REVENUE CODE TABLE

C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Reserved
All-Inclusive Rate
ALL INCL R&B/ANC
ALL INCL R&B
Reserved
NA
NA
NA
-
NA
NA
-
-
-
NA
NA
-
-
NC
NC
-
HCPCS REQ
-
UNITS REQ
C
PDN
COV SVC
-
HCPCS REQ
-
UNITS REQ
NA
HOME HEALTH
Y
Y
COV SVC
-
HCPCS REQ
-
NA
HOSPICE
UNITS REQ
NA
NA
NA
NA
INPATIENT
COV SVC
Y
HCPCS REQ
-
UNITS REQ
COV SVC
OPPS
-
Y
COV SVC
HCPCS REQ
002X
0020
0021
0022
0023
0024
0025-9
003X to
009X
010X
0100
0101
0102-9
TOTAL CHARGE
Reserved for Internal Payer Use
Health Insurance-Prospective Payment
System (HIPPS)
Reserved
Reserved
SNF PPS (RUG)
HH PPS (HRG)
REHAB PPS (CMG)
Reserved
RATE/HCPCS
REQ
UNITS REQ
NA
OPH
0001
001X
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
Y
Y
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
C
Y
Y
011X
0110
0111
0112
0113
0114
0115
0116
0117
0118
0119
Room & Board (R&B) Private(One Bed)
ROOM-BOARD
MED-SUR-GY
OB
PEDS
PSYCH
HOSPICE
DETOX
ONCOLOGY
REHAB
Other *
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
C
C
C
C
NA
C
C
C
NC
Y
Y
Y
Y
Y
Y
Y
Y
-
Y
Y
Y
Y
Y
Y
Y
Y
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
NA
NA
NA
NA
NA
NA
NA
NA
C
Y
-
N
-
012X
0120
0121
0122
0123
Room & Board Semi Private(Two beds)
ROOM-BOARD/SEMI
MED-SUR-GY/SEMI
OB/SEMI-PVT
PEDS/SEMI-PVT
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
C
NA
NA
NA
Y
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
C
NA
NA
NA
Y
-
N
-
Rev. 12/3/15
Page 1 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
HOME HEALTH
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
C
C
C
C
NA
C
C
C
NC
Y
Y
Y
Y
Y
Y
Y
Y
-
Y
Y
Y
Y
Y
Y
Y
Y
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NC
NC
NC
NC
NC
NA
NC
NC
NC
NC
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
PDN
-
-
SNF - NRSG FAC
NA
NA
NA
NA
NA
C
Y
N
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
NA
NA
NA
NA
NA
NA
NA
NA
NA
Y
-
N
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
NA
NA
NA
NA
NA
NA
NA
NA
NA
Y
-
N
-
-
NA
NA
NA
NA
NA
-
-
C
NA
NA
NA
NA
Y
-
N
-
Special Notes
T5 = Title V
* = FIDS Beds
HCPCS REQ
-
UNITS REQ
HOSPICE
-
COV SVC
-
HCPCS REQ
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
UNITS REQ
NA
NA
NA
NA
NA
NA
COV SVC
INPATIENT
C
Y
Y
NA
C
Y
Y
C
Y
Y
C
Y
Y
NC
-
HCPCS REQ
-
UNITS REQ
OPPS
-
COV SVC
HCPCS REQ
NA
NA
NA
NA
NA
NA
Page 2 of 19
UNITS REQ
-
COV SVC
HCPCS REQ
RATE/HCPCS
REQ
UNITS REQ
OPH
-
UNITS REQ
COV SVC
NA
NA
NA
NA
NA
NA
COV SVC
HCPCS REQ
PSYCH/SEMI-PVT
H0SPICE/SEMI-PVT
DETOX/SEMI-PVT
ONCOLOGY/SEMI
REHAB/SEMI-PVT
Other/SEMI-PVT *
Room & Board (3 & 4 beds)
ROOM-BOARD/3&4BED
MED-SUR-GY/3&4BED
0B/3&4BED
PEDS/3&4BED
PSYCH/3&4BED
HOSPICE/3&4BED
DETOX/3&4BED
ONCOLOGY/3&4BED
REHAB/3&4BED
Other/3&4BED
Room & Board - Deluxe Private
ROOM-BOARD/DLX PVT
MED-SUR-GY/DLX PVT
OB/DLXPVT
PEDS/DLXPVT
PSYCH/DLXPVT
HOSPICE/DLXPVT
DETOX/DLXPVT
ONCOLOGY/DLXPVT
REHAB//DLXPVT
Other/DLXPVT
ROOM & BOARD WARD
ROOM-BOARD/WARD
MED-SUR-GY/WARD
OB/WARD
PEDS/WARD
PSYCH/WARD
UNITS REQ
0124
0125
0126
0127
0128
0129
013X
0130
0131
0132
0133
0134
0135
0136
0137
0138
0139
014X
0140
0141
0142
0143
0144
0145
0146
0147
0148
0149
015X
0150
0151
0152
0153
0154
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
