ICM ADULT FOSTER CARE LEVEL 1
AL RESIDENTIAL CARE - APT (LEVEL 6)
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5125
S5125
S5140
S5140
S5140
S5140
S5140
S5140
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
P
P
I
I
I
I
I
I
P
I
P
I
P
I
P
I
I
I
I
P
P
I
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
09/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
Page 21 of 67
17W
17Y
18W
18W
18W
18Y
18Y
18Y
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
PR
PR
AL
AL
AL
AL
AL
AL
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
2
2
1
2
3
1
2
3
211
211
210
210
209
209
208
208
202
207
206
202
207
206
S5125
UB
3105
3105
3105
3105
3105
3105
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2

CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
201
203
204
205
201
203
204
205
BC1
PA1
BA1
PA2
BA2
IA1
IA2
BC1
PA1
BA1
PA2
BA2
IA1
IA2
PB1
CA1
PB2
PB1
CA1
PB2
SSA
PC2
BB2
IB2
PD1
SSA
PC2
BB2
IB2
PD1
CA2
PC1
BB1
IB1
CA2
PC1
BB1
IB1
RAB
RAA
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
CLAIM FIL IND
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
CPT
CODE
MODIFIER 4
Page 22 of 67

AL RESIDENTIAL CARE - APT (LEVEL 6) BC1
AL RESIDENTIAL CARE - APT (LEVEL 6) PA1
AL RESIDENTIAL CARE - APT (LEVEL 6) BA1
AL RESIDENTIAL CARE - APT (LEVEL 6) IA1
AL RESIDENTIAL CARE - APT (LEVEL 6) BC1
AL RESIDENTIAL CARE - APT (LEVEL 5) PB1
AL RESIDENTIAL CARE - APT (LEVEL 5) CA1
AL RESIDENTIAL CARE - APT (LEVEL 4) SSA
AL RESIDENTIAL CARE - APT (LEVEL 4) PC2
AL RESIDENTIAL CARE - APT (LEVEL 4) BB2
AL RESIDENTIAL CARE - APT (LEVEL 4) IB2
AL RESIDENTIAL CARE - APT (LEVEL 4) PD1
AL RESIDENTIAL CARE - APT (LEVEL 4) SSA
AL RESIDENTIAL CARE - APT (LEVEL 2) RAB
AL RESIDENTIAL CARE - APT (LEVEL 2) RAA
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0926
G0926
G0926
G0926
G0926
G0926
G0926
G0926
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG921
RG922
RG922
RG922
RG922
RG922
RG922
RG923
RG923
RG923
RG923
RG923
RG923
RG923
RG923
RG923
RG923
RG924
RG924
RG924
RG924
RG924
RG924
RG924
RG924
RG925
RG925
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
P
P
P
P
P
P
P
P
P
P
P
I
I
I
I
I
I
I
P
P
P
I
I
I
P
P
P
P
P
I
I
I
I
I
P
P
P
P
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CB1
RAC
CB2
SE2
PD2
PE1
SSB
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SSC
CC1
RAD
SSC
CC1
RAD
CC2
PE2
SE3
SE1
SE1
CC2
PE2
SE3
211
211
210
210
209
209
208
208
202
206
207
202
206
207
201
203
204
205
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U1
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19A
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
CPT
CODE
MODIFIER 4
Page 23 of 67
AL RESIDENTIAL CARE - APT (LEVEL 2) CB1

AL RESIDENTIAL CARE - APT (LEVEL 2) RAC
AL RESIDENTIAL CARE - APT (LEVEL 2) SE2
AL RESIDENTIAL CARE - APT (LEVEL 2) PE1
AL RESIDENTIAL CARE - APT (LEVEL 2) SSB
AL RESIDENTIAL CARE - APT (LEVEL 2) RAA
AL RESIDENTIAL CARE - APT (LEVEL 2) RAB
AL RESIDENTIAL CARE - APT (LEVEL 2) RAC
AL RESIDENTIAL CARE - APT (LEVEL 2) SSB
AL RESIDENTIAL CARE - APT (LEVEL 1) SSC
AL RESIDENTIAL CARE - APT (LEVEL 1) CC1
AL RESIDENTIAL CARE - APT (LEVEL 1) RAD
AL RESIDENTIAL CARE - APT (LEVEL 1) SSC
AL RESIDENTIAL CARE - APT (LEVEL 1) RAD
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 6)
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG925
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
RG926
W0921
W0921
W0922
W0922
W0923
W0923
W0924
W0924
W0925
W0925
W0925
W0925
W0925
W0925
W0926
W0926
W0926
W0926
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
P
P
P
P
P
P
P
P
P
P
P
P
I
I
I
I
I
I
P
I
P
P
P
P
I
P
I
P
I
P
I
P
P
P
I
I
I
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009

CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
201
203
204
205
BC1
BA1
PA2
BA2
IA1
BC1
PA1
BA1
PA2
BA2
IA1
IA2
PA1
PB1
CA1
PB2
PB1
CA1
PB2
SSA
BB2
IB2
PD1
BB2
PC2
IB2
PD1
PC2
SSA
CA2
PC1
BB1
IB1
CA2
PC1
BB1
IB1
RAA
RAB
CB1
RAC
CB2
SE2
PD2
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
CPT
CODE
MODIFIER 4
Page 24 of 67

ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 6) BC1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 6) BA1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 6) PA2
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 6) IA1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 6) BC1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 5) PB1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 5) CA1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 4) SSA
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 4) BB2
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 4) IB2
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 4) PD1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 4) PC2
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 4) SSA
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) RAA
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) RAB
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) CB1
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) RAC
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) SE2
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
W0926
W0926
W0926
W0926
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR921
WR922
WR922
WR922
WR922
WR922
WR922
WR923
WR923
WR923
WR923
WR923
WR923
WR923
WR923
WR923
WR923
WR924
WR924
WR924
WR924
WR924
WR924
WR924
WR924
WR925
WR925
WR925
WR925
WR925
WR925
WR925
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
P
P
P
P
P
I
I
I
I
I
I
I
P
P
P
P
I
I
I
P
P
P
P
I
I
I
I
P
I
P
P
P
P
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
PE1
SSB
RAB
RAA
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SE1
SE3
PE2
CC2
RAD
CC1
SSC
SSC
CC1
RAD
CC2
PE2
SE3
SE1
211
211
210
210
209
209
208
208
206
202
207
202
206
207
201
203
204
205
203
204
205
201
PA2
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AW
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
CPT
CODE
MODIFIER 4
Page 25 of 67
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) PE1

ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) SSB
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) RAB
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) RAA
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) RAC
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 2) SSB
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 1) CC2
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 1) RAD
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 1) SSC
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 1) SSC
ICM/MAO AL RESIDENTIAL CARE - APT (LEVEL 1) RAD
ICM AL RESIDENTIAL CARE - APT (LEVEL 6)
ICM AL RESIDENTIAL CARE - APT (LEVEL 6) PA2
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
WR925
WR925
WR925
WR925
WR925
WR925
WR925
WR925
WR925
WR925
WR925
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
WR926
Y0921
Y0921
Y0922
Y0922
Y0923
Y0923
Y0924
Y0924
Y0925
Y0925
Y0925
Y0925
Y0925
Y0925
Y0926
Y0926
Y0926
Y0926
Y0926
Y0926
Y0926
Y0926
YR921
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
I
I
I
I
I
I
I
P
I
P
I
P
I
P
I
I
I
I
P
P
P
I
I
I
I
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
BA2
IA1
IA2
PA2
BA2
IA1
IA2
PA1
PA1
BA1
BA1
PB1
CA1
PB2
PB1
CA1
PB2
SSA
PC2
BB2
IB2
PD1
SSA
PC2
BB2
IB2
PD1
CA2
PC1
BB1
IB1
CA2
PC1
BB1
IB1
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
RAA
RAB
CB1
RAC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2030
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
CPT
CODE
MODIFIER 4
Page 26 of 67
ICM AL RESIDENTIAL CARE - APT (LEVEL 6) BA2

ICM AL RESIDENTIAL CARE - APT (LEVEL 6) IA1
ICM AL RESIDENTIAL CARE - APT (LEVEL 6) BA2
ICM/AL RESIDENTIAL CARE - APT (LEVEL 6) BA1
ICM/AL RESIDENTIAL CARE - APT (LEVEL 6) BA1
ICM AL RESIDENTIAL CARE - APT (LEVEL 5) PB1
ICM AL RESIDENTIAL CARE - APT (LEVEL 5) CA1
ICM AL RESIDENTIAL CARE - APT (LEVEL 4) SSA
ICM AL RESIDENTIAL CARE - APT (LEVEL 4) PC2
ICM AL RESIDENTIAL CARE - APT (LEVEL 4) BB2
ICM AL RESIDENTIAL CARE - APT (LEVEL 4) IB2
ICM AL RESIDENTIAL CARE - APT (LEVEL 4) PD1
ICM AL RESIDENTIAL CARE - APT (LEVEL 4) SSA
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) RAA
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) RAB
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) CB1
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) RAC
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) SE2
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) PE1
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) SSB
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) RAA
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) RAB
ICM AL RESIDENTIAL CARE - APT (LEVEL 2) RAC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
YR921
YR921
YR921
YR921
YR921
YR921
YR921
YR921
YR921
YR921
YR921
YR922
YR922
YR922
YR922
YR922
YR922
YR923
YR923
YR923
YR923
YR923
YR923
YR923
YR923
YR923
YR923
YR924
YR924
YR924
YR924
YR924
YR924
YR924
YR924
YR925
YR925
YR925
YR925
YR925
YR925
YR925
YR925
YR925
YR925
YR925
YR925
YR925
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
I
I
I
I
P
I
P
I
P
P
P
I
I
I
P
P
P
P
P
I
I
I
I
I
P
P
P
P
I
I
I
I
I
I
I
I
I
I
I
I
I
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CB2
SE2
PD2
PE1
SSB
SSC
CC1
RAD
CC2
PE2
SE3
SE1
SSC
CC1
RAD
CC2
PE2
SE3
SE1
211
210
209
208
202
206
207
201
203
204
205
BC1
PA1
BA1
PA2
BA2
IA1
IA2
CA1
PA2
PB1
SSA
PC2
BB2
IB2
PD1
CA2
PC1
BB1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
CLAIM FIL IND
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19AY
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
CPT
CODE
MODIFIER 4
Page 27 of 67

ICM AL RESIDENTIAL CARE - APT (LEVEL 2) SSB
ICM AL RESIDENTIAL CARE - APT (LEVEL 1) SSC
ICM AL RESIDENTIAL CARE - APT (LEVEL 1) CC1
ICM AL RESIDENTIAL CARE - APT (LEVEL 1) RAD
ICM AL RESIDENTIAL CARE - APT (LEVEL 1) SSC
ICM AL RESIDENTIAL CARE - APT (LEVEL 1) RAD
AL RESIDENTIAL CARE - NON APT (LEVEL 6)
AL RESIDENTIAL CARE - NON APT (LEVEL 6) BC1
AL RESIDENTIAL CARE - NON APT (LEVEL 6) PA1
AL RESIDENTIAL CARE - NON APT (LEVEL 6) BA1
AL RESIDENTIAL CARE - NON APT (LEVEL 6) BA2
AL RESIDENTIAL CARE - NON APT (LEVEL 6) IA1
AL RESIDENTIAL CARE - NON APT (LEVEL 6) IA2
AL RESIDENTIAL CARE - NON APT (LEVEL 5) CA1
AL RESIDENTIAL CARE - NON APT (LEVEL 5) PB2
AL RESIDENTIAL CARE - NON APT (LEVEL 5) PB1
AL RESIDENTIAL CARE - NON APT (LEVEL 4) SSA
AL RESIDENTIAL CARE - NON APT (LEVEL 4) PC2
AL RESIDENTIAL CARE - NON APT (LEVEL 4) BB2
AL RESIDENTIAL CARE - NON APT (LEVEL 4) IB2
AL RESIDENTIAL CARE - NON APT (LEVEL 4) PD1
AL RESIDENTIAL CARE - NON APT (LEVEL 3) CA2
AL RESIDENTIAL CARE - NON APT (LEVEL 3) PC1
AL RESIDENTIAL CARE - NON APT (LEVEL 3) BB1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
YR925
YR925
YR925
YR925
YR925
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
YR926
G0928
G0929
G0930
G0931
G0932
G0932
G0932
G0933
G0933
G0933
G0933
RG928
RG928
RG928
RG928
RG928
RG928
RG928
RG929
RG929
RG929
RG930
RG930
RG930
RG930
RG930
RG931
RG931
RG931
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
I
I
I
I
I
I
I
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
IB1
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SSC
CC1
RAD
CC2
PE2
SE3
SE1
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
211
210
209
208
202
206
207
201
203
204
205
BC1
BA1
PA2
BA2
IA1
IA2
PA1
PB1
CA1
PB2
SSA
PC2
BB2
IB2
PD1
CA2
PC1
BB1
IB1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
CLAIM FIL IND
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19B
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
CPT
CODE
MODIFIER 4
Page 28 of 67
AL RESIDENTIAL CARE - NON APT (LEVEL 3) IB1

AL RESIDENTIAL CARE - NON APT (LEVEL 2) RAA
AL RESIDENTIAL CARE - NON APT (LEVEL 2) RAB
AL RESIDENTIAL CARE - NON APT (LEVEL 2) CB1
AL RESIDENTIAL CARE - NON APT (LEVEL 2) RAC
AL RESIDENTIAL CARE - NON APT (LEVEL 2) CB2
AL RESIDENTIAL CARE - NON APT (LEVEL 2) SE2
AL RESIDENTIAL CARE - NON APT (LEVEL 2) PD2
AL RESIDENTIAL CARE - NON APT (LEVEL 2) PE1
AL RESIDENTIAL CARE - NON APT (LEVEL 2) SSB
AL RESIDENTIAL CARE - NON APT (LEVEL 1) SSC
AL RESIDENTIAL CARE - NON APT (LEVEL 1) CC1
AL RESIDENTIAL CARE - NON APT (LEVEL 1) RAD
AL RESIDENTIAL CARE - NON APT (LEVEL 1) CC2
AL RESIDENTIAL CARE - NON APT (LEVEL 1) PE2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6)
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) BC1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) BA1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) PA2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) BA2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) IA1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) IA2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) PA1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) PB1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) CA1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 6) PB2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 4) SSA
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 4) PC2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 4) BB2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 4) IB2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 4) PD1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 3) CA2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 3) PC1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 3) BB1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 3) IB1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG931
RG932
RG932
RG932
RG932
RG932
RG932
RG932
RG932
RG932
RG933
RG933
RG933
RG933
RG933
RG933
RG933
W0928
W0928
W0929
W0930
W0931
W0932
W0932
W0932
W0933
W0933
W0933
W0933
WR928
WR928
WR928
WR928
WR928
WR928
WR928
WR929
WR929
WR929
WR930
WR930
WR930
WR930
WR930
WR931
WR931
WR931
WR931
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SSC
CC1
RAD
CC2
PE2
SE3
SE1
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
211
210
209
208
202
206
207
201
203
204
205
PA2
BA2
IA1
IA2
BA1
PA1
PB1
CA1
PB2
PC2
BB2
IB2
PD1
SSA
CA2
PC1
BB1
IB1
RAA
RAB
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
CLAIM FIL IND
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BW
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
CPT
CODE
MODIFIER 4
Page 29 of 67
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) RAA

ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) RAB
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) CB1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) RAC
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) CB2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) SE2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) PD2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) PE1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 2) SSB
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 1) SSC
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 1) CC1
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 1) RAD
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 1) CC2
ICM/MAO RESIDENTIAL CARE - NON APT (LEVEL 1) PE2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 6)
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 6) PA2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 6) BA2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 6) IA1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 6) IA2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 6) BA1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 5) PB1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 5) CA1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 5) PB2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 4) PC2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 4) BB2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 4) IB2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 4) PD1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 4) SSA
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 3) CA2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 3) PC1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 3) BB1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 3) IB1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) RAA
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) RAB
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
WR932
WR932
WR932
WR932
WR932
WR932
WR932
WR932
WR932
WR933
WR933
WR933
WR933
WR933
WR933
WR933
Y0928
Y0928
Y0929
Y0930
Y0931
Y0932
Y0932
Y0932
Y0933
Y0933
Y0933
Y0933
YR928
YR928
YR928
YR928
YR928
YR928
YR929
YR929
YR929
YR930
YR930
YR930
YR930
YR930
YR931
YR931
YR931
YR931
YR932
YR932
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SSC
CC1
RAD
CC2
SE3
SE1
PE2
205
205
205
211
211
210
210
209
209
208
208
202
206
207
202
206
207
201
203
204
205
201
203
204
205
BC1
PA1
BA1
PA2
BA2
IA1
IA2
BC1
PA1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U2
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19BY
19C
19CW
19CY
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
CPT
CODE
MODIFIER 4
Page 30 of 67
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) CB1

ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) RAC
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) CB2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) SE2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) PD2
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) PE1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 2) SSB
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 1) SSC
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 1) CC1
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 1) RAD
ICM AL RESIDENTIAL CARE - NON APT (LEVEL 1) CC2
ICM AL RESIDENTIAL CARE- NON APT (LEVEL 1) PE2
ASSISTED LIVING - PERSONAL CARE 3
ICM/MAO ASSISTED LIVING - PERSONAL CARE 3
ICM ASSISTED LIVING- PERSONAL CARE 3
ICM/MAO ASSISTED LIVING - APT (LEVEL 6)
ICM/MAO ASSISTED LIVING - APT (LEVEL 6) BC1
ICM/MAO ASSISTED LIVING - APT (LEVEL 6) PA1
ICM/MAO ASSISTED LIVING - APT (LEVEL 6) BA1
ICM/MAO ASSISTED LIVING - APT (LEVEL 6) IA1
ICM/MAO ASSISTED LIVING - APT (LEVEL 6) BC1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
YR932
YR932
YR932
YR932
YR932
YR932
YR932
YR933
YR933
YR933
YR933
YR933
YR933
YR933
G0935
W0935
Y0935
W0900
W0900
W1900
W1900
W2900
W2900
W3900
W3900
W4900
W4900
W4900
W4900
W4900
W4900
W5900
W5900
W5900
W5900
W5900
W5900
W5900
W5900
WR009
WR009
WR009
WR009
WR009
WR009
WR009
WR009
WR009
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
I
P
I
P
I
P
I
P
P
P
I
I
I
P
P
P
P
I
I
I
I
P
P
P
P
P
P
P
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
09/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
BA1
PA2
BA2
IA1
IA2
PB1
CA1
PB2
PB1
CA1
PB2
SSA
PC2
BB2
IB2
PD1
SSA
PC2
BB2
IB2
PD1
CA2
PC1
BB1
IB1
CA2
PC1
BB1
IB1
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
SSC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
CPT
CODE
MODIFIER 4
Page 31 of 67

ICM/MAO ASSISTED LIVING - APT (LEVEL 5) PB1
ICM/MAO ASSISTED LIVING - APT (LEVEL 5) CA1
ICM/MAO ASSISTED LIVING - APT (LEVEL 4) SSA
ICM/MAO ASSISTED LIVING - APT (LEVEL 4) PC2
ICM/MAO ASSISTED LIVING - APT (LEVEL 4) BB2
ICM/MAO ASSISTED LIVING - APT (LEVEL 4) IB2
ICM/MAO ASSISTED LIVING - APT (LEVEL 4) PD1
ICM/MAO ASSISTED LIVING - APT (LEVEL 4) SSA
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) RAA
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) RAB
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) CB1
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) RAC
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) SE2
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) PE1
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) SSB
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) RAA
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) RAB
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) RAC
ICM/MAO ASSISTED LIVING - APT (LEVEL 2) SSB
ICM/MAO ASSISTED LIVING - APT (LEVEL 1) SSC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
WR009
WR009
WR009
WR009
WR009
WR019
WR019
WR019
WR019
WR019
WR019
WR029
WR029
WR029
WR029
WR029
WR029
WR029
WR029
WR029
WR029
WR039
WR039
WR039
WR039
WR039
WR039
WR039
WR039
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR049
WR059
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
P
P
P
I
I
I
P
P
P
P
P
I
I
I
I
I
P
P
P
P
I
I
I
I
P
P
P
P
P
P
P
P
P
I
I
I
I
I
I
I
I
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CT
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CC1
RAD
CC2
PE2
SE3
SE1
SSC
CC1
RAD
CC2
PE2
SE1
SE3
211
211
210
210
209
209
208
208
202
206
207
202
206
207
201
203
204
205
201
203
204
205
PA2
BA2
IA1
IA2
PA2
BA2
IA1
IA2
PA1
PA1
BA1
BA1
PB1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19W
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
CPT
CODE
MODIFIER 4
Page 32 of 67
ICM/MAO ASSISTED LIVING - APT (LEVEL 1) CC1

ICM/MAO ASSISTED LIVING - APT (LEVEL 1) RAD
ICM/MAO ASSISTED LIVING - APT (LEVEL 1) SSC
ICM/MAO ASSISTED LIVING - APT (LEVEL 1) RAD
ICM ASSISTED LIVING - APT (LEVEL 6)
ICM ASSISTED LIVING - APT (LEVEL 6) PA2
ICM ASSISTED LIVING - APT (LEVEL 6) BA2
ICM ASSISTED LIVING - APT (LEVEL 6) IA1
ICM ASSISTED LIVING - APT (LEVEL 5) PB1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
WR059
WR059
WR059
WR059
WR059
WR059
WR059
WR059
WR059
WR059
WR059
WR059
YR059
Y0900
Y0900
Y1900
Y1900
Y2900
Y2900
Y3900
Y3900
Y4900
Y4900
Y4900
Y4900
Y4900
Y4900
Y5900
Y5900
Y5900
Y5900
Y5900
Y5900
Y5900
Y5900
YR009
YR009
YR009
YR009
YR009
YR009
YR009
YR009
YR009
YR009
YR009
YR009
YR019
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
I
I
I
I
I
I
I
P
I
P
I
P
I
P
I
P
P
P
I
I
I
P
P
P
P
I
I
I
I
P
P
P
P
I
I
I
I
P
I
P
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
11/30/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CR
CA1
PB2
PB1
CA1
PB2
SSA
PC2
BB2
IB2
PD1
BB2
PC2
IB2
PD1
SSA
CA2
PC1
BB1
IB1
CA2
PC1
BB1
IB1
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
RAA
RAB
CB1
RAC
CB2
SE2
PD2
PE1
SSB
CC2
PE2
SE1
SSC
CC1
RAD
SSC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
T2031
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
0240
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
19Y
CPT
CODE
MODIFIER 4
Page 33 of 67
ICM ASSISTED LIVING - APT (LEVEL 5) CA1

ICM ASSISTED LIVING - APT (LEVEL 4) SSA
ICM ASSISTED LIVING - APT (LEVEL 4) PC2
ICM ASSISTED LIVING - APT (LEVEL 4) BB2
ICM ASSISTED LIVING - APT (LEVEL 4) IB2
ICM ASSISTED LIVING - APT (LEVEL 4) PD1
ICM ASSISTED LIVING - APT (LEVEL 4) SSA
ICM ASSISTED LIVING - APT (LEVEL 2) RAA
ICM ASSISTED LIVING - APT (LEVEL 2) RAB
ICM ASSISTED LIVING - APT (LEVEL 2) CB1
ICM ASSISTED LIVING - APT (LEVEL 2) RAC
ICM ASSISTED LIVING - APT (LEVEL 2) SE2
ICM ASSISTED LIVING - APT (LEVEL 2) PE1
ICM ASSISTED LIVING - APT (LEVEL 2) SSB
ICM ASSISTED LIVING - APT (LEVEL 2) RAA
ICM ASSISTED LIVING - APT (LEVEL 2) RAB
ICM ASSISTED LIVING - APT (LEVEL 2) RAC
ICM ASSISTED LIVING - APT (LEVEL 2) SSB
ICM ASSISTED LIVING - APT (LEVEL 1) CC2
ICM ASSISTED LIVING - APT (LEVEL 1) SSC
ICM ASSISTED LIVING - APT (LEVEL 1) RAD
ICM ASSISTED LIVING - APT (LEVEL 1) SSC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
YR019
YR019
YR019
YR019
YR019
YR029
YR029
YR029
YR029
YR029
YR029
YR029
YR029
YR029
YR029
YR039
YR039
YR039
YR039
YR039
YR039
YR039
YR039
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR049
YR059
YR059
YR059
YR059
YR059
YR059
YR059
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
I
I
I
P
P
P
P
P
I
I
I
I
I
P
P
P
P
I
I
I
I
P
P
P
P
P
P
P
P
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Y1000
Y1000
W1200
W1200
Y1200
Y1200
W0102
Y0102
G0722
G0207
W0207
Y0207
G1212
G1213
G1214
G1215
G1216
G1217
G1218
G1219
G1220
G1221
G1222
W1223
W1213
W1214
W1215
W1216
W1217
W1218
W1219
W1220
W1221
W1222
Y1223
Y1213
ICM EMERGENCY RESPONSE SERVICES - ONGOING MONTH

ICM EMERGENCY RESPONSE SERVICES-ALL SERVICES
ICM/MAO MEDICAL SUPPLIES
ICM/MAO MEDICAL SUPPLIES
ICM MEDICAL SUPPLIES
ICM MEDICAL SUPPLIES
ICM/MAO TITLE XIX MEALS
ICM HOME DELIVERED MEALS
PRE-ASSESSMENT
ICM/MAO PRE-ASSESSMENT
ICM PRE-ASSESSMENT
MEDICAL S/REQUISITION FEES 3000.00 - 3499. 99
ICM/MAO MEDICAL S/REQUISITION FEES 0 - 499.99
ICM/MAO MEDICAL S/REQUISITION FEES 500.00 - 999.99
ICM/MAO MEDICAL S/REQUISITION FEES 5000.00 - OVER
ICM MEDICAL S/REQUISITION FEES 0 - 499.99
ICM MEDICAL S/REQUISITION FEES 500.00 - 999.99
Page 34 of 67
19Y
19Y
19Y
19Y
19Y
19Y
19Y
20W
20W
20W
20Y
20Y
20Y
22W
22W
22Y
22Y
25W
25Y
27A
40A
40AW
40AY
41A
41A
41A
41A
41A
41A
41A
41A
41A
41A
41A
41AW
41AW
41AW
41AW
41AW
41AW
41AW
41AW
41AW
41AW
41AW
41AY
41AY
CR
CR
CR
CR
CR
CR
CR
CC1
RAD
CC2
PE2
SE3
SE1
SE3
REVENUE
POS
CODE
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
U1
CLAIM FIL IND

ICM ASSISTED LIVING - APT (LEVEL 1) RAD
ICM/MAO EMERGENCY RESPONSE SERVICES
ICM EMERGENCY RESPONSE SERVICES - INITIAL MONTH
CPT
CODE
MODIFIER 4
YR059
YR059
YR059
YR059
YR059
YR059
YR059
W1000
W1000
W1000
Y1000
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
3
3
3
3
3
3
3
3
3
3
3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
I
P
P
P
P
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2031
T2031
T2031
T2031
T2031
T2031
T2031
S5160
S5161
S5162
S5160
HC
HC
HC
HC
HC
HC
HC
HC
S5161
S5162
S5199
T2028
S5199
T2028
S5170
S5170
P
P
P
P
P
P
P
P
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
T2024
T2024
T2024
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
0240
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
A
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2007
09/01/2007
09/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
07/01/2007
07/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
09/01/2007
07/01/2007
01/01/1900
01/01/1900
04/01/2009
04/01/2009
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
09/30/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
ACTIVE

ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
REVENUE
POS
CODE
CLAIM FIL IND
41AY
41AY
41AY
41AY
41AY
41AY
41AY
41AY
41AY
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BW
41BY
41BY
41BY
41BY
41BY
41BY
41BY
41BY
41BY
41BY
41BY
CPT
CODE
MODIFIER 4
Page 35 of 67

ICM MEDICAL S/REQUISITION FEES 5000.00 - OVER
ICM/MAO MH MODS/REQUISITION FEES 0 - 499.99
ICM/MAO MH MODS/REQUISITION FEES 500.00 - 999.99
ICM/MAO MH MODS/REQUISITION FEES 6500.00 - OVER
ICM MH MODS/REQUISITION FEES 0 - 499.99
ICM MH MODS/REQUISITION FEES 500.00 - 999.99
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
Y1214
Y1215
Y1216
Y1217
Y1218
Y1219
Y1220
Y1221
Y1222
G0623
G0624
G0625
G0626
G0627
G0628
G0629
G0630
G0631
G0632
G0633
G0634
G0635
G0636
W0623
W0624
W0625
W0626
W0627
W0628
W0629
W0630
W0631
W0632
W0633
W0634
W0635
W0636
Y0623
Y0624
Y0625
Y0626
Y0627
Y0628
Y0629
Y0630
Y0631
Y0632
Y0633
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
REVENUE
POS
CODE
CLAIM FIL IND
41BY
41BY
41BY
41C
41CW
41CY
41D
41DW
41DY
41E
41E
41E
41E
41E
41EW
41EW
41EW
41EW
41EW
41EY
41EY
41EY
41EY
41EY
41W
41W
41W
41W
41W
41W
41W
41W
41W
41W
41W
41Y
41Y
41Y
41Y
41Y
41Y
41Y
41Y
41Y
41Y
41Y
53A
53AW
CPT
CODE
MODIFIER 4
Page 36 of 67