HCPCS REQ
HCPCS REQ
UNITS REQ
INPATIENT
NA
C
Y
Y
C
Y
Y
C
Y
Y
NC
-
NA
NA
NA
NA
NA
HOSPICE
-
-
HOME HEALTH
NA
NA
NA
NA
NA
-
NA
NA
NA
NA
NA
PDN
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
N
NA
-
-
NA
-
-
C
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
-
-
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
C
C
C
C
C
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
-
-
-
-
C
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
-
NA
NA
NA
-
-
C
Y
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
C
Y
N
NA
NA
-
-
NA
NA
-
-
NA
C
Y
N
NA
-
-
NA
-
-
NA
-
-
C
Y
N
NA
-
-
NA
-
-
C
Y
N
NA
NA
NA
NA
NA
-
-
-
-
NC
-
-
C
-
-
NA
-
-
NA
-
-
C
Y
N
-
-
NA
NA
NA
NA
NA
-
-
C
C
Y
Y
Y
Y
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
UNITS REQ
COV SVC
-
COV SVC
HCPCS REQ
OPPS
-
Page 3 of 19
HCPCS REQ
UNITS REQ
NA
NA
NA
NA
NA
UNITS REQ
COV SVC
-
COV SVC
HCPCS REQ
RATE/HCPCS
REQ
UNITS REQ
OPH
-
UNITS REQ
COV SVC
NA
NA
NA
NA
NA
COV SVC
HCPCS REQ
HOSPICE/WARD
DETOX/WARD
ONCOLOGY/WARD
REHAB/WARD
Other/WARD
ROOM & BOARD OTHER
R&B
RESERVED
R&B/STERILE
RESERVED
R&B/SELF
RESERVED
R&B/OTHER
NURSERY
NURSERY
NURSERY/LEVEL I
NURSERY/LEVEL II
NURSERY/LEVEL III
NURSERY/LEVEL IV
RESERVED
NURSERY/OTHER
LEAVE OF ABSENCE
Leave of Absence or LOA
RESERVED
LOA/PT CONV
LOA/THERAPEUTIC
RESERVED
LOA/NURS HOME
RESERVED
LOA/OTHER *
SUBACUTE CARE
INTENSIVE CARE UNIT
INTENSIVE CARE (ICU)
ICU/SURGICAL
UNITS REQ
0155
0156
0157
0158
0159
016X
0160
0161-3
0164
0165-6
0167
0168
0169
017X
0170
0171
0172
0173
0174
0175-8
0179
018X
0180
0181
0182
0183
0184
0185
0186-8
0189
019X
020X
0200
0201
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
NA
NA
NA
NA
NA
-
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
-
-
C
C
C
NC
Y
Y
Y
-
Y
Y
Y
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
-
-
NA
-
-
NC
-
-
C
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NC
NC
NC
NC
NC
-
C
NA
NA
NA
NA
NA
NA
NA
-
-
Y
Y
NC
-
-
NC
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
-
SNF - NRSG FAC
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
C
C
NA
N
N
N
N
N
-
N
N
N
N
N
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Page 4 of 19
Special Notes
T5 = Title V
* = FIDS Beds
HCPCS REQ
PDN
-
HOSPICE
-
UNITS REQ
NA
NA
NA
NA
NA
NA
NA
COV SVC
-
HCPCS REQ
-
UNITS REQ
-
COV SVC
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
HOME HEALTH
NA
NA
NA
-
INPATIENT
Y
Y
Y
Y
Y
Y
HCPCS REQ
C
C
C
UNITS REQ
-
COV SVC
OPPS
-
HCPCS REQ
NA
NA
NA
UNITS REQ
COV SVC
-
COV SVC
HCPCS REQ
OPH
-
RATE/HCPCS
REQ
UNITS REQ
NA
NA
NA
UNITS REQ
COV SVC
HCPCS REQ
ICU/MEDICAL
ICU/PEDS
ICU/PSYCH
RESERVED
ICU/INTERMEDIATE
ICU/BURN CARE
ICU/TRAUMA
ICU/OTHER
CORONARY CARE UNIT)
CORONARY CARE(CCU)
CCU/MYO INFARC
CCU/PULMONARY
CCU/TRANSPLANT
CCU/INTERMEDIATE
RESERVED
CCU/OTHER
SPECIAL CHARGES
SPECIAL CHARGE
ADMIT CHARGE
TECH SUPPT CHG
UR CHARGE
LATE DISCH/MED NEC
RESERVED
OTHER SPEC CHG
INCREMENTAL NURSING CHARGE
NURSING INCREM
NUR INCR/NURSERY
NUR INCR/OB
NUR INCR/ICU
NUR INCR/CCU
NUR INCR/HOSPICE
RESERVED
NUR INCR/OTHER
ALL INCLUSIVE ANCILLARY
UNITS REQ
0202
0203
0204
0205
0206
0207
0208
0209
021X
0210
0211
0212
0213
0214
0215-8
0219
22X
0220
0221
0222
0223
0224
0225-8