ICM MH MODS/REQUISITION FEES 6500.00 - OVER
ICM/MAO SPECIFICATIONS - ADAPTIVE AIDS
ICM SPEFICATIONS - ADAPTIVE AIDS
ICM/MAO SPECIFICATIONS - MH MODS
ICM SPECIFICATIONS - HOME MODIFICATIONS
DENTAL/REQUISITION FEES 0 - 499.99
DENTAL/REQUISITION FEES 500.00 -999.99
DENTAL/REQUISITION FEES 1000.00 - 1499.99
DENTAL/REQUISITION FEES 1500.00 - 1999.99
DENTAL/REQUISITION FEES 2000.00 - OVER
ICM/MAO DENTAL / REQUISITION FEES 0 - 499.99
ICM/MAO DENTAL / REQUISITION FEES 500.00 - 999.99
ICM/MAO DENTAL / REQUISTION FEES 1000.00 - 1499.99
ICM/MAO DENTAL / REQUISITION FEES 1500.00 - 1999.99
ICM/MAO DENTAL / REQUISITION FEES 2000.00 - OVER
ICM DENTAL/REQUISITION FEES 0 - 499.99
ICM DENTAL/REQUISITION FEES 500.00 - 999.99
ICM DENTAL/REQUISITION FEES 2000.00 - OVER
ICM/MAO ADP AIDES/REQUISITION FEES 0 - 499.99
ICM/MAO ADP AIDES/REQUISITION FEES 500.00 - 999 .99
ICM/MAO ADP AIDES/REQUISITION FEES 1000.00 - 1499.99
ICM/MAO ADP AIDES/REQUISITION FEES 2500 - 2999.99
ICM/MAO ADP AIDES/REQUISITION FEES 4000.00 -4499.99
ICM/MAO ADP AIDES/REQUISITION FEES 5000.00 - OVER
ICM ADP AIDES/REQUISITION FEES 0 - 499.99
ICM ADP AIDES/REQUISITION FEES 500.00 - 999.99
ICM ADP AIDES/REQUISITION FEES 5000.00 - OVER
TAS FEES
ICM/MAO TRANSITION ASSISTANCE SERVICES FEES
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
Y0634
Y0635
Y0636
G0607
W0607
Y0607
G0604
W0604
Y0604
G0637
G0638
G0639
G0640
G0641
W0637
W0638
W0639
W0640
W0641
Y0637
Y0638
Y0639
Y0640
Y0641
W0515
W0516
W0517
W0518
W0519
W0520
W0521
W0522
W0523
W0524
W0525
Y0515
Y0516
Y0517
Y0518
Y0519
Y0520
Y0521
Y0522
Y0523
Y0524
Y0525
G0239
W0239
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
07/01/2007
07/01/2007
07/01/2007
01/01/1900
09/01/2007
07/01/2007
01/01/1900
09/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
07/01/2007
09/01/2004
09/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

F0225
F0108
Page 37 of 67
ZZ
HC
HC
ZZ
ZZ
ZZ
AD
AD
AD
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
1
1
1
1
1
1
1
1
1
1
1
1
LC
LC
LC
LC
LC
LC
LC
1
5
6
8
1
5
6
LC
LC
REVENUE
POS
CODE
T2038
T2038
D9999
D9999
D9999
KX
G0152
G0152
G0152
G0152
G0152
G0151
G0151
G0151
G0151
G0151
G0153
G0153
G0153
G0153
G0153
GO
GO
GO
GO
GO
GP
GP
GP
GP
GP
GN
GN
GN
GN
GN
CLAIM FIL IND
F0100
F0101
F0102
F0103
F0104
F0105
F0106
F0210
F0211
F0212
F0213
F0214
53AY
53W
53Y
57V
57VW
57VY
5A
5A
5AW
5AY
62V
63V
63VW
63VY
65V
7V
7VW
7VY
7W
7Y
8V
8VW
8VY
8W
8Y
9V
9VW
9VY
9W
9Y
CPT
CODE
MODIFIER 4
4
4
4
4
4
4
4
4
4
4
4
4
ICM TRANSITION ASSISTANCE SERVICES FEES

ICM/MAO TRANSITION ASSISTANCE SERVICES
ICM TRANSITION ASSISTANCE SERVICES
CDS/ICM/MAO SUPPORT CONSULTATION
CDS/ICM SUPPORT CONSULTATION
DENTAL SERVICES
DENTAL WAIVER PROGRAMS
ICM/MAO DENTAL WAIVER
ICM DENTAL WAIVER PROGRAMS
CDS - CBA ORIENTATION FEE
CDS CBA MONTHLY ADMINISTRATION FEE
CDS/ICM/MAO MONTHLY ADMIN FEE
CDS/ICM MONTHLY ADMIN FEE
CDS OVERNIGHT SUPPORT SERVICES
CDS OCCUPATION THERAPY
CDS/ICM/MAO OCCUPATION THERAPY
CDS/ICM/SSI OCCUPATIONAL THERAPY
ICM/MAO OCCUPATIONAL THERAPY
ICM OCCUPATIONAL THERAPY
CDS PHYSICAL THERAPY
CDS/ICM/MAO PHYSICAL THERAPY
CDS/ICM/SSI PHYSICAL THERAPY
ICM/MAO PHYSICAL THERAPY
ICM PHYSICAL THERAPY
CDS SPEECH THERAPY
CDS/ICM/MAO SPEECH THERAPY
CDS/ICM/SSI SPEECH THERAPY
ICM/MAO SPEECH THERAPY
ICM SPEECH/LANGUAGE/ PATHOLOGY THERAPY
ICF/MR CAMPUS/STATE - LOC 1 CONTRACT SPECIFIC - WITH
DRUGS
ICF/MR CAMPUS/STATE - LOC 5 CONTRACT SPECIFIC
ICF/MR CAMPUS/STATE -LOC 1
ICF/MR CAMPUS/STATE -LON 1
ICF/MR CAMPUS/STATE - LOC 1 CONTRACT SPECIFIC WITHOUT DRUGS
ICF/MR STATE/COMMUNITY RESIDENTIAL LOC 8 CONTRACT
SPECIFIC - WITH DRUGS
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
Y0239
W2038
Y2038
G0757
W0757
Y0757
N0600
N0601
W0601
Y0601
G0220
G0224
W0164
Y0164
G0818
G0408
W0408
Y0408
W0400
Y0400
G0409
W0409
Y0409
W0401
Y0401
G0410
W0410
Y0410
W0402
Y0402
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
07/01/2007
09/01/2007
07/01/2007
01/01/2009
01/01/2009
01/01/2009
01/01/1900
09/01/2007
09/01/2007
07/01/2007
09/01/2007
09/01/2007
09/01/2007
09/01/2007
12/01/2008
05/01/2008
05/01/2008
05/01/2008
09/01/2007
07/01/2007
05/01/2008
05/01/2008
05/01/2008
09/01/2007
07/01/2007
05/01/2008
05/01/2008
05/01/2008
09/01/2007
07/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
10/31/2002
10/31/2002
12/31/2199
04/30/1996
04/30/1996
04/30/1996
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
01/01/2006
12/31/2199
01/01/1900
12/31/2199
D
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
0100
0100
0101
0100
ACTIVE

F0110
5
5
5
5
5
5
5
5
5
F0111
F0112
F0113
F0114
F0215
F0216
F0217
F0218
F0219
F0226
5
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Page 38 of 67
LC
REVENUE
POS
CODE
0100
CLAIM FIL IND
DME/ ADAPTIVE AIDS (LON 5) - REFURBISHED WHEELCHAIR

DME - ADAPTIVE AIDS - LON 5 - PROSTHETIC/ORTHOTIC
DME/ADAPTIVE AIDS -LON 5 - HOSPITAL WATERBED
DME - ADAPTIVE AIDS - LON 5 - GAIT TRAINERS
DME/ADAPTIVE AIDS (LON 6) - STANDING BOARD
DME/ADAPTIVE AIDS (LON 6) - TRAVEL CHAIR
DME/ADAPTIVE AIDS -LON 6 - AIR MATTRESS
DME (LON 6) - ADAPTIVE STROLLER
DME (LON 6) - REFURBISHED WHEELCHAIR
DME - ADAPTIVE AIDS - LON 6 -PROSTHETIC/ORTHOTIC
DME (LON 6) - STANDARD WHEELCHAIR
CPT
CODE
MODIFIER 4
G0508
G0508
G0508
G0508
G0508
G0509
G0509
G0509
G0509
G0509
G0509
G0509
F0109
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
F0227
F0200
F0201
F0202
F0203
F0204
F0205
F0206
F0207
F0208
F0209
G0508
G0508
G0508
G0508
G0508
G0508
G0508

SPECIFIC
SPECIFIC
ICF/MR STATE/COMMUNITY RESIDENTIAL LOC 1
ICF/MR STATE/COMMUNITY -LON 1
ICF/MR STATE/COMMUNITY - LON 8
SPECIFIC - WITHOUT DRUGS
SPECIFIC - WITHOUT DRUGS
ICF/MR NON-STATE COMMUNITY RESIDENTIAL LOC 1
ICF/MR NON-STATE COMMUNITY RESIDENTIAL LOC 6A
ICF/MR NON-STATE COMMUNITY RESIDENTIAL LON 1
DME/ADAPTIVE AIDS (LON 5) - COMMUNICATION DEVICE
DME/ADAPTIVE AIDS (LON 5) - COMMUNICATION OTHER
DME/ADAPTIVE AIDS (LON 5) - ADAPTIVE STROLLER
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
1
1
1
1
1
1
1
1
1
1
BEGIN
DATE
END
DATE
01/01/1900
12/31/2199
01/01/1900
10/31/2002
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/31/2002
04/30/1996
04/30/1996
04/30/1996
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
LC
LC
0101
01/01/2006
12/31/2199
1
1
1
1
1
1
1
1
1
1
1
15
15
15
15
15
15
15
LC
LC
LC
LC
LC
LC
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
1
1
5
6
6A
8
1
5
6
8
9
5
5
5
5
5
5
5
0101
HC
HC
HC
HC
HC
HC
HC
E1399
E1130
E1900
E1902
E1035
E0186
E1031
0100
0100
0100
0100
0100
0290
0290
0290
0290
0290
0290
0290
I
I
I
I
I
I
I
I
I
I
I
I
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/2006
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
12/31/2199
12/31/1996
12/31/1996
12/31/1996
12/31/1996
12/31/1996
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
15
15
15
15
15
15
15
15
15
15
15
15
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
5
5
5
5
5
6
6
6
6
6
6
6
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
E1340
L3952
E0250
S8470
E8001
E1399
E1035
E0186
E1031
E1340
L3952
E1130
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
I
I
I
I
I
I
I
I
I
I
I
I
A
A
A
A
A
A
A
A
A
A
A
A
05/19/1998
05/19/1998
05/19/1998
07/01/2003
02/01/2008
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
12/31/2199
12/31/2199
12/31/2199
01/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
LN
6
6
6
6
6
8
8
8
8
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
9
9
9
1
1
1
1
1
1
1
1
1
1
1
1
1
5
6
8
9
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
E1900
E1902
E0250
S8470
E8001
E1130
E1900
E1902
E1399
E1035
E0186
E1031
E1340
L3952
E0250
S8470
E8001
E1399
E1035
E0186
E1031
E1340
L3952
E1130
E1900
E1902
E0250
S8470
E8001
E1130
E1900
E1902
E1399
E1035
E0186
E1031
E1340
L3952
E0250
S8470
E8001
REVENUE
POS
CODE
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0290
0100
0100
0100
0100
0100
CLAIM FIL IND
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
1T
1T
1T
1T
1T
11
11
CPT
CODE
MODIFIER 4
Page 39 of 67

DME - ADAPTIVE AIDS - LON 6 - COMMUNICATION OTHER
DME/ADAPTIVE AIDS -LON 6 - HOSPITALBED
DME/ADAPTIVE AIDS - LON 8 - COMMUNICATION OTHER
DME (LON 8) - ADAPTIVE STROLLER
DME/ADAPTIVE AIDS - LON 8 -PROSTHETIC/ORTHOTIC
DME/ADAPTIVE AIDS - LON 8 - GAIT TRAINERS
DME (LON 9) ADAPTIVE STROLLER
DME (LON 1) ADAPTIVE STROLLER
TRANSITIONAL ADD-ON/NON-STATE OPERATED LON 1
RESPITE - ADULT FOSTER CARE - CCAD LEVEL
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0509
G0509
G0509
G0509
G0509
G0510
G0510
G0510
G0510
G0510
G0510
G0510
G0510
G0510
G0510
G0510
G0510
G0511
G0511
G0511
G0511
G0511
G0511
G0511
G0511
G0511
G0511
G0511
G0511
G0512
G0512
G0512
G0512
G0512
G0512
G0512
G0512
G0512
G0512
G0512
G0512
F0220
F0221
F0222
F0223
F0224
G0103
G0108
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
7
7
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
05/19/1998
05/19/1998
05/19/1998
07/01/2003
02/01/2008
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
07/01/2003
02/01/2008
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
07/01/2003
02/01/2008
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
07/01/2003
02/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
01/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
01/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
01/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
01/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003


SSPD - DAY CARE (HALF DAY)
SSPD - 24 HR ATTENDANT CARE
SSPD - OTHER
SSPD - 24 HOUR ATTENDANT CARE (TILE 201)
VENTILATOR - FULL
27
27
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
Page 40 of 67
17
17
17
18
18
19
19
19
19
20
20
20
25
25
26
26
26
27
HC
ZZ
S5150
REVENUE
POS
CODE
CLAIM FIL IND
G0720
G0721
C0300
C0301
C0302
N0201
N0202
N0203
N0204
N0205
N0206
N0207
N0208
N0209
N0210
N0211
N0212
N0500
G0120
G0121
G0122
G0123
G0124
G0125
G0126
G0127
99999
G0701
CPT
CODE
MODIFIER 4
11
11
11
11
11
11
11
11
17
17
G0702
G0703
G0704
G0800
G0803
G0903
G0904
G0906
G0907
G1000
G1000
G1000
C0100
C0101
C0400
C0401
C0402
G0710
RESPITE - LON 9
RESPITE - PERSONAL ASSISTANCE SERVICES
RESPITE - SITTER SERVICES
RESPITE - ADULT DAY CARE
RESPITE - NURSING FACILITY
RESPITE - HOSPITAL
ASSISTED LIVING CCAD RC APT
ASSISTED LIVING CCAD RC NON APT
EXPEDITED PAYMENT
PERSONAL ASSISTANCE SERVICES - LEVEL 1 - NONPRIORITY
FC PRIORITY PRIOR TO 9/1997
FC NON PRIORITY PRIOR TO 9/1998
ADULT FOSTER CARE - CCAD LEVEL
ASSISTED LIVING - BED HOLD
ASSISTED LIVING - EMERGENCY CARE
ASSISTED LIVING - RESIDENTIAL CARE APARTMENT
ASSISTED LIVING - RESIDENTIAL CARE NON- APARTMENT
EMERGENCY RESPONSE SERVICES - ALL SERVICES
TITLE XIX CBA MEALS
IHFS CAPITAL EXPENDITURES
IHFS SUBSIDY GRANTS
SSI CLIENT PAYMENT
SUPPORTED HOME LIVING - LON 1
7
7
7
7
7
7
7
7
7
7
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
PR
ZZ
2 HC
S5125
E
P
PR
1 HC
S5125
HC
S5140
HC
HC
HC
HC
S5160
S5161
S5162
S5170
P
P
P
P
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
201
202
203
204
205
206
207
208
209
210
211
212
ZZ
ZZ
P
P
ZZ
HC
S5101
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
P
P
P
P
P
P
P
P
P
P
P
P
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/31/2003
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
04/30/2009
12/31/2199
A
C
C
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
09/23/1998
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
08/31/2003
08/31/2003
08/31/2003
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
01/31/2009
08/31/2003
08/31/2003
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
01/01/1900
12/31/2199
08/31/2003
12/31/2199
09/30/2003
09/30/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
ACTIVE

ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
ST
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
201
202
203
204
205
206
207
208
209
210
211
212
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
S5126
REVENUE
POS
CODE
CLAIM FIL IND
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
CPT
CODE
MODIFIER 4
Page 41 of 67
SSPD - 24 HOUR ATTENDANT CARE WITH ERS (TILE 201)
SSPD - 24 HOUR ATTENDANT CARE - RAD
SSPD - 24 HOUR ATTENDANT CARE - RAC
SSPD - 24 HOUR ATTENDANT CARE - RAB
SSPD - 24 HOUR ATTENDANT CARE - RAA
SSPD - 24 HOUR ATTENDANT CARE - SE3
SSPD - 24 HOUR ATTENDANT CARE - SSC
SSPD - 24 HOUR ATTENDANT CARE - SSB
SSPD - 24 HOUR ATTENDANT CARE - SSA
SSPD - 24 HOUR ATTENDANT CARE - CC2
SSPD - 24 HOUR ATTENDANT CARE - CC1
SSPD - 24 HOUR ATTENDANT CARE - CB2
SSPD - 24 HOUR ATTENDANT CARE - CB1
SSPD - 24 HOUR ATTENDANT CARE - CA2
SSPD - 24 HOUR ATTENDANT CARE - CA1
SSPD - 24 HOUR ATTENDANT CARE - IB2
SSPD - 24 HOUR ATTENDANT CARE - IB1
SSPD - 24 HOUR ATTENDANT CARE - IA2
SSPD - 24 HOUR ATTENDANT CARE - IA1
SSPD - 24 HOUR ATTENDANT CARE - BB2
SSPD - 24 HOUR ATTENDANT CARE - BB1
SSPD - 24 HOUR ATTENDANT CARE - BA2
SSPD - 24 HOUR ATTENDANT CARE - BA1
SSPD - 24 HOUR ATTENDANT CARE - PE2
SSPD - 24 HOUR ATTENDANT CARE - PE1
SSPD - 24 HOUR ATTENDANT CARE - PD2
SSPD - 24 HOUR ATTENDANT CARE - PD1
SSPD - 24 HOUR ATTENDANT CARE - PC2
SSPD - 24 HOUR ATTENDANT CARE - PC1
SSPD - 24 HOUR ATTENDANT CARE - PB2
SSPD - 24 HOUR ATTENDANT CARE - PB1
SSPD - 24 HOUR ATTENDANT CARE - PA2
SSPD - 24 HOUR ATTENDANT CARE - PA1
SSPD - 24 HOUR ATTENDANT CARE - BC1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
N0501
N1201
N1202
N1203
N1204
N1205
N1206
N1207
N1208
N1209
N1210
N1211
N1212
RG001
RG002
RG003
RG004
RG005
RG006
RG007
RG008
RG009
RG010
RG011
RG012
RG013
RG014
RG015
RG016
RG017
RG018
RG019
RG020
RG021
RG022
RG023
RG024
RG025
RG026
RG027
RG028
RG029
RG030
RG031
RG032
RG033
RG034
RG035
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

Page 42 of 67
29
11A
11A
11A
11B
11D
11E
11F
11F
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
SR
PCE
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
REVENUE
POS
CODE
S5126
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5101
ZZ
0660
0660
0660
HC
HC
89
32
S5151
S5151
U2
U2
0660
0660
25
27
U1
U2
CLAIM FIL IND
C0201
G0129
G0130
G0130
G0131
G0141
G0148
G0155
G0155
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
28
29
CPT
CODE
MODIFIER 4
7
7
7
7
7
7
7
7
7
SSPD - 24 HOUR ATTENDANT CARE - PCE

SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAD
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAC
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAB
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - RAA
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SE3
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SSC
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SSB
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - SSA
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CC2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CC1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CB2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CB1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CA2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - CA1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IB2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IB1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IA2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - IA1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BB2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BB1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BA2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BA1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PE2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PE1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PD2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PD1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PC2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PC1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PB2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PB1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PA2
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PA1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - BC1
SSPD - 24 HOUR ATTENDANT CARE WITH ERS - PCE
DAY ACTIVITY AND HEALTH SERVICES (TITLE XIX)
DAY ACTIVITY/HEATLH SERVICES - DAHS TITLE XIX
NEGOTIATED RATE
RESPITE - ADULT DAY CARE
RESPITE - HOSPITAL
RESPITE - HOSPITAL
RESPITE - ADULT FOSTER CARE - CCAD LEVEL
RESPITE - RESIDENTIAL CARE - APT (CCAD)
RESPITE - RESIDENTIAL CARE - NON APT (CCAD)
RESPITE - NURSING FACILITY (CCAD)
RESPITE - NURSING FACILITY (CCAD)
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG036
RG101
RG102
RG103
RG104
RG105
RG106
RG107
RG108
RG109
RG110
RG111
RG112
RG113
RG114
RG115
RG116
RG117
RG118
RG119
RG120
RG121
RG122
RG123
RG124
RG125
RG126
RG127
RG128
RG129
RG130
RG131
RG132
RG133
RG134
RG135
RG136
C0200
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
I
I
I
P
P
I
I
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
ACTIVE

7
7
G0746
G0747
G0742
7
7
7
7
G0743
G0755
G0756
G0748
7
7
7
7
7
7
7
7
7
G0749
G0750
G0751
G0752
Y0167
Y0168
G0717
G0717
G0718
PAS FAMILY CARE - LVL 2 (PRIORITY)

PAS FAMILY CARE - LVL 1 (NON-PRIORITY)
PAS FAMILY CARE SRO - PRIORITY
PAS FAMILY CARE SRO - NON-PRIORITY
PARTICIPANT - PAS FAMILY CARE CDS - LVL 2 (PRIORITY)
PARTICIPANT PAS FAMILY CARE CDS - LVL 1 (NONPRIORITY)
AGENCY ADMIN - PAS FAMILY CARE CDS
PAS COMMUNITY ATTENDANT SERVICES (1929B) - LVL 2
(PRIORITY)
PAS COMMUNITY ATTENDANT SERVICES (1929B) - LVL 1
(NON-PRIORITY)
CAS SERVICE RESPONSIBILTY OPTON - PRIORITY
CAS SERVICE RESPONSIBILTY OPTON - NON-PRIORITY
CDS Community Attendant Services (1929b) - Level 2 (Priority)
CDS Community Attendant Services (1929b) - Level 1 (NonPriority)
PAS COMMUNITY ATTENDANT SERVICES - CDS - AGENCY
PAS SERVICE RESPONSIBILITY OPTION PRIORITY
PAS SERVICE RESPONSIBILITY OPTION NON-PRIORITY
ICM PAS/SRO - LEVEL 2 - PRIORITY
ICM PAS/SRO - LEVEL 1 - NON-PRIORITY
G0719
17V
7
7
7
7
7
7
7
7
7
G0719
Y0165
Y0166
Y0701
Y0702
G0920
G0927
G0936
G0934

CDS/ICM - PAS LEVEL 2 PRIORITY
CDS/ICM - PAS LEVEL 1 NON PRIORITY
ASSISTED LIVING - RESIDENTIAL CARE APARTMENT
ASSISTED LIVING - RESIDENTIAL CARE NON- APARTMENT
ASSISTED LIVING - EMERGENCY CARE
ASSISTED LIVING - BED HOLD - APARTMENT
17V
17VY
17VY
17Y
17Y
19A
19B
19D
19H
7
7
7
7
7
7
7
7
7
7
G0943
G0944
G0945
G0946
G0947
G0948
G0949
C0401
G0722
C0303
RESIDENTIAL CARE BED HOLD - NON-APARTMENT TITLE XX

RESIDENTIAL CARE BED HOLD - APARTMENT TITLE XX
RESIDENTIAL CARE - APARTMENT TITLE XX
RESIDENTIAL CARE - NON-APARTMENT TITLE XX
RESIDENTIAL CARE EMERGENCY CARE
RESIDENTIAL CARE - ROOM & BOARD NON-APARTMENT
RESIDENTIAL CARE - ROOM & BOARD APARTMENT
IHFSP SERVICE SUBSIDY
SSPD - CASE MANAGEMENT
19I
19J
19K
19L
19M
19N
19O
26A
27A
28A
Page 43 of 67
17C
17C
17CS
17CS
17CV
PR
PR
PR
PR
2
1
2
1
17CV
17CV
HC
HC
ZZ
ZZ
ZZ
REVENUE
POS
CODE
S5125
S5125
ZZ
ZZ
CLAIM FIL IND
G0740
G0741
G0753
G0754
G0745
CPT
CODE
MODIFIER 4
7
7
7
7
7
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
BEGIN
DATE
END
DATE
A
A
A
A
A
01/01/1900
01/01/1900
01/02/2006
01/02/2006
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
P
P
A
A
01/01/1900
01/01/1900
12/31/2199
12/31/2199
ACTIVE
17D
PR
2 HC
S5125
01/01/1900
12/31/2199
17D
17DS
17DS
17DV
PR
PR
PR
1 HC
2 ZZ
1 ZZ
ZZ
S5125
P
P
P
P
A
A
A
A
01/01/1900
01/02/2006
01/02/2006
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
P
P
P
P
P
P
P
P
P
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/02/2006
01/02/2006
09/01/2007
09/01/2007
01/01/1900
06/01/2005
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
05/31/2009
05/31/2009
05/31/2005
12/31/2199
12/31/2199
01/01/1900
05/31/2005
P
P
P
P
P
A
A
A
A
A
A
A
A
A
06/01/2005
09/01/2007
09/01/2007
07/01/2007
07/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
05/31/2009
05/31/2009
05/31/2009
05/31/2009
08/31/2003
08/31/2003
08/31/2003
08/31/2003
P
P
P
P
P
P
P
P
P
P
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
02/01/2009
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
17DV
17DV
17S
17S
17SY
17SY
17V
17V
17V
PR
PR
PR
PR
2
1
2
1
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
ZZ
S5125
UB
ZZ
PR
PR
HC
HC
HC
2 HC
1 HC
ZZ
ZZ
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
HC
S5125
S5125
S5125
S5125
S5125
T1020
T1020
T1020
T1016
UC
U2
U2
U1
U2

HC
HC
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
REVENUE
POS
CODE
S5101
S5101
T2042
T2043
T2044
T2045
94657
94004
36489
36533
49080
71010
74000
74020
85023
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99221
99222
99223
99231
99232
99233
99238
99239
99251
99252
99253
99254
99255
99341
99342
99343
0651
0652
0655
0656
0659
0659
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
CLAIM FIL IND
29A
29Y
57CV
57DV
57V
57VY
62V
63V
63VY
1
1
1
1
4
4
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
CPT
CODE
MODIFIER 4
Page 44 of 67
DAY ACTIVITY/HEALTH SERVICES (DAHS) - TITLE 20

ICM DAY ACTIVITY/HEALTH SERVICES (DAHS)
CDS FC SUPPORT CONSULTATION
CDS CAS SUPPORT CONSULTATION
CDS/ICM SUPPORT CONSULTATION
CDS - CCAD ORIENTATION FEE
CDS CCAD MONTHLY ADMINISTRATION FEE
CDS/ICM CCAD MONTHLY ADMIN FEE
ROUTINE IN HOME CARE
CONTINUOUS HOME CARE
INPATIENT RESPITE CARE
GENERAL INPATIENT CARE
VENTILATOR PARTIAL
VENTILATOR FULL
PHYSICIAN DIRECT CARE
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
C0202
Y0200
G0758
G0759
G0757
Y0757
G0223
G0227
Y0169
T0100
T0200
T0300
T0301
N0500
N0501
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
7
7
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
07/01/2007
01/01/2009
01/01/2009
01/01/2009
01/01/2009
09/01/2007
09/01/2007
09/01/2007
01/01/1900
01/01/1900
01/01/1900
01/01/1900
05/01/2009
05/01/2009
02/24/1999
05/19/1999
01/31/2003
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
08/21/2001
05/19/1998
02/24/1999
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
12/31/2199
05/31/2009
12/31/2199
12/31/2199
12/31/2199
05/31/2009
12/31/2199
12/31/2199
05/31/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
07/31/2004
07/31/2004
12/31/2199
12/31/2199
12/31/2199
12/31/2199
07/31/2004
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
99345
99347
99348
99349
99350
99352
99354
99355
99356
99357
99241
99242
99243
99244
99344
99245
85004
85007
85008
85009
85013
85014
85018
85025
85027
85032
85041
85044
85045
85046
85048
85049
99315
99316
99304
99305
99306
99307
99308
99309
99324
99325
99326
99334
99335
99336
99261
99262
REVENUE
POS
CODE
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
CLAIM FIL IND
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
CPT
CODE
MODIFIER 4
Page 45 of 67

LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
03/29/2001
12/01/2002
12/01/2002
12/01/2002
12/01/2002
05/19/1998
03/29/2001
03/29/2001
03/29/2001
03/29/2001
12/01/2002
12/01/2002
12/01/2002
12/01/2002
12/01/2002
12/01/2002
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
08/01/2004
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
02/01/2008
05/19/1998
02/24/1999
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
07/31/2004
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2008
12/31/2008

8
8
8
8
8
F0100
F0101
F0102
F0103
F0103
F0108
F0108
F0109
F0109
F0110
8
8
8
8
8
8
8
8
8
F0111
F0113
F0114
F0205
F0205
F0206
F0206
F0207
F0207
Page 46 of 67
REVENUE
POS
CODE
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
99263
99301
99302
99303
99311
99312
99313
99321
99322
99323
99331
99332
99333
99310
99318
99337
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
0657
HC
HC
HC
71260 0657
72193 0657
74170 0657
CLAIM FIL IND
F0100
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
30
CPT
CODE
MODIFIER 4

PHYSICAN DIRECT CARE-SPECIAL
DRUGS
DRUGS
SPECIFIC
SPECIFIC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0302
T0303
T0303
T0303
T0303
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
BEGIN
DATE
END
DATE
I
I
I
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
02/24/1999
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
02/24/1999
05/19/1998
05/19/1998
05/19/1998
05/19/1998
02/01/2008
02/01/2008
02/01/2008
01/01/1900
09/01/2005
09/01/2005
09/01/2005
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2008
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
ACTIVE
31
LC
1 HC
T2046
0658
U3
01/01/1900
12/31/2199
31
31
31
31
31
LC
LC
LC
LC
LC
1 HC
5
6
8 HC
8 HC
T2046
0659
U3
T2046
T2046
0658
0659
UA
UA
I
I
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
10/31/2002
10/31/2002
12/31/2199
12/31/2199
31
LC
8 HC
T2046
0658
01/01/1900
12/31/2199
31
LC
8 HC
T2046
0659
01/01/1900
12/31/2199
31
LC
1 HC
T2046
0658
01/01/1900
12/31/2199
31
LC
1 HC
T2046
0659
01/01/1900
12/31/2199
31
01/01/1900
10/31/2002
31
31
31
31
31
31
31
31
31
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/31/2002
04/30/1996
04/30/1996
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
LN
LN
LN
LN
LN
LN
1
1
5
5
6
6
HC
HC
HC
HC
HC
HC
T2046
T2046
T2046
T2046
T2046
T2046
0658
0659
0658
0659
0658
0659
I
I
I
I
I
I

8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
F0225
N0201
N0201
N0202
N0202
N0203
N0203
N0204
N0204
N0205
N0205
N0206
N0206
N0207
N0207
N0208
N0208
N0209
N0209
N0210
N0210
N0211
N0211
N0212
N0212
RG001
RG001
RG002
RG002
RG003
RG003
RG004
RG004
RG005
RG005
RG006
RG006
RG007
RG007
RG008
RG008
Page 47 of 67
REVENUE
POS
CODE
CLAIM FIL IND
F0225
CPT
CODE
MODIFIER 4