0229
023X
0230
0231
0232
0233
0234
0235
0236-8
0239
024X
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
025X
0250
0251
0252
0253
0254
0255
0256
0257
0258
0259
026X
0260
0261
0262
0263
0264
0265-8
0269
027X
0270
0271
0272
0273
0274
0275
0276
0277
0278
0279
028X
0280
Pharmacy (also see 063X, an extension of
025X)
PHARMACY
DRUGS/GENERIC
DRUGS/NONGENERIC
DRUGS/TAKEHOME
DRUGS/ICIDENT ODX
DRUGS/ICIDENT RAD
DRUGS/EXPERIMT
DRUGS/NONPSCRPT
IV SOLUTIONS
DRUGS/OTHER
IV THERAPY
IV THERAPY
IV THER/INFSN PUMP
IV THER/PHARM SVC
IV THER/DRUG/SUPPLY/DEL
IV THER/SUPPLIES
RESERVED
IV THERAPY/OTHER
MED/SURG Supplies & Devices (also see
062X , an extension of 027X)
MED-SUR SUPPLIES
NON-STER SUPPLY
STERILE SUPPLY
TAKEHOME SUPPLY
PROSTH/ORTH DEV
PACE MAKER
INTRA OC LENS
02/TAKEHOME
SUPPLY/IMPLANTS
SUPPLY/OTHER
ONCOLOGY
ONCOLOGY
Rev. 12/3/15
OPPS
INPATIENT
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
C
C
C
NA
C
C
NC
C
C
C
N
N
N
-
Pkg
Pkg
Pkg
NC
Pkg
Pkg
NC
Pkg
Pkg
Pkg
-
-
C
C
C
NA
NA
NA
NC
C
C
NC
N
N
N
N
N
-
N
N
N
N
N
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
NC
C
C
C
-
-
Pkg
C
Pkg
Pkg
Pkg
Y
-
Y
-
C
C
NA
NA
NA
N
N
-
N
N
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
C
N
Pkg
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
NC
C
C
C
NC
C
C
-
Pkg
Pkg
Pkg
Pkg
C
Pkg
Pkg
NC
Pkg
Pkg
Y
-
Y
-
C
C
C
NC
C
C
C
NA
C
C
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
Y
Y
Y
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
Y
Y
Y
-
-
-
C
C
C
NC
NC
NC
NC
NC
NC
NC
-
-
C
Y
Pkg
-
-
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
-
Page 5 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
0281-8
0289
029X
030X
0300
0301
0302
0303
0304
0305
0306
0307
0308
0309
031X
0310
0311
0312
0313
0314
0315-8
0319
032X
0320
0321
0322
0323
0324
0325-8
0329
033X
0330
RESERVED
ONCOLOGY/OTHER
Durable Medical Equipment (DME) (other
than renal)
LABORATORY
LAB
CHEMISTRY TESTS
IMMUNOLOGY TESTS
RENAL-HOME
NON-RTNE DIALYSIS
HEMATOLOGY TESTS
BACT & MICRO TESTS
UROLOGY TESTS
RESERVED
OTHER LAB TESTS
LABORATORY PATHOLOGY
PATHOLOGY LAB
CYTOLOGY TESTS
HYSTOLOGY TESTS
RESERVED
BIOPSY TESTS
RESERVED
PATH LAB OTHER
RADIOLOGY - DIAGNOSTIC
DX X-RAY
DX X-RAY/ANGlO
DX X-RAY/ARTHO
DX X-RAY/ARTER
DX X-RAY/CHEST
RESERVED
DX X-RAY/OTHER
Radiology -Therapeutic and/or
Chemotherapy Administration
RADIOLOGY THERAPY
Rev. 12/3/15
C
Y
NA
OPPS
Pkg
INPATIENT
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
-
-
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NC
C
C
C
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
C
C
C
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
NA
C
NA
C
Y
Y
Y
Y
Y
C
C
C
Y
Y
Y
Y
Y
Y
C
Y
Y
C
Y
Y
C
C
C
NA
C
NA
C
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
C
C
C
C
C
NA
C
Y
Y
Y
Y
Y
Y
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
Y
Y
C
C
C
C
C
NA
C
N
N
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
C
Y
C
Y
Y
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Page 6 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
HOME HEALTH
NA
NA
NA
NA
NA
-
NA
NA
NA
NA
NA
PDN
-
-
SNF - NRSG FAC
NA
NA
NA
NA
NA
-
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
C
C
Y
Y
Y
Y
Y
C
C
C
Pkg
Pkg
Y
Y
Y
-
Y
Y
Y
-
C
C
C
C
C
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
C
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
Y
Y
Y
C
C
C
Y
Y
Y
Y
Y
Y
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
NA
Y
Y
-
C
C
C
Y
Y
-
Y
Y
Y
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
-
-
-
-
-
-
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
-
NC
-
-
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
C
Y
Y
NC
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
N
N
N
Pkg
Pkg
Pkg
-
-
C
C
C
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
Page 7 of 19
N
N
N
Special Notes
T5 = Title V
* = FIDS Beds
HCPCS REQ
HCPCS REQ
-
UNITS REQ
UNITS REQ
HOSPICE
-
COV SVC
COV SVC
Y
HCPCS REQ
NA
NA
NA
NA
NA
UNITS REQ
HCPCS REQ
Y
INPATIENT
C
N
N
C
N
N
C
N
N
NA
C
N
N
COV SVC
UNITS REQ
C
RATE/HCPCS
REQ
Y
Y
Y
UNITS REQ
OPPS
Y
Y
Y
OPH
N
Y
N
COV SVC
C
C
C
C
NA
C
NA
C
HCPCS REQ
COV SVC
COMPUTED TOMOGRAPH (CT) SCAN
CT SCAN
CT SCAN/HEAD
CT SCAN/BODY
RESERVED
CT SCAN/OTHER
OPERATING ROOM SERVICES
OR SERYICES
OR/MINOR
OR/ORGAN TRANS
RESERVED
OR/KIDNEY TRANS
RESERVED
OR/OTHER
ANESTHESIA
ANESTHESIA
ANESTH/INCIDENT RAD
ANESTH/INCDNT OTHR DX
HCPCS REQ
035X
0350
0351
0352
0353-8
0359
036X
0360
0361
0362
0363-6
0367
0368
0369
037X
0370
0371
0372
UNITS REQ
RAD-CHEMO-INJECT
RAD-CHEMO-ORAL
RAD-RADIATION
RESERVED
RAD-CHEMO-IV
RESERVED
RADIOLOGY/OTHER
NUCLEAR MEDICINE (NUC MED)
NUCLEAR MEDICINE
NUC MED/DX
NUC MED/RX
NUC MED/DX RADIOPHARM
NUC MED/RX RADIOPHARM
RESERVED
NUC MED/OTHER
COV SVC
0331
0332
0333
0334
0335
0336-8
0339
034X
0340
0341
0342
0343
0344
0345-8
0349
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
0373
0374
0375-8
0379
038X
0380
0381
0382
0383
0384
0385
0386
0387
0388
0389
039X
0390
0391
0392
0393-8
0399
040X
0400
0401
0402
0403
0404
0405-8
0409
041X
0410
0411
0412
0413
RESERVED
ANESTH/ACUPUNC
RESERVED
ANESTH/OTHER
BLOOD & BLOOD COMPONENTS
BLOOD & BLOOD COMP
BLOOD/PKD RED
BLOOD/WHOLE
BLOOD/PLASMA
BLOOD/PLATELETS
BLOOD/LEUKOCYTES
BLOOD/COMPONENTS
BLOOD/DERIVATIVES
RESERVED
BLOOD/OTHER
BLOOD STORAGE & PROCESSING
BLOOD/ADMIN/STOR
BLOOD/ADMIN
BLOOD/STORAGE
RESERVED
BLOOD/ADMIN/STOR/OTHER
OTHER IMAGING SERVICES
IMAGING SERVICE
DIAG MAMMOGRAPHY
ULTRASOUND
SCRN MAMMOGRAPHY
PET SCAN
RESERVED
OTHER IMAG SVS
RESPIRATORY SERVICES
RESPIRATORY SVC
RESERVED
INHALATION SVC
HYPERBARIC O2
Rev. 12/3/15
OPPS
INPATIENT
NC
-
NC
-
-
NC
C
N
Pkg
-
-
NC
C
C
C
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
C
C
C
C
Y
C
Y
Y
C
C
C
Y
Y
Y
Pkg
C
C
Y
Y
C
Y
Pkg
C
C
C
C
C
Y
Y
Y
Y
Y
C
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
HOSPICE
SNF - NRSG FAC
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Y
Y
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
-
-
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
C
Y
Y
C
N
N
NA
-
-
NA
-
-
NA
-
-
C
Y
N
C
C
Y
Y
C
C
Y
Y
Y
Y
C
C
N
N
N
N
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
Page 8 of 19
-
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
0414-8
0419
042X
0420
0421
0422
0423
0424
0425-8
0429
043X
0430
0431
0432
0433
0434
0435-8
0439
044X
0440
0440
0441
0441
0442
0442
0443
0444
0444
0445-8
0449
045X
0450
0451
0452
T5
T5
T5
T5
RESERVED
OTHER RESPIR SVCS