NURSING FACILITY TILE 201 - ROOM & BOARD
NURSING FACILITY - ROOM & BOARD - RAD
NURSING FACILITY - ROOM & BOARD - RAD
NURSING FACILITY - ROOM & BOARD - RAC
NURSING FACILITY - ROOM & BOARD - RAC
NURSING FACILITY - ROOM & BOARD - RAB
NURSING FACILITY - ROOM & BOARD - RAB
NURSING FACILITY - ROOM & BOARD - RAA
NURSING FACILITY - ROOM & BOARD - RAA
NURSING FACILITY - ROOM & BOARD - SE3
NURSING FACILITY - ROOM & BOARD - SSC
NURSING FACILITY - ROOM & BOARD - SSC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
F0208
F0208
F0209
F0209
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
BEGIN
DATE
END
DATE
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
ACTIVE
31
31
31
31
LN
LN
LN
LN
8
8
9
9
HC
HC
HC
HC
T2046
T2046
T2046
T2046
0658
0659
0658
0659
31
LC
1 HC
T2046
0658
U3
U4
10/01/2008
12/31/2199
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
LC
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0659
0658
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
U3
U4
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
10/01/2008
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
1
201
201
202
202
203
203
204
204
205
205
206
206
207
207
208
208
209
209
210
210
211
211
212
212
RAD
RAD
RAC
RAC
RAB
RAB
RAA
RAA
SE3
SE3
SE2
SE2
SE1
SE1
SSC
SSC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC

RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
SSB
SSB
SSA
SSA
CC2
CC2
CC1
CC1
CB2
CB2
CB1
CB1
CA2
CA2
CA1
CA1
IB2
IB2
IB1
IB1
IA2
IA2
IA1
IA1
BB2
BB2
BB1
BB1
BA2
BA2
BA1
BA1
PE2
PE2
PE1
PE1
PD2
PD2
PD1
PD1
PC2
PC2
PC1
PC1
PB2
PB2
PB1
PB1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
REVENUE
POS
CODE
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
CLAIM FIL IND
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
CPT
CODE
MODIFIER 4
Page 48 of 67
NURSING FACILITY - ROOM & BOARD - SSB

NURSING FACILITY - ROOM & BOARD - SSB
NURSING FACILITY - ROOM & BOARD - SSA
NURSING FACILITY - ROOM & BOARD - SSA
NURSING FACILITY - ROOM & BOARD - CC2
NURSING FACILITY - ROOM & BOARD - CB2
NURSING FACILITY - ROOM & BOARD - CA2
NURSING FACILITY - ROOM & BOARD - IB2
NURSING FACILITY - ROOM & BOARD - IA2
NURSING FACILITY - ROOM & BOARD - BB2
NURSING FACILITY - ROOM & BOARD - BA2
NURSING FACILITY - ROOM & BOARD - PE2
NURSING FACILITY - ROOM & BOARD - PD2
NURSING FACILITY - ROOM & BOARD - PC2
NURSING FACILITY - ROOM & BOARD - PB2
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG009
RG009
RG010
RG010
RG011
RG011
RG012
RG012
RG013
RG013
RG014
RG014
RG015
RG015
RG016
RG016
RG017
RG017
RG018
RG018
RG019
RG019
RG020
RG020
RG021
RG021
RG022
RG022
RG023
RG023
RG024
RG024
RG025
RG025
RG026
RG026
RG027
RG027
RG028
RG028
RG029
RG029
RG030
RG030
RG031
RG031
RG032
RG032
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
PA2
PA2
PA1
PA1
BC1
BC1
PCE
PCE
RAD
RAD
RAC
RAC
RAB
RAB
RAA
RAA
SE3
SE3
SE2
SE2
SE1
SE1
SSC
SSC
SSB
SSB
SSA
SSA
CC2
CC2
CC1
CC1
CB2
CB2
CB1
CB1
CA2
CA2
CA1
CA1
IB2
IB2
IB1
IB1
IA2
IA2
IA1
IA1
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
REVENUE
POS
CODE
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
CLAIM FIL IND
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
CPT
CODE
MODIFIER 4
Page 49 of 67
NURSING FACILITY - ROOM & BOARD - PA2

NURSING FACILITY - ROOM & BOARD - BC1
NURSING FACILITY - ROOM & BOARD - BC1
NURSING FACILITY - ROOM & BOARD - PCE
NURSING FACILITY - ROOM & BOARD - PCE
VA DAILY CARE - RAD
VA DAILY CARE - RAD
VA DAILY CARE - RAC
VA DAILY CARE - RAC
VA DAILY CARE - RAB
VA DAILY CARE - RAB
VA DAILY CARE - RAA
VA DAILY CARE - RAA
VA DAILY CARE - SE3
VA DAILY CARE - SE3
VA DAILY CARE - SE2
VA DAILY CARE - SE2
VA DAILY CARE - SE1
VA DAILY CARE - SE1
VA DAILY CARE - SSC
VA DAILY CARE - SSC
VA DAILY CARE - SSB
VA DAILY CARE SSB
VA DAILY CARE SSA
VA DAILY CARE SSA
VA DAILY CARE CC2
VA DAILY CARE CC2
VA DAILY CARE CC1
VA DAILY CARE CC1
VA DAILY CARE CB2
VA DAILY CARE CB2
VA DAILY CARE CB1
VA DAILY CARE CB1
VA DAILY CARE CA2
VA DAILY CARE CA2
VA DAILY CARE CA1
VA DAILY CARE CA1
VA DAILY CARE IB2
VA DAILY CARE IB2
VA DAILY CARE IB1
VA DAILY CARE IB1
VA DAILY CARE IA2
VA DAILY CARE IA2
VA DAILY CARE IA1
VA DAILY CARE IA1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG033
RG033
RG034
RG034
RG035
RG035
RG036
RG036
V0101
V0101
V0102
V0102
V0103
V0103
V0104
V0104
V0105
V0105
V0106
V0106
V0107
V0107
V0108
V0108
V0109
V0109
V0110
V0110
V0111
V0111
V0112
V0112
V0113
V0113
V0114
V0114
V0115
V0115
V0116
V0116
V0117
V0117
V0118
V0118
V0119
V0119
V0120
V0120
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
RG
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
TI
BB2
BB2
BB1
BB1
BA2
BA2
BA1
BA1
PE2
PE2
PE1
PE1
PD2
PD2
PD1
PD1
PC2
PC2
PC1
PC1
PB2
PB2
PB1
PB1
PA2
PA2
PA1
PA1
BC1
BC1
PCE
PCE
201
201
202
202
203
203
204
204
205
205
206
206
207
207
208
208
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
REVENUE
POS
CODE
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
0658
0659
CLAIM FIL IND
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
CPT
CODE
MODIFIER 4
Page 50 of 67
VA DAILY CARE BB2

VA DAILY CARE BB2
VA DAILY CARE BB1
VA DAILY CARE BB1
VA DAILY CARE BA2
VA DAILY CARE BA2
VA DAILY CARE BA1
VA DAILY CARE BA1
VA DAILY CARE PE2
VA DAILY CARE PE2
VA DAILY CARE PE1
VA DAILY CARE PE1
VA DAILY CARE PD2
VA DAILY CARE PD2
VA DAILY CARE PD1
VA DAILY CARE PD1
VA DAILY CARE PC2
VA DAILY CARE PC2
VA DAILY CARE PC1
VA DAILY CARE PC1
VA DAILY CARE PB2
VA DAILY CARE PB2
VA DAILY CARE PB1
VA DAILY CARE PB1
VA DAILY CARE PA2
VA DAILY CARE PA2
VA DAILY CARE PA1
VA DAILY CARE PA1
VA DAILY CARE BC1
VA DAILY CARE BC1
VA DAILY CARE PCE
VA DAILY CARE PCE
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
V0121
V0121
V0122
V0122
V0123
V0123
V0124
V0124
V0125
V0125
V0126
V0126
V0127
V0127
V0128
V0128
V0129
V0129
V0130
V0130
V0131
V0131
V0132
V0132
V0133
V0133
V0134
V0134
V0135
V0135
V0136
V0136
V0201
V0201
V0202
V0202
V0203
V0203
V0204
V0204
V0205
V0205
V0206
V0206
V0207
V0207
V0208
V0208
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
VA
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

TI
TI
TI
TI
TI
TI
TI
TI
209
209
210
210
211
211
212
212
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
T2046
T2046
T2046
T2046
T2046
T2046
T2046
T2046
REVENUE
POS
CODE
0658
0659
0658
0659
0658
0659
0658
0659
HC
HC
HC
HC
HC
HC
HC
97039
97003 0434
97003
97039 0431
97039
97003 0434
97003
HC
HC
HC
HC
HC
HC
HC
HC
97039
97039
97001
97001
97039
97039
97001
97001
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
92507 0441
92507
92506 0444
0444
92506
V5364
GO
GO
GO
GO
GO
GO
GP
0424
0424
V5364
V5364
VA
VA
VA
VA
VA
VA
VA
VA
0421
0421
92507 0441
92507
92506 0444
0444
CLAIM FIL IND
31
31
31
31
31
31
31
31
32
33
4
4
6
6
6
6
6
6
6
6
6
7
7
7
7
7
7
7
7
8
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
9
CPT
CODE
MODIFIER 4
Page 51 of 67

MEDICARE PHARMACY COINSURANCE
MEDICARE RESPITE COINSURANCE
VENTILATOR - FULL
NAT - TRAINING COURSE
NAT - SKILLS TEST - PASSED
NAT - SKILLS TEST - FAILED
NAT - WRITTEN TEST - PASSED
NAT - WRITTEN TEST - FAILED
NAT-ORAL TEST - PASSED
NAT-ORAL TEST - FAILED
NAT - TRAINING MATERIALS
NAT - INCOMPLETE TRAINING COURSE
OT-SPECIALIZED SERV
OT HABILITATION (S)
PT-SPECIALIZED SERV
PT-SPECIALIZED SERV
PT HABILITATION (S)
ST-SPECIALIZED SERV
ST-SPECIALIZED SERV
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
V0209
V0209
V0210
V0210
V0211
V0211
V0212
V0212
T0400
T0401
N0500
N0501
N0700
N0701
N0702
N0703
N0704
N0705
N0706
N0707
N0708
G0446
G0447
G0447
G0452
G0452
G0453
G0453
G0458
G0448
G0448
G0449
G0449
G0454
G0454
G0455
G0455
G0459
G0450
G0450
G0451
G0451
G0451
G0451
G0456
G0456
G0457
G0457
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
8
8
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
GP
GP
GP
GP
GP
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
P
P
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
P
I
I
P
P
I
P
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
10/15/2003
10/15/2003
10/15/2003
10/31/2008
10/31/2008
10/31/2008
10/31/2008
08/31/2003
10/15/2003
10/15/2003
10/15/2003
10/15/2003
10/31/2008
10/31/2008
10/31/2008
10/31/2008
08/31/2003
10/15/2003
10/15/2003
10/15/2003
10/15/2003
10/15/2003
10/15/2003
10/31/2008
10/31/2008
10/31/2008
10/31/2008

HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SB
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
201
202
203
204
205
206
207
208
209
210
211
212
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
REVENUE
POS
CODE
92506
V5364
97039
97039
97003
97003
97542
97039
97039
97001
97001
97542
92507
92507
92506
92506
V5364
V5364
0434
0434
0434
0421
0424
0424
0441
0444
0444
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
GO
GO
GO
GP
GO
GP
GP
GP
GP
GO
CLAIM FIL IND
9
9
9
15
7A
7A
7A
7A
7B
8A
8A
8A
8A
8B
9A
9A
9A
9A
9A
9A
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CPT
CODE
MODIFIER 4
Page 52 of 67
ST HABILITATION (S)
DME/ADAPTIVE AIDS - LIFT
CPWC ASSESSMENTS BY OT
CPWC ASSESSMENTS BY PT
ST - NF SPECIALIZED SERVICES
ST - NF SPECIALIZED SERVICES
ST - NF ASSESSMENT-SPECIALIZED SERV.
ST - NF ASSESSMENT-SPECIALIZED SERV.
NF - TILE 201
NF - TILE 202
NF - TILE 203
NF - TILE 204
NF - TILE 205
NF - TILE 206
NF - TILE 207
NF - TILE 208
NF - TILE 209
NF - TILE 210
NF - TILE 211
NF - TILE 212
NF - RAD
NF - RAC
NF - RAB
NF - RAA
NF - SE3
NF - SE2
NF - SE1
NF - SSC
NF - SSB
NF - SSA
NF - CC2
NF - CC1
NF - CB2
NF - CB1
NF - CA2
NF - CA1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0457
G0457
G0460
G0500
G0461
G0461
G0462
G0462
G0956
G0463
G0463
G0464
G0464
G0957
G0465
G0465
G0466
G0466
G0466
G0466
N0201
N0202
N0203
N0204
N0205
N0206
N0207
N0208
N0209
N0210
N0211
N0212
RG001
RG002
RG003
RG004
RG005
RG006
RG007
RG008
RG009
RG010
RG011
RG012
RG013
RG014
RG015
RG016
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
I
P
I
I
I
P
I
P
I
I
P
I
P
I
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
10/16/2003
10/16/2003
01/01/1900
01/01/1900
10/16/2003
10/16/2003
10/16/2003
10/16/2003
01/01/2008
10/16/2003
10/16/2003
10/16/2003
10/16/2003
01/01/2008
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
10/31/2008
10/31/2008
08/31/2003
08/31/2003
10/31/2008
10/31/2008
12/31/2199
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
10/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
SW
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1 HC
PCE HC
ZZ
ZZ
ZZ
HC
HC
HC
HC
ZZ
ZZ
REVENUE
POS
CODE
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
0100
G0152
G0151
G0153
T2021
ZZ
HC
HC
HC
HC
HC
HC
AD
HC
HC
HC
T1016
S9123
T1001
T1002
S9124
T1003
D9999
T2039
E1031
E1130
HC
HC
HC
HC
HC
E1900
E1902
T2029
T2028
T2003
GO
GP
GN
U5
TD
TD
TD
TE
TE
CLAIM FIL IND
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
39
39A
39B
7
8
9
10
11
11
11
11
12
13
13
13
13
13
15
15
15
15
15
15
15
15
15
15
CPT
CODE
MODIFIER 4
Page 53 of 67
NF - IB2
NF - IB1
NF - IA2
NF - IA1
NF - BB2
NF - BB1
NF - BA2
NF - BA1
NF - PE2
NF - PE1
NF - PD2
NF - PD1
NF - PC2
NF - PC1
NF - PB2
NF - PB1
NF - PA2
NF - PA1
NF - BC1
NF - PCE
PACE - DUAL ELIGIBLE
PACE - MEDICAID ONLY
PACE - QMB
PHYSICAL THERAPY
SPEECH THERAPY
RESPITE - IN HOME
RESPITE - IN-HOME CDS (INDIVIDUAL)
CASE MANAGEMENT
NURSING CARE - RN
NURSING ASSEMMENT/EVALUATION
NURSING SERVICES - RN PARTIAL UNIT
NURSING CARE - LVN
NURSING SERVICES - LVN/LPN - PARTIAL UNIT
ADAPTIVE AIDS - DENTAL
DME/ADAPTIVE AIDS
DME - MEDICAL EQUIPMENT (NOS)
MEDICAL SUPPLIES
ADAPTIVE AIDS - TRANSPORTATION
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG017
RG018
RG019
RG020
RG021
RG022
RG023
RG024
RG025
RG026
RG027
RG028
RG029
RG030
RG031
RG032
RG033
RG034
RG035
RG036
G2000
G2001
G2002
G0400
G0401
G0402
S0101
G0100
G0101
G0102
G0171
G0200
G0300
G0300
G0300
G0301
G0301
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
11
11
11
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
D
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
01/01/1900
01/01/1900
07/01/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
05/19/1998
10/01/2003
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
10/01/2003
10/01/2003
05/19/1998
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
09/30/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