PHYSICAL THERAPY
PHYSICAL THERP
PHYS THERP/VISIT
PHYS THERP/HOUR
PHYS THERP/GROUP
PHYS THERP/EVAL
RESERVED
OTHER PHYS THERP
OCCUPATIONAL THERAPY
OCCUPATIONAL THER
OCCUP THERP/VISIT
OCCUP THERP/HOUR
OCCUP THERP/GROUP
OCCUP THERP/EVAL
RESERVED
OCCUP THER/OTHER
SPEECH-LANGUAGE PATHOLOGY
SPEECH THERAPY
SPEECH THERAPY
SPEECH THERP/VISIT
SPEECH THERP/VISIT
SPEECH THERP/HOUR
SPEECH THERP/HOUR
SPEECH THERP/GROUP
SPEECH THERP/EVAL
SPEECH THERP/EVAL
RESERVED
OTHER SPEECH THERP
EMERGENCY ROOM
EMERG ROOM
ER/EMATALA
ER/BEYOND EMTALA
Rev. 12/3/15
OPPS
INPATIENT
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
C
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
C
C
Y
Y
Y
Y
Y
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
-
-
C
C
C
NC
C
Y
Y
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
-
-
C
NA
NA
NA
C
Y
Y
Y
Y
C
Y
C
Y
Y
NC
-
-
NA
-
-
NC
-
-
NA
-
-
C
Y
Y
C
C
C
C
C
Y
Y
Y
Y
Y
C
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
-
-
C
C
C
NC
C
Y
Y
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
-
-
C
NA
NA
NA
C
Y
Y
Y
Y
C
Y
C
Y
Y
NC
-
-
NA
-
-
NC
-
-
NA
-
-
C
Y
Y
C
Y
C
Y
Y
C
N
N
NA
-
-
-
C
Y
Y
C
Y
Y
C
N
N
NA
-
-
NA
-
-
NA
-
-
C
Y
C
Y
Y
C
N
N
NA
-
-
NA
-
-
NA
-
-
C
C
Y
Y
C
C
Y
Y
Y
Y
C
C
N
N
N
N
NA
NA
-
-
Y
Y
Y
Y
-
Y
Y
Y
Y
Y
NA
C
NC
C
NC
C
NC
C
NC
NC
C
NA
NA
-
-
C
C
Y
Y
Y
Y
C
Y
C
Y
Y
NC
-
-
NA
-
-
NC
-
-
NA
-
-
C
Y
Y
C
C
C
N
N
N
C
C
C
Y
Y
Y
Y
Y
Y
C
NA
NA
N
-
N
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
Page 9 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
0453-5
0456
0457-8
0459
046X
0460
0461-8
0469
047X
0470
0471
0472
0473-8
0479
048X
0480
0481
0482
0483
0484-8
0489
049X
050X
051X
0510
0511
0512
0513
0514
0515
0516
0517
0518
0519
RESERVED
ER/URGENT
RESERVED
OTHER EMERG ROOM
PULMONARY FUNCTION
PULMONARY FUNC
RESERVED
OTHER PULMONARY FUNC
AUDIOLOGY
AUDIOLOGY
AUDIOLOGY/DX
AUDIOLOGY/RX
RESERVED
OTHER AUDIOL
CARDIOLOGY
CARDIOLOGY
CARDIAC CATH LAB
STRESS TEST
ECHOCARDIOLOGY
RESERVED
OTHER CARDIOL
AMBULATORY SURGICAL CARE
OUTPATIENT SERVICES
CLINIC
CLINIC
CHRONIC PAIN CLINIC
DENTAL CLINIC
PSYCHIATRIC CLINIC (PT 21 ONLY)
OB-GYN CLINIC
PEDIATRIC CLINIC
URGENT CARE CLINIC
FAMILY CLINIC
RESERVED
OTHER CLINIC
Rev. 12/3/15
OPPS
INPATIENT
HOSPICE
HOME HEALTH
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
PDN
SNF - NRSG FAC
C
N
C
Y
Y
NA
-
-
NA
NC
-
NC
-
-
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
C
Y
Y
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
Y
Y
Y
C
C
C
Y
Y
Y
Y
Y
Y
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
Y
C
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
C
Y
Y
Y
Y
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
N
N
N
N
N
N
N
N
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
C
NC
NC
Y
C
NC
NC
Y
Y
NC
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
NC
C
C
C
C
C
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
NC
NC
C
C
C
C
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
-
-
C
Y
Y
C
Y
Y
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Page 10 of 19
NA
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
NA
NA
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
052X
053X
054X
0540
0541
0542
0543
0544
0545
0546
0547