REVENUE
POS
CODE
CLAIM FIL IND
CPT
CODE
MODIFIER 4
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
15
15
HC
HC
E0636
E1399
P
P
A
A
05/19/1998
05/19/1998
12/31/2199
12/31/2199
G0500
G0608
G0730
G0731
G0900
G0908
G0909
G1100

ADAPTIVE AIDS - PERSONAL CARE ITEMS (CONSUMERABLE
SUPPLIES/DIAPERS/BED PADS/ENSURE)
HOME MODIFICATIONS
RESIDENTIAL HABILITATION - HOURLY
PERSONAL ASSISTANCE SERVICES - CHORE
ASSISTED LIVING (LESS THAN 24 HR)
AL RESIDENTIAL CARE - HABILITATION (24 HR)
PRESCRIPTIONS - DISCONTINUED
15
16
17
17
19
19
19
21
HC
HC
HC
S5199
S5165
T2016
P
P
P
HC
T2031
A
A
A
A
A
A
A
A
01/01/2003
01/01/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
08/31/2003
08/31/2003
08/31/2003
G0720
G0721
U0210
U0210
U0210
H2024
G0202
G0515
G0516
G0517
G0518
G0519
G0520
G0521
G0522
G0523
G0524
G0525
G0230
G0231
G0231
G0232
G0236
T2038
H2026
G0119
G0128
G0170
G0196
G0197
G0302
G0303
S9800
T1002
T1003

DIETARY - DIABETIC SERVICES
DIETARY - NUTRITIONAL SERVICES
DIETARY SERVICES - EVALUATION
SUPPORTED EMPLOYMENT
PRE-ASSESSMENT
ADP Aides/Requisition Fees 0-499.99
ADP Aides/Requisition Fees 500.00-999.99
ADP Aides/Requisition Fees 5000.00-OVER
BEHAVIOR COMMUNICATION SPECIALIST
ORIENTATION & MOBILITY - OUT OF HOME
ORIENTATION & MOBILITY - IN HOME
INTERVENOR
AGENCY ADMIN - INTERVENOR CDS
EMPLOYMENT ASSISTANCE
RESPITE - OUT OF HOME - CDS
AGENCY ADMIN - OUT OF HOME RESPITE CDS
CDS RESPITE OUT-OF-HOME
CDS RESPITE IN-HOME
NURSING SERVICES - RN
27
27
34
34
34
37
40
41
41
41
41
41
41
41
41
41
41
41
43
44
44
45
45
53
54
11A
11A
11A
11AV
11PV
13A
13B
13C
13C
13D
ZZ
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/01/2008
01/01/1900
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
01/01/1900
01/01/1900
01/01/1900
10/16/2003
01/01/1900
09/01/2004
08/01/2008
01/01/1900
01/01/1900
01/01/1900
12/01/2008
12/01/2008
12/01/2008
12/01/2008
10/16/2003
01/01/2008
10/16/2003
01/31/2009
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2007
12/31/2199
12/31/2007
16
16
G0500
G0500
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
Page 54 of 67
HC
HC
HC
HC
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
ZZ
HC
HC
HC
ZZ
HC
HC
HC
HC
HC
HC
HC
U1
U1
P
S9465
S9470
P
P
P
P
97802
H2024
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
97537
97535
T1013
T2038
H2026
S5151
S5151
S9125
T1003
T1002
S9800
T1002
T1003
TG
TG
TG
TD
P
P
P
P
P
P
P
P
P

REVENUE
POS
CODE
CLAIM FIL IND
CPT
CODE
MODIFIER 4
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
P
P
I
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
BEGIN
DATE
END
DATE
D
D
P
P
P
P
P
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/2008
01/01/1900
01/01/1900
06/01/2005
01/01/1900
01/01/1900
06/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
08/01/2009
07/01/2008
09/01/2004
01/01/2009
01/01/1900
09/01/2008
09/01/2008
06/01/2008
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
05/31/2005
12/31/2199
12/31/2199
05/31/2005
05/31/2009
12/31/2199
12/31/2199
12/31/2199
01/31/2009
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
ACTIVE
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
16
17
17
17
17
17
17
17
T1003
G0744
G0717
G0717
G0718
G0719
G0719
G0937
G0938
G0938
G0722
G0207
G0623
G0624
G0625
G0626
G0627
G0628
G0629
G0630
G0631
G0632
G0633
G0634
G0635
G0636
H2019
G0239
G0757
N0600
N0601
N0602
G0228
G0400
G0401
G0402
S0101
G0101
G0301
G0301

PAS CHORE
CDS-PAS-PARTICIPANT
RESIDENTIAL HABILITATION - CDS (INDIVIDUAL)
CDS-PAS-AGENCY
18 HOUR RESIDENTIAL HABILITATION
18 HOUR ASSISTED LIVING
PRE-ASSESSMENT
MH Mods/Requisition Fees
0-499.99
500.00-999.99
1000.00-1499.99
1500.00-1999.99
2000.00-2499.99
2500.00-2999.99
3000.00-3499.99
3500.00-3999.99
4000.00-4499.99
4500.00-4999.99
5000.00-5499.99
5500.00-5999.99
6000.00-6499.99
6500.00-Over
BEHAVIORAL SUPPORT
TAS FEES
DENTAL SERVICES
DENTAL WAIVER SERVICES
DBMD DENTAL SEDATION
CDS DBMD MONTHLY ADMINISTRATION FEE
PHYSICAL THERAPY
SPEECH THERAPY
RESPITE - IN-HOME
NURSING CARE - LVN (FUTURE USE)
NURSING SERVICES - LVN/LPN (FUTURE USE)
13D
17E
17V
17V
17V
17V
17V
19E
19F
19F
27A
40A
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
43A
53A
57V
5A
5A
5B
63V
7
8
9
10
11
13
13
17
G0403
14
HC
90801
01/01/1900
12/31/2199
17
G0403
14
HC
90810
01/01/1900
12/31/2199
17
G0403
14
HC
90812
01/01/1900
12/31/2199
17
G0403
PSYCHOLOGICAL SERVICES-INITIAL NEEDS ASSESSMENT

PSYCHOLOGICAL SERVICES-1 ON 1 THERAPY-30 MIN OR
LESS IN OFFICE OR OUTPATIENT CLINIC
PSYCHOLOGICAL SERVICES-1 ON 1 THERAPY-31-50 MIN IN
OFFICE OR OUTPATIENT CLINIC
PSYCHOLOGICAL SERVICES-1 ON 1 THERAPY-51-80 MIN IN
OFFICE OR OUTPATIENT CLINIC
14
HC
90814
01/01/1900
12/31/2199
Page 55 of 67
HC
HC
ZZ
HC
ZZ
ZZ
HC
HC
HC
T1003
S5120
TG
TE
S5125
UB
S5125
T2033
T1020
UC
U1
0240
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
BL
ZZ
HC
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
ZZ
ZZ
AD
ZZ
HC
HC
HC
HC
ZZ
HC
HC
T2024
H2019
D9999
D9220
KX
G0152
G0151
G0153
T2021
GO
GP
GN
U5
S9124
T1003
TE
TE

17
G0403
17
G0403
17
G0403
17
17
17
17
G0403
G0403
G0403
G0403
17
17
17
17
17
17
17
17
17
G0403
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
G0500
G0608
G0701
G0800
G0801
G0802
G0900
G1900
G2900
G3900
G4900
G5900
G1000
G1000
G1000
G1200
G1200
C0100
C0101
U0210
U0210
Page 56 of 67
PSYCHOLOGICAL SERVICES-1 ON 1 THERAPY-NON VERBAL

30 MIN OR LESS IN OFFICE OR OUTPATIENT CLINIC
31-50 MIN IN OFFICE OR OUTPATIENT CLINIC
51-80 MIN IN OFFICE OR OUTPATIENT CLINIC
PSYCHOLOGICAL SERVICES-PSYCHOANALYSIS
PSYCHOLOGICAL SERVICES-GROUP THERAPY
PSYCHOLOGICAL SERVICES-PSYCHIATRIC COUNSELING
PSYCHOLOGICAL SERVICES-PROFESSIONAL ASSESSMENT
DME/ADP AIDS - VEHICLE MODIFICATIONS
DME/ADP AIDS - POSITIONING DEVICE
DME/ADP AIDS - ROLLING CHAIR
DME/ADP AIDS - STANDARD WHEELCHAIR
DME/ADAPTIVE AIDS
DME/ADP AIDS - COMMUNICATION-ELECTRONIC DEVICE
DME/ADP AIDS - COMMUNICATION-OTHER
DME/ADP AIDS - MEDICAL EQUIPMENT
DME/ADP AIDS - MISCELLANEOUS (HOSPITAL
BEDS/VENTILATOR)
HOME MODIFICATIONS
EMERGENCY RESPONSE SERVICES - ALL SERVICES
MEDICAL SUPPLIES - OTHER
MEDICAL SUPPLIES - SPECIALIZED SUPPLIES
TITLE XIX CBA MEALS
DIETARY SERVICES - DIABETES
DIETARY SERVICES - OTHER
REVENUE
POS
CODE
CLAIM FIL IND
G0403
CPT
CODE
MODIFIER 4
17
PSYCHOLOGICAL SERVICES-1 ON 1 BEHAVIOR THERAPY-30

MIN OR LESS IN OFFICE OR OUTPATIENT CLINIC
PSYCHOLOGICAL SERVICES-1 ON 1 BEHAVIOR THERAPY-3150 MIN IN OFFICE OR OUTPATIENT CLINIC
PSYCHOLOGICAL SERVICES-1 ON 1 BEHAVIOR THERAPY-5180 MIN IN OFFICE OR OUTPATIENT CLINIC
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0403
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
17
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
14
HC
90816
01/01/1900
12/31/2199
14
HC
90818
01/01/1900
12/31/2199
14
HC
90821
01/01/1900
12/31/2199
14
HC
90823
01/01/1900
12/31/2199
14
HC
90826
01/01/1900
12/31/2199
14
14
14
14
HC
HC
HC
HC
90828
90845
90847
90862
P
P
P
P
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
14
15
15
15
15
15
15
15
15
HC
HC
HC
HC
HC
96100
T2039
E0636
E1031
E1130
P
P
P
P
P
HC
HC
HC
E1900
E1902
T2029
P
P
P
A
A
A
A
A
A
A
A
A
01/01/1900
10/01/2003
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
10/01/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
09/30/2003
12/31/2199
12/31/2199
12/31/2199
15
16
17
18
18
18
19
19
19
19
19
19
20
20
20
22
22
25
25
34
34
HC
HC
HC
HC
HC
HC
HC
E1399
S5165
S5125
S5140
S5140
S5140
T2031
P
P
P
I
I
I
P
HC
HC
HC
HC
HC
S5160
S5161
S5162
S5199
T2028
P
P
P
P
P
HC
HC
HC
S5170
S9465
S9470
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
05/19/1998
01/01/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2003
10/01/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
3105
3105
3105
U3
U4
U5
U1
U1

U0210
U0300
U0300
U0300
U0300
U0400
U0505
G0205
G0515
G0516
G0517
G0518
G0519
G0520
G0521
G0522
G0523
G0524
G0525
G0230
G0231
G0231
G0232
G0233
G0233
G0233
G0233
G0233
G0233
G0233
G0233
G0233
G0233
DIETARY SERVICES - EVALUATION

AUDIOLOGY/AU-EVALUATION
AUDIOLOGY/AU-HEARING AID-SCREENING
AUDIOLOGY/AU-HEARING AID-ACCLIMATION
AUDIOLOGY/AU-FOLLOW UP
SOCIAL WORK/SW
SUPPORTED EMPLOYMENT/SE
ANNUAL ASSESSMENT
ADP AIDES/REQUISITION FEES 0 - 499.99
ADP AIDES/REQUISITION FEES 4500.00 -4999.99
BEHAVIOR COMMUNICATION SPECIALIST
ORIENTATION & MOBILITY-EXTERNAL NEEDS
ORIENTATION & MOBILITY-PERSONAL NEEDS
INTERVENOR
TRANSPORTATION (TAXI)
TRANSPORTATION (BUS)
TRANSPORTATION (MINI BUS)
TRANSPORTATION (WHEELCHAIR VAN)
TRANSPORTATION (CASE MANAGER)
TRANSPORTATION (MISCELLANEOUS EXPENSES)
TRANSPORTATION (ESCORT MEALS)
TRANSPORTATION (ESCORT MEDICAL-NON MEDICAID)
TRANSPORTATION - (ENCOUNTER/TRIP)
TRANSPORTATION - (COMMERCIAL CARRIER)
34
35
35
35
35
36
37
40
41
41
41
41
41
41
41
41
41
41
41
43
44
44
45
48
48
48
48
48
48
48
48
48
48
17
17
17
17
17
17
17
17
17
17
G0233
G0234
G0235
T2038
S0106
S0107
S0125
S0126
S0127
S0128
48
49
51
53
10B
10B
10B
10B
10B
10B
HC
ZZ
ZZ
HC
T2005
HC
T2015
17
17
S0108
S0108
TRANSPORTATION - (NON-AMBULATORY STRETCHER VAN)

CHILD SUPPORT SERVICES
INDEPENDENT ADVOCACY
HABILITATION - PREVOCATIONAL LON 1 INTERMITTENT
HABILITATION - PREVOCATIONAL LON 5 LIMITED
HABILITATION - PREVOCATIONAL LON 6 PERVASIVE
HABILITATION - PREVOCATIONAL LON 8 EXTENSIVE
HABILITATION - DAY HABILITATION-INDEPENDENT LIVING
SKILLS-PERSONAL NEEDS
HABILITATION - DAY HABILITATION-GENERAL SKILLS
10C
10C
HC
Page 57 of 67
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
REVENUE
POS
CODE
97802
97537
97535
CLAIM FIL IND
T1013
A0100
A0110
A0120
A0130
A0160
A0170
A0210
T2001
T2003
T2004
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
CPT
CODE
MODIFIER 4
V5008
V5010
V5011
V5020
G0155
T2019
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
P
P
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
P
P
P
P
T2038
U4
97535
0942
P
I
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
10/16/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
A
A
A
A
A
A
A
A
A
A
01/01/1900
01/01/1900
01/01/1900
09/01/2004
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
A
A
01/01/1900
01/01/1900
12/31/2199
12/31/2199
ACTIVE