0548
0549
055X
0550
0551
0552
0553-8
0559
056X
057X
0570
0571
0572
0573-8
0579
058X
0580
0581
0582
0583
0584-8
0589
FREE-STANDING CLINIC
OSTEOPATHIC SERVICES
AMBULANCE
AMBULANCE
AMBUL/SUPPLY
AMBUL/MED TRANS
AMBUL/HEART MOB
AMBUL/OXYGEN
AIR AMBULANCE
AMBUL/NEONAT
AMBUL/PHARMAS
AMBUL/EKG TRANS
AMBUL/OTHER
SKILLED NURSING
SKILLED NURSING
SKILLED NURS/VISIT
SKILLED NURS/HOUR
RESERVED
SKILLED NURS/OTHER
HOME HEALTH (HH) - MEDICAL
SOCIAL SERVICES
HOME HEALTH (HH) AIDE
HH AIDE
HH AIDE-VISIT
HH AIDE-HOUR
RESERVED
HH AIDE-OTHER
HOME HEALTH (HH) - OTHER VISITS
HH-OTH VIS
HH-OTH VIS/VISIT
HH-OTH VIS/HOUR
HH-OTH VIS/ASSESS
RESERVED
HH-OTH VIS/OTHER
Rev. 12/3/15
OPPS
INPATIENT
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
NC
NC
NA
NA
NA
NA
NA
NA
NA
NA
NA
C
NA
NA
NA
NA
N
NA
NA
NA
NA
NA
NA
Y
Y
Y
-
Y
Y
Y
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
-
C
NC
NC
NC
NC
C
C
NC
NC
NC
NC
NC
NC
NC
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
C
C
Y
Y
Y
Y
Y
Y
NA
NA
NA
-
-
NA
NA
NA
-
-
-
NC
-
-
NA
-
-
NA
-
-
NC
-
-
NA
-
-
NA
-
-
-
NC
NC
NC
NC
NC
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
C
C
Y
Y
Y
Y
Y
Y
NA
NA
NA
-
-
NA
NA
NA
-
-
-
-
NA
-
-
NA
-
-
NC
-
-
NA
-
-
NA
-
-
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NC
NC
NC
NC
-
-
NA
NA
C
NA
Y
-
Y
-
NA
NA
NA
NA
-
-
-
-
NA
-
-
NA
-
-
NC
-
-
NA
-
-
NA
-
-
`
NA
NA
NA
NA
NA
NA
-
NC
NC
NC
NC
NC
NC
NA
-
NC
Page 11 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
059X
060X
061X
0610
0611
0612
0613
0614
0615
0616
0617
0618
0619
062X
0620
0621
0622
0623
0624
0625-9
063X
0630
0631
0632
0633
0634
0635
0636
0637
HOME HEALTH (HH) UNITS OF
SERVICE
HOME HEALTH (HH) - OXYGEN
MAGNETIC RESONANCE
TECHNOLOGY (MRT)
MRT
MRI/BRAIN
MRI/SPINE
RESERVED
MRI/OTHER
MRA/HEAD & NECK
MRA/LOWER EXTRM
RESERVED
MRA/OTHER
MRT/OTHER
Medical/Surgical Supplies (Extension of
027X)
RESERVED (use 0270 for General
Classification)
MED SURG SUPL-INCDT RAD
MED SURG SUPL-INCDT ODX
SURG DRESSINGS
FDA INVEST DEVICE
RESERVED
PHARMACY - Extension of 025X
RESERVED (Use 0250 for General
Classification)
DRUG/SINGLE
DRUG/MULTIPLE
DRUG/RESTRICT
DRUG/EPO<10,000 Units
DRUG/EPO>=10,000 Units
DRUG/DETAIL CODE
DRUG/SELF ADMIN
Rev. 12/3/15
OPPS
NA
NA
INPATIENT
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
NC
NC
C
C
C
Y
Y
Y
C
C
C
Y
Y
Y
Y
Y
Y
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
C
C
Y
Y
Y
C
C
C
Y
Y
Y
Y
Y
Y
NA
C
C
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
C
C
Y
Y
C
C
Y
Y
Y
Y
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
C
NC
C
NA
-
Pkg
Pkg
C
NC
Y
-
Y
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
NA
NA
NA
NA
-
-
C
C
NC
C
C
C
NC
N
N
Y
Y
Y
-
Pkg
Pkg
NC
C
C
C
NC
Y
Y
Y
-
Y
Y
Y
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
-
Page 12 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
0638-9
064X
065X
0650
0651
0652
0653-4
0655
0656
0657
0658
0659
066X
067X
068X
0680
0681
0682
0683
0684
0685-8
0689
069X
0700X
0700
0701-9
071X
0710
0711-9
072X
0720
0721
0722
RESERVED
HOME IV THERAPY SERVICES
HOSPICE SERVICES
HOSPICE
HOSPICE/RTN HOME
HOSPICE/CTNS HOME
RESERVED
HOSPICE/IP RESPITE
HOSPICE/IP NON RESPITE
HOSPICE/PHYSICIAN
HOSPICE/R&B NURSE FAC
HOSPICE/OTHER *