HC
97537
HC
HC
T2017
T2017
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
S5151
ZZ
ZZ
HC
HC
ZZ
ZZ
HC
HC
ZZ
REVENUE
POS
CODE
S5151
S5151
S5151
S5151
CLAIM FIL IND
10C
10C
10C
10C
10C
10V
10V
11A
11A
11B
11B
11B
11B
11B
11B
11BV
11BV
11BV
11BV
11BV
11BV
11C
11C
11C
11C
11C
11C
11C
11CV
11CV
11D
11D
11D
11D
11D
11D
11D
11DV
11DV
11E
11E
11E
11E
11E
11E
11E
11EV
CPT
CODE
MODIFIER 4
Page 58 of 67
HABILITATION - DAY HABILITATION-INDEPENDENT LIVING

SKILLS-EXTERNAL NEEDS
HABILITATION - DAY HABILITATION LON 1 INTERMITTENT
HABILITATION - DAY HABILITATION LON 5 LIMITED
HABILITATION - DAY HABILITATION LON 6 PERVASIVE
HABILITATION - DAY HABILITATION LON 8 EXTENSIVE
CDS- RESIDENTIAL HABILITATION - CONSUMER
CDS - RESIDENTIAL HABILITATION - AGENCY
RESPITE - LON 8
CDS - RESPITE ADULT FOSTER CARE - IND
CDS - RESPITE ADULT FOSTER CARE - AGENCY LEVEL-1
CDS ASSISTED LIVING APT RESPITE - IND
CDS - ASSISTED LIVING APT RESPITE - AGENCY
CDS RESIDENTIAL CARE APT RESPITE - CONSUMER
CDS RESIDENTIAL CARE APT RESPITE - AGENCY
CDS-RESPITE RESIDENTIAL CARE NON APT - CONSUMER
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
S0108
S0129
S0130
S0131
S0132
G0724
G0725
G0119
G0128
G0132
G0132
G0133
G0133
G0134
G0134
G0094
G0095
G0096
G0097
G0098
G0099
G0135
G0135
G0136
G0137
G0138
G0139
G0140
G0173
G0174
G0142
G0142
G0143
G0144
G0145
G0146
G0147
G0175
G0176
G0149
G0149
G0150
G0151
G0152
G0153
G0154
G0177
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
U5
U5
0660
0660
0660
0660
0660
0660
U3
U3
U4
U4
U5
U5
U3
U3
U4
U4
U5
U5
U1
U1
U2
U2
U2
U2
UB
UC
P
P
UB
UC
UB
UC
UB
UC
U1
U1
P
I
P
I
P
I
P
P
P
P
P
P
P
I
P
U1
U1
P
P
I
P
U2
U2
P
P
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2005
01/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2005
01/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2005
01/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2005
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199

REVENUE
POS
CODE
ZZ
CW
CW
CW
CW
CW
CW
CW
CW
CW
CW
CW
CW
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
WR
201
202
203
204
205
206
207
208
209
210
211
212
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
HC
HC
HC
HC
HC
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
CLAIM FIL IND
11EV
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
CPT
CODE
MODIFIER 4
Page 59 of 67
CDS RESIDENTIAL CARE NON APT RESPITE - AGENCY

RESPITE NF RAD
RESPITE NF RAC
RESPITE NF RAB
RESPITE NF - RAA
RESPITE NF - SE3
RESPITE NF - SE2
RESPITE NF - SE1
RESPITE NF - SSC
RESPITE NF - SSB
RESPITE NF - SSA
RESPITE NF - CC2
RESPITE NF - CC1
RESPITE NF - CB2
RESPITE NF - CB1
RESPITE NF - CA2
RESPITE NF - CA1
RESPITE NF - IB2
RESPITE NF - IB1
RESPITE NF - IA2
RESPITE NF - IA1
RESPITE NF - BB2
RESPITE NF - BB1
RESPITE NF - BA2
RESPITE NF - BA1
RESPITE NF - PE2
RESPITE NF - PE1
RESPITE NF - PD2
RESPITE NF - PD1
RESPITE NF - PC2
RESPITE NF - PC1
RESPITE NF - PB2
RESPITE NF - PB1
RESPITE NF - PA2
RESPITE NF - PA1
RESPITE NF - BC1
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0178
N1201
N1202
N1203
N1204
N1205
N1206
N1207
N1208
N1209
N1210
N1211
N1212
RG101
RG102
RG103
RG104
RG105
RG106
RG107
RG108
RG109
RG110
RG111
RG112
RG113
RG114
RG115
RG116
RG117
RG118
RG119
RG120
RG121
RG122
RG123
RG124
RG125
RG126
RG127
RG128
RG129
RG130
RG131
RG132
RG133
RG134
RG135
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/2005
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

17
17
17
17
17
17
17
17
17
17
17
17
G0717
G0719
G0921
G0921
G0922
G0923
G0924
G0925
G0926
G0928
G0929
G0930
CDS PERSONAL ASSISTANCE SERVICES (PAS) CONSUMER

Page 60 of 67
11F
11FV
11FV
11G
11GV
11GV
11H
11HV
11HV
11K
11KV
11KV
11KV
11KV
11L
11L
11LV
11LV
11LV
11LV
11N
11PV
11PV
11PV
12A
13A
13A
13B
13B
13B
13C
13D
17A
17B
17E
17V
17V
19A
19A
19A
19A
19A
19A
19A
19B
19B
19B
WR
PCE HC
ZZ
ZZ
HC
HC
HC
HC
HC
HC
T2037
T2037
T2037
T2026
T2026
T2026
HC
HC
HC
HC
H0045
H0045
H0045
H0045
REVENUE
POS
CODE
UB
UB
UC
UC
UB
UC
UC
I
P
I
TD
TE
P
P
P
P
P
P
P
U2
U2
UB
UC
U1
U1
P
P
P
I
U2
U2
0663
H0045
H0045
H0045
H0045
HC
HC
HC
S5150
S5150
S5150
HC
HC
HC
HC
HC
HC
HC
S9124
T1003
S9123
T1001
T1002
T1002
T1003
HC
HC
HC
HC
S5125
S5125
T2031
T2031
HC
T2031
0663
UB
UC
0663
UB
UC
0660
0660
0660
0660
0660
0660
0660
0660
0660
66
66
66
66
66
89
32
89
32
89
32
UC
UC
UB
UB
0662
0662
TG
TG
0240
CLAIM FIL IND
RESPITE NF - PCE
CDS-RESPITE NF - CONSUMER
CDS-RESPITE NURSING FACILITY - AGENCY
RESPITE - CAMP
CDS-RESPITE-CAMP - CONSUMER
CDS-RESPITE CAMP - AGENCY
RESPITE - DAY CARE/LICENSED CHILD CARE FACILITY
CDS RESPITE - CHILD SUPPORT SERVICES - IND
CDS RESPITE - CHILD SUPPORT SERVICES - AGENCY
RESPITE - ICF/MR
CDS-RESPITE ICF/MR - AGENCY
CDS-RESPITE ICF/MR - AGENCY
CDS-RESPITE-ICF/MR - CONSUMER
CDS-RESPITE-ICF/MR - CONSUMER
RESPITE - HOSPITAL
RESPITE - HOSPITAL
CDS-RESPITE-HOSPITAL - CONSUMER
RESPITE - LVN
CDS - RESPITE-IN-HOME - IND
CDS - RESPITE-IN-HOME - AGENCY
TARGETED CASE MANAGEMENT
NURSING CARE - LVN-WHOLE UNIT
NURSING SERVICES BY LPN/LVN-PARTIAL UNIT
NURSING SERVICES IN THE HOME - RN-WHOLE UNIT
NURSING SERVICES - RN - ASSESSMENT/EVALUATION
NURSING SERVICES - RN-PARTIAL UNIT
PAS DELEGATED (FOR FUTURE USE)
PAS PROTECTIVE SUPERVISION (FOR FUTURE USE)
PAS CHORE
CPT
CODE
MODIFIER 4
RG136
G0179
G0180
G0156
G0184
G0185
G0157
G0186
G0187
G0159
G0188
G0188
G0191
G0191
G0160
G0160
G0189
G0189
G0190
G0190
G0162
G0182
G0183
G0183
G0216
G0302
G0302
G0303
G0303
G0303
T1002
T1003
G0705
G0706
G0744
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
P
P
I
P
P
I
P
P
I
I
P
I
P
I
I
I
I
I
I
MODIFIER 3
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
BEGIN
DATE
END
DATE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
09/01/2008
01/01/2005
01/01/2005
01/01/1900
01/01/2005
01/01/2005
01/01/1900
01/01/2005
01/01/2005
01/01/1900
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/1900
01/01/1900
01/01/2005
01/01/2005
01/01/2005
01/01/2005
01/01/1900
01/01/2005
01/01/2005
01/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/2008
01/01/2008
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
A
A
A
A
A
A
A
A
A
A
A
A
06/01/2005
06/01/2005
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
08/31/2003
08/31/2003
08/31/2003
08/31/2003
12/31/2199
08/31/2003
08/31/2003
ACTIVE

LC
LC
LN
LN
LN
LN
LN
LN
1
1
5
5
6
6
8
8
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
ZZ
T2031
T1020
T1020
T1020
T1020
T1020
T1020
T1020
T1020
T2033
T1020
T1020
T1020
T1020
T1020
T1020
T1020
T1020
T2024
REVENUE
POS
CODE
0240
0240
0240
0240
0240
0240
0240
0240
U3
U3
U7
U7
U8
U8
UA
UA
U3
U3
U7
U7
UA
UA
U8
U8
U1
U2
U2
U2
U2
U2
U2
U2
U2
U1
U2
U2
U2
U2
U2
U2
U2
U2
CLAIM FIL IND
19B
19B
19B
19C
19E
19E
19E
19E
19E
19E
19E
19E
19E
19G
19G
19G
19G
19G
19G
19G
19G
40A
41A
41A
41A
41A
41A
41A
41A
41A
41A
41A
41A
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41B
41C
CPT
CODE
MODIFIER 4
Page 61 of 67

ASSISTED LIVING - PERSONAL CARE 3
RESIDENTIAL SUPPORT/RS - LON 1
AL - FAMILY SURROGATE SERVICES LON 1
PRE-ASSESSMENT
MEDICAL S/REQUISITION FEES 4000.00 - 4499.99.
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0931
G0932
G0933
G0935
G0910
G0910
G0911
G0911
G0912
G0912
G0913
G0913
G0937
G0939
G0939
G0940
G0940
G0941
G0941
G0942
G0942
G0207
G1212
G1213
G1214
G1215
G1216
G1217
G1218
G1219
G1220
G1221
G1222
G0623
G0624
G0625
G0626
G0627
G0628
G0629
G0630
G0631
G0632
G0633
G0634
G0635
G0636
G0607
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
17
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
I
P
I
P
I
P
I
P
P
I
P
I
P
I
P
I
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
08/31/2003
08/31/2003
08/31/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
MD
CP
CP
CP
ZZ
ZZ
ZZ
ZZ
ZZ
AD
D9999
HC
HC
S5150
S5150
ZZ
HC
HC
HC
HC
HC
E1031
E1399
E1031
E1130
E1399
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
T2029
T2029
E1130
E0636
E0636
T2039
E1902
T2028
E1902
T2028
T2039
E1900
E1900
S5165
S5165
T2038
201
202
203
204
205
206
207
208
209
210
211
212
RAD HC
RAC HC
RAB HC
REVENUE
POS
CODE
0662
0290
0290
0290
0290
0290
3106
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
CLAIM FIL IND
41D
45V
45V
53A
57V
5A
4
11
11
11
11
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
15
16
16
53
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
CPT
CODE
MODIFIER 4
Page 62 of 67
CDS-INTERVENOR - CONSUMER
CDS-INTERVENOR - AGENCY
TAS FEES
EMERGENCY DENTAL
VENTILATOR - FULL
RESPITE - SITTER SERVICES
DME/ADAPTIVE AIDS
DME - SPECIALIZED EQUIPMENT (NOS)
MEDICAL SUPPLIES - SPECIALIZED SUPPLIES (NOS)
MEDICAL SUPPLIES - SPECIALIZED SUPPLIES (NOS)
HOME MODIFICATIONS
HOME MODIFICATIONS
RESPITE NF - RAD
RESPITE NF - RAC
RESPITE NF - RAB
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0604
G0240
G0241
G0239
G0757
N0600
N0500
G0121
G0121
G0122
G0171
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0500
G0608
G0608
T2038
N1201
N1202
N1203
N1204
N1205
N1206
N1207
N1208
N1209
N1210
N1211
N1212
RG101
RG102
RG103
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
17
17
17
17
17
17
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
P
P
P
P
P
D
P
I
P
I
I
P
P
P
P
P
I
I
P
I
P
P
P
I
I
I
P
I
P
I
P
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/2005
01/01/2005
09/01/2004
01/01/2009
10/01/2000
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
05/19/1998
10/01/2003
10/01/2003
05/19/1998
05/19/1998
05/19/1998
10/01/2003
05/19/1998
10/01/2003
05/19/1998
10/01/2003
10/01/2003
05/19/1998
05/19/1998
01/01/2003
01/01/2003
09/01/2004
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
10/16/2003
09/01/2008
09/01/2008
09/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2003
12/31/2199
12/31/2199
08/31/2003
12/31/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
09/30/2003
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
REVENUE
POS
CODE
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
CLAIM FIL IND
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11F
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
CPT
CODE
MODIFIER 4
Page 63 of 67
RESPITE NF - RAA
RESPITE NF - SE3
RESPITE NF - SE2
RESPITE NF - SE1
RESPITE NF - SSC
RESPITE NF - SSB
RESPITE NF - SSA
RESPITE NF - CC2
RESPITE NF - CC1
RESPITE NF - CB2
RESPITE NF - CB1
RESPITE NF - CA2
RESPITE NF - CA1
RESPITE NF - IB2
RESPITE NF - IB2
RESPITE NF - IA2
RESPITE NF - IA1
RESPITE NF - BB2
RESPITE NF - BB1
RESPITE NF - BA2
RESPITE NF - BA1
RESPITE NF - PE2
RESPITE NF - PE1
RESPITE NF - PD2
RESPITE NF - PD1
RESPITE NF - PC2
RESPITE NF - PC1
RESPITE NF - PB2
RESPITE NF - PB1
RESPITE NF - PA2
RESPITE NF - PA1
RESPITE NF - BC1
RESPITE NF - PCE
RESPITE NF W/24 HOUR VENT RAD
RESPITE NF W/24 HOUR VENT RAC
RESPITE NF W/24 HOUR VENT RAB
RESPITE NF W/24 HOUR VENT RAA
RESPITE NF W/24 HOUR VENT SE3
RESPITE NF W/24 HOUR VENT SSC
RESPITE NF W/24 HOUR VENT SSB
RESPITE NF W/24 HOUR VENT SSA
RESPITE NF W/24 HOUR VENT CC2
RESPITE NF W/24 HOUR VENT CC1
RESPITE NF W/24 HOUR VENT CB2
RESPITE NF W/24 HOUR VENT CB1
RESPITE NF W/24 HOUR VENT CA2
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG104
RG105
RG106
RG107
RG108
RG109
RG110
RG111
RG112
RG113
RG114
RG115
RG116
RG117
RG118
RG119
RG120
RG121
RG122
RG123
RG124
RG125
RG126
RG127
RG128
RG129
RG130
RG131
RG132
RG133
RG134
RG135
RG136
RG201
RG202
RG203
RG204
RG205
RG206
RG207
RG208
RG209
RG210
RG211
RG212
RG213
RG214
RG215
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
09/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
REVENUE
POS
CODE
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
CLAIM FIL IND
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FA
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
CPT
CODE
MODIFIER 4
Page 64 of 67
RESPITE NF W/24 HOUR VENT CA1