RESPITE CARE (HHA ONLY)
OUTPATIENT SPECIAL RESIDENCE
CHARGES
TRAUMA RESPONSE
NOT USED
TRAUMA LEVEL I
TRAUMA LEVEL II
TRAUMA LEVEL III
TRAUMA LEVEL IV
RESERVED
TRAUMA OTHER
NOT ASSIGNED
CAST ROOM
CAST ROOM
RESERVED
RECOVERY ROOM
RECOVERY ROOM
RESERVED
LABOR ROOM/DELIVERY
DELIVERY ROOM/LABOR
LABOR
DELIVERY ROOM
Rev. 12/3/15
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NC
NC
NC
NC
NC
-
-
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
INPATIENT
SNF - NRSG FAC
-
-
NA
NA
NA
-
-
NC
C
C
Y
Y
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
-
-
NA
NA
NA
-
-
Y
Y
Y
N
N
N
Y
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
-
-
C
C
C
C
C
NA
-
-
NA
-
-
NA
-
-
NC
NC
NA
C
C
C
C
NA
A
A
A
A
-
-
NA
C
C
C
C
NA
A
A
A
A
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NC
NC
NC
NC
NC
NC
-
UNITS REQ
COV SVC
HCPCS REQ
OPPS
-
-
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
C
N
Pkg
-
-
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
Pkg
-
-
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
N
N
N
Pkg
Pkg
C
Y
Y
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
Page 13 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
N
C
Y
Y
C
N
N
NA
-
C
C
C
Y
Y
Y
C
C
Pkg
Y
Y
-
Y
Y
-
C
C
C
N
N
N
N
N
N
NA
NA
NA
C
Y
C
Y
Y
C
N
N
C
Y
C
Y
Y
C
N
C
Y
C
Y
Y
C
C
C
C
Y
Y
Y
C
C
Pkg
Y
Y
-
Y
Y
-
C
Y
C
Y
C
C
N
N
C
C
C
-
C
N
-
SNF - NRSG FAC
NA
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
C
N
N
N
N
N
N
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
NA
NA
NA
-
-
Y
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Y
Y
Y
Y
C
C
N
N
N
N
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
C
Y
Y
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
Y
Y
C
N
N
NA
-
-
NA
-
-
NA
-
-
NA
-
-
Page 14 of 19
Special Notes
T5 = Title V
* = FIDS Beds
HCPCS REQ
HCPCS REQ
PDN
-
HOSPICE
-
UNITS REQ
UNITS REQ
NA
NA
NA
NA
COV SVC
COV SVC
C
Y
HOME HEALTH
NA
NA
-
INPATIENT
N
N
N
N
HCPCS REQ
C
C
UNITS REQ
Y
COV SVC
OPPS
Y
UNITS REQ
NC
C
COV SVC
OPH
N
HCPCS REQ
RATE/HCPCS
REQ
NA
C
UNITS REQ
COV SVC
HCPCS REQ
HCPCS REQ
EXTRA-CORPOREAL SHOCK WAVE
THERAPY (FORMERLY LITHOTRIPSY)
ESWT
RESERVED
UNITS REQ
079X
0790
0791-9
COV SVC
076X
0760
0761
0762
0763-8
0769
077X
0770
0771
0772-9
078X
0780
0781-9
CIRCUMCISION
BIRTHING CNTR (LICENSED)
RESERVED
OTHER/DELIV-LABOR
ELECTROCARDIOGRAM (EKG/ECG)
EKG/ECG
HOLTER MONT
TELEMETRY
RESERVED
OTHER EKG/ECG
ELECTROENCEPHALOGRAM (EEG)
EEG
RESERVED
GASTRO-INTESTINAL (GI) SERVICES
GASTRO-INTSTL SVCS
RESERVED
SPECIALTY ROOM TREATMENT/OBSERVATION ROOM
SPECIALTY ROOM
TREATMENT RM
OBSERVATION RM
RESERVED
OTHER TREAT/OBSERV RM
PREVENTIVE CARE SERVICES
PREVENT CARE SVCS
VACCINE ADMIN
RESERVED
TELEMEDICINE
TELEMEDICINE
RESERVED
UNITS REQ
0723
0724
0725-8
0729
073X
0730
0731
0732
0733-8
0739
074X
0740
0741-9
075X
0750
0751-9
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
080X
0800
0801
0802
0803
0804
0805-8
0809
INPATIENT RENAL DIALYSIS
RENAL DIALYSIS
DIALY/INPATIENT
DIALY/IP/PER
DIALY/IPCAPD
DlALY/lP/CCPD
RESERVED
DIALY/IP/OTHER
081X
0810
0811
0812
0813
0814
0815-8
0819
ACQUISITION OF BODY COMPONENTS
ORGAN ACQUISIT
LIVING DONOR
CADAVER DONOR
UNKNOWN DONOR
UNSUCCESSFUL SEARCH
RESERVED
OTHER DONOR