RESPITE NF W/24 HOUR VENT IB2
RESPITE NF W/24 HOUR VENT IB1
RESPITE NF W/24 HOUR VENT IA2
RESPITE NF W/24 HOUR VENT IA1
RESPITE NF W/24 HOUR VENT BB2
RESPITE NF W/24 HOUR VENT BB1
RESPITE NF W/24 HOUR VENT BA2
RESPITE NF W/24 HOUR VENT BA1
RESPITE NF W/24 HOUR VENT PE2
RESPITE NF W/24 HOUR VENT PE1
RESPITE NF W/24 HOUR VENT PD2
RESPITE NF W/24 HOUR VENT PD1
RESPITE NF W/24 HOUR VENT PC2
RESPITE NF W/24 HOUR VENT PC1
RESPITE NF W/24 HOUR VENT PB2
RESPITE NF W/24 HOUR VENT PB1
RESPITE NF W/24 HOUR VENT PA2
RESPITE NF W/24 HOUR VENT PA1
RESPITE NF W/24 HOUR VENT BC1
RESPITE NF W/24 HOUR VENT PCE
RESPITE NF W/<24 HOUR VENT RAD
RESPITE NF W/<24 HOUR VENT RAC
RESPITE NF W/<24 HOUR VENT RAB
RESPITE NF W/<24 HOUR VENT RAA
RESPITE NF W/<24 HOUR VENT SE3
RESPITE NF W/<24 HOUR VENT SSC
RESPITE NF W/<24 HOUR VENT SSB
RESPITE NF W/<24 HOUR VENT SSA
RESPITE NF W/<24 HOUR VENT CC2
RESPITE NF W/<24 HOUR VENT CC1
RESPITE NF W/<24 HOUR VENT CB2
RESPITE NF W/<24 HOUR VENT CB1
RESPITE NF W/<24 HOUR VENT CA2
RESPITE NF W/<24 HOUR VENT CA1
RESPITE NF W/<24 HOUR VENT IB2
RESPITE NF W/<24 HOUR VENT IB1
RESPITE NF W/<24 HOUR VENT IA2
RESPITE NF W/<24 HOUR VENT IA1
RESPITE NF W/<24 HOUR VENT BB2
RESPITE NF W/<24 HOUR VENT BB1
RESPITE NF W/<24 HOUR VENT BA2
RESPITE NF W/<24 HOUR VENT BA1
RESPITE NF W/<24 HOUR VENT PE2
RESPITE NF W/<24 HOUR VENT PE1
RESPITE NF W/<24 HOUR VENT PD2
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG216
RG217
RG218
RG219
RG220
RG221
RG222
RG223
RG224
RG225
RG226
RG227
RG228
RG229
RG230
RG231
RG232
RG233
RG234
RG235
RG236
RG301
RG302
RG303
RG304
RG305
RG306
RG307
RG308
RG309
RG310
RG311
RG312
RG313
RG314
RG315
RG316
RG317
RG318
RG319
RG320
RG321
RG322
RG323
RG324
RG325
RG326
RG327
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
CP
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
RAD
RAC
RAB
RAA
SE3
SE2
SE1
SSC
SSB
SSA
CC2
CC1
CB2
CB1
CA2
CA1
IB2
IB1
IA2
IA1
BB2
BB1
BA2
BA1
PE2
PE1
PD2
PD1
PC2
PC1
PB2
PB1
PA2
PA1
BC1
PCE
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
H0045
T2037
T2026
S5150
REVENUE
POS
CODE
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
0663
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
KX
CLAIM FIL IND
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FB
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11FC
11G
11H
11J
CPT
CODE
MODIFIER 4
Page 65 of 67
RESPITE NF W/<24 HOUR VENT PD1

RESPITE NF W/<24 HOUR VENT PC2
RESPITE NF W/<24 HOUR VENT PC1
RESPITE NF W/<24 HOUR VENT PB2
RESPITE NF W/<24 HOUR VENT PB1
RESPITE NF W/<24 HOUR VENT PA2
RESPITE NF W/<24 HOUR VENT PA1
RESPITE NF W/<24 HOUR VENT BC1
RESPITE NF W/<24 HOUR VENT PCE
RESPITE NF W/PEDIATRIC TRACH RAD
RESPITE NF W/PEDIATRIC TRACH RAC
RESPITE NF W/PEDIATRIC TRACH RAB
RESPITE NF W/PEDIATRIC TRACH RAA
RESPITE NF W/PEDIATRIC TRACH SE3
RESPITE NF W/PEDIATRIC TRACH SSC
RESPITE NF W/PEDIATRIC TRACH SSB
RESPITE NF W/PEDIATRIC TRACH SSA
RESPITE NF W/PEDIATRIC TRACH CC2
RESPITE NF W/PEDIATRIC TRACH CC1
RESPITE NF W/PEDIATRIC TRACH CB1
RESPITE NF W/PEDIATRIC TRACH CB1
RESPITE NF W/PEDIATRIC TRACH CA2
RESPITE NF W/PEDIATRIC TRACH CA1
RESPITE NF W/PEDIATRIC TRACH IB2
RESPITE NF W/PEDIATRIC TRACH IB1
RESPITE NF W/PEDIATRIC TRACH IA2
RESPITE NF W/PEDIATRIC TRACH IA1
RESPITE NF W/PEDIATRIC TRACH BB2
RESPITE NF W/PEDIATRIC TRACH BB1
RESPITE NF W/PEDIATRIC TRACH BA2
RESPITE NF W/PEDIATRIC TRACH BA1
RESPITE NF W/PEDIATRIC TRACH PE2
RESPITE NF W/PEDIATRIC TRACH PE1
RESPITE NF W/PEDIATRIC TRACH PD2
RESPITE NF W/PEDIATRIC TRACH PD1
RESPITE NF W/PEDIATRIC TRACH PC2
RESPITE NF W/PEDIATRIC TRACH PC1
RESPITE NF W/PEDIATRIC TRACH PB2
RESPITE NF W/PEDIATRIC TRACH PB1
RESPITE NF W/PEDIATRIC TRACH PA2
RESPITE NF W/PEDIATRIC TRACH PA1
RESPITE NF W/PEDIATRIC TRACH BC1
RESPITE NF W/PEDIATRIC TRACH PCE
RESPITE - CAMP
RESPITE - DAY CARE/LICENSED CHILD CARE FACILITY
RESPITE - LICENSED SPECIAL CARE FACILITY
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
RG328
RG329
RG330
RG331
RG332
RG333
RG334
RG335
RG336
RG401
RG402
RG403
RG404
RG405
RG406
RG407
RG408
RG409
RG410
RG411
RG412
RG413
RG414
RG415
RG416
RG417
RG418
RG419
RG420
RG421
RG422
RG423
RG424
RG425
RG426
RG427
RG428
RG429
RG430
RG431
RG432
RG433
RG434
RG435
RG436
G0156
G0157
G0158
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
11/01/2008
01/01/1900
01/01/1900
01/01/1900
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
S9124
S9123
S9124
S9124
S9123
S9123
T1030
T1031
T1003
T1031
T1031
T1003
T1002
T1030
T1030
S9125
T1005
T1005
S9124
S9123
S9124
S9123
S9123
S9124
T1030
T1031
T1003
T1003
T1031
T1031
T1003
T1002
T1002
T1030
T1030
T1002
S5120
S5130
S5135
T1019
T1019
S5120
S5130
S5135
S5120
REVENUE
POS
CODE
0660
0660
0661
0661
89
32
TE
TD
TE
TG
TG
0661
TG
TD
TD
TE
TE
TE
TE
TE
0661
TG
TD
TD
TD
0662
0552
0552
TG
TG
TD
TE
TD
TE
0552
TG
TE
TE
0552
TG
TD
TD
0572
0572
0572
0572
UB
CLAIM FIL IND
11L
11L
11M
11M
11M
11M
11M
11M
11MS
11MS
11N
11NS
11NSV
11NV
11P
11PS
11PSV
11PV
11Q
11Q
11R
11R
11R
11R
11R
11R
11R
11RS
11RS
11S
11S
11SS
11SSV
11SV
11T
11T
11TS
11TSV
11TV
11U
11U
11U
11U
11U
11U
11U
11U
11UV
CPT
CODE
MODIFIER 4
Page 66 of 67
RESPITE-HOSPITAL
RESPITE-HOSPITAL
RESPITE - HCSS (RN/LVN) LVN
RESPITE - HCSS (RN/LVN) RN
RESPITE - HCSS (RN/LVN) RN
SPECIALIZED RESPITE - HCSS RN
SPECIALIZED RESPITE - HCSS LVN
RESPITE - LVN
SPECIALIZED RESPITE - LVN
CDS SPECIALIZED RESPITE - LVN
CDS RESPITE - LVN
RESPITE - RN
SPECIALIZED RESPITE - RN
CDS SPECIALIZED RESPITE RN
CDS RESPITE IN HOME RN
RESPITE - PAS DELEGATED
RESPITE - PAS DELEGATED
ADJUNCT - HCSS (RN/LVN) RN
ADJUNCT-NURSING IN HOME RN
AGENCY ADMIN - ADJUNCT HCSS (RN/LVN) CDS
ADJUNCT - HCSS (RN/LVN) LVN
SPECIALIZED ADJUNCT - HCSS RN
SPECIALIZED ADJUNCT - HCSS LVN
ADJUNCT - LVN
ADJUNCT - LVN
SPECIALIZED ADJUNCT - LVN
CDS SPECIALIZED ADJUNCT - LVN
CDS ADJUNCT - LVN
ADJUNCT - RN
ADJUNCT - RN
SPECIALIZED ADJUNCT - RN
CDS SPECIALIZED ADJUNCT - RN
CDS ADJUNCT - RN
ADJUNCT - PAS HCSS CHORE SERVICE
ADJUNCT - PAS HCSS - HOMEMAKER SERVICE
ADJUNCT - PAS HCSS COMPANION CARE-ADULT
ADJUNCT - PAS HCSS
ADJUNCT - PAS HCSS
ADJUNCT - PAS HCSS
ADJUNCT - PAS HCSS HOMEMAKER SERVICE
ADJUNCT - PAS HCSS COMPANION CARE-ADULT
CDS - ADJUNCT PAS HCSS - INDIVIDUAL CHORE SERVICES
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
G0160
G0160
G0161
G0161
G0161
G0161
G0194
G0194
T1032
T1033
G0162
T1031
G0963
G0962
G0163
T1030
G0961
G0960
G0164
G0164
G0165
G0165
G0165
G0165
G0165
G0181
G0195
T1036
T1037
G0166
G0166
T1035
G0965
G0964
G0167
G0167
T1034
G0967
G0966
G0168
G0168
G0168
G0168
G0168
G0168
G0168
G0168
G0192
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
I
I
I
I
P
P
P
P
P
P
I
P
P
P
I
P
P
P
I
P
P
I
I
P
P
P
P
P
P
P
I
P
P
P
P
I
P
P
P
P
P
P
P
I
I
I
I
P
ACTIVE
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
BEGIN
DATE
END
DATE
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
03/01/2008
09/01/2007
03/01/2008
08/01/2008
08/01/2008
01/01/1900
08/01/2008
01/01/2009
01/01/2009
01/01/1900
08/01/2008
01/01/2009
01/01/2009
01/01/1900
10/16/2003
01/01/1900
01/01/1900
01/01/1900
01/01/1900
09/01/2007
01/01/1900
09/01/2007
08/01/2008
08/01/2008
01/01/1900
01/01/1900
08/01/2008
01/01/2009
01/01/2009
01/01/1900
01/01/1900
08/01/2008
01/01/2009
01/01/2009
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
01/01/1900
04/01/2005
12/31/2199
12/31/2199
08/31/2007
08/31/2007
02/29/2008
12/31/2199
02/29/2008
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
08/31/2007
08/31/2007
08/31/2007
08/31/2007
12/31/2199
08/31/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199

REVENUE
POS
CODE
CLAIM FIL IND
CPT
CODE
MODIFIER 4
LEVEL PROC CD HCPCS

VALUE QUAL
CODE
MODIFIER 3
SERVICE LEVEL
CODE
TYPE
MODIFIER 2
DESCRIPTION
MODIFIER 1
SERVICE
BILL CODE
GROUP
National Codes
ClaimType to
File I=837I;
P=837P;
D=837D;
E=Expdtd;
N=NAT
ACTIVE
BEGIN
DATE
END
DATE
18
G0192
CDS - ADJUNCT PAS HCSS - INDIVIDUAL HOMEMAKER

SERVICE
11UV
HC
S5130
UB
04/01/2005
12/31/2199
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
18
G0192
G0192
G0192
G0192
G0192
G0192
G0193
G0193
G0193
G0193
G0193
G0193
G0193
G0193
G0169
G0169
G0182
G0182
G0182
G0183
G0183
G0722
G0239
G0221
G0225
CDS - ADJUNCT PAS HCSS - INDIVIDUAL COMPANION CARE

CDS - ADJUNCT PAS HCSS - ICF/MR OR IMD
CDS - ADJUNCT PAS HCSS - IND
CDS - ADJUNCT PAS HCSS
CDS - ADJUNCT PAS HCSS - AGENCY - CHORE SERVICES
SERVICE
CDS - ADJUNCT PAS HCSS - AGENCY - COMPANION CARE
CDS - ADJUNCT PAS HCSS - AGENCY
CDS - ADJUNCT PAS HCSS - AGENCY - CHORE SERVICES
SERVICE
CDS - ADJUNCT PAS HCSS - AGENCY - COMPANION CARE
CDS - ADJUNCT PAS HCSS - AGENCY
ADJUNCT - PAS DELEGATED
ADJUNCT - PAS DELEGATED
CDS - RESPITE-IN-HOME - IND
CDS - RESPITE-IN-HOME - IND.
CDS - RESPITE-IN-HOME - IND.
TAS FEES
CDS - MDCP ORIENTATION FEE
CDS MDCP MONTHLY ADMINISTRATION FEE
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11UV
11V
11V
11ZV
11ZV
11ZV
11ZV
11ZV
27A
53A
62V
63V
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
HC
ZZ
ZZ
ZZ
ZZ
S5135
T1019
S5120
S5130
S5135
T1019
S5120
S5130
S5135
T1019
S5120
S5130
S5135
T1019
S5125
S5125
S5150
S5150
S5150
S5150
S5150
UB
UB
UB
UB
UB
UB
UC
UC
UC
UC
UC
UC
UC
UC
P
P
I
I
I
I
P
P
P
P
I
I
I
I
P
I
I
P
P
P
I
P
P
P
P
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
04/01/2005
01/01/1900
01/01/1900
04/01/2005
01/01/2005
04/01/2005
04/01/2005
04/01/2005
01/01/1900
09/01/2004
09/01/2007
09/01/2007
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2199
12/31/2008
12/31/2199
12/31/2199
12/31/2199
Page 67 of 67
0572
0572
0572
0572
0572
0572
0572
0572
0572
0662
0662
UB
UB
UB
UC
UC

LTCBillCodeCrosswalk 100109

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LTCBillCodeCrosswalk 100109

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LTC Bill Code Crosswalk

Texas LTC Local Codes

CLAIM FIL IND

LEVEL PROC CD HCPCS

Last Update 10/01/2009