HEMODIALYSIS - OUTPATIENT or
HOME
HEMO/OP OR HOME
HEMO/COMPOSITE
HEMO/HOME/SUPPL
HEMO/HOME/EQUIP
HEMO/HOME/100%
HEMO/HOME/SUPSERV
RESERVED
HEMO-OTHER op
PERITONEAL DIALYSIS - OUTPATIENT
or HOME
PERlTONEAL/OP OR HOME
PERTNL/COMPOSITE
PERTNL/HOME/SUPPL
PERTINL/HOME/EQUIP
PERTINL/HOME/100%
082X
0820
0821
0822
0823
0824
0825
0826-8
0829
083X
0830
0831
0832
0833
0834
Rev. 12/3/15
NA
NA
NA
NA
NA
NA
OPPS
INPATIENT
HOSPICE
HOME HEALTH
PDN
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
SNF - NRSG FAC
-
NC
NA
NA
NA
NA
NA
-
-
NA
C
C
C
C
Y
Y
Y
Y
N
N
N
N
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
NA
NA
NA
C
N
NA
NA
NA
NA
C
Y
Y
NA
C
C
NA
NA
N
N
-
N
N
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
-
C
-
Y
C
-
Y
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
NA
NA
NA
C
Y
Y
N
C
C
NC
NC
NC
C
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
C
N
C
Y
Y
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
C
C
NA
NA
NA
Y
Y
-
C
C
NC
NC
NC
Y
Y
-
Y
Y
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
-
-
Page 15 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
N
C
Y
Y
NA
-
-
NA
-
C
C
NA
NA
NA
C
Y
Y
N
C
C
NC
NC
NC
C
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
C
N
C
Y
Y
NA
-
-
C
C
NA
NA
NA
C
C
Y
Y
Y
N
C
C
NC
NC
NC
C
C
Y
Y
Y
Y
Y
Y
Y
Y
NA
NA
NA
NA
NA
NA
NA
-
NA
NA
-
C
C
Y
Y
Y
Y
Y
Y
Y
Y
HCPCS REQ
-
SNF - NRSG FAC
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
-
-
C
C
N
N
N
N
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
C
C
N
N
N
N
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
UNITS REQ
HCPCS REQ
PDN
-
COV SVC
UNITS REQ
C
HCPCS REQ
NA
UNITS REQ
HOME HEALTH
NA
-
HOSPICE
-
COV SVC
NA
UNITS REQ
INPATIENT
NA
-
COV SVC
Y
HCPCS REQ
RATE/HCPCS
REQ
OPPS
Y
UNITS REQ
C
COV SVC
OPH
N
C
C
HCPCS REQ
C
NA
COV SVC
090X
0900
0901
HCPCS REQ
085X
0850
0851
0852
0853
0854
0855
0859
086X
0860
0861
0863-9
087X
088X
089X
UNITS REQ
0849
COV SVC
084X
0840
0841
0842
0843
0844
0845
PERTNL/HOME/SUPSERV
RESERVED
PERTNL/HOME/OTHER
Continuous Ambulatory Peritoneal
Dialysis (CAPD) - Outpatient or Home
CAPD/OP OR HOME
CAPD/COMPOSITE
CAPD/HOME/SUPPL
CAPD/HOME/EQUIP
CAPD/HOME/100%
CAPD/HOME/SUPSERV
RESERVED
CAPD/HOME/OTHER
Continuous Cycling Peritoneal Dialysis
(CCPD) - Outpatient or Home
CCPD/OP OR HOME
CCPD/COMPOSITE
CCPD/HOME/SUPPL
CCPD/HOME/EQUIP
CCPD/HOME/100%
CCPD/HOME/SUPSERV
CCPD/HOME/OTHER
Magnetoencephalography (MEG)
General Classification
MEG
RESERVED
RESERVED
MISCELLANEOUS DIALYSIS
RESERVED
BEHAVIORAL HEALTH
TREATMENT/SERVICES (also see 091x,
an extension of 090x)
BH/TREATMENTS
BH/ELECTRO SHOCK
UNITS REQ
0835
0836-8
0839
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
NC
Y
Y
C
C
Page 16 of 19
Special Notes
T5 = Title V
* = FIDS Beds
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
Rev. 12/3/15
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
-
-
-
-
-
-
-
-
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
NA
NA
-
-
N
N
N
N
N
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
C
C
C
C
C
C
N
N
N
N
N
N
N
N
N
N
N
N
NA
NA
NA
NA
NA
NA
C
NC
Y
Y
NA
-
-
C
NC
Y
-
Y
-
C
C
N
N
N
N
Page 17 of 19
Special Notes
T5 = Title V
* = FIDS Beds
HCPCS REQ
-
N
N
N
N
N
-
UNITS REQ
NA
NA
NA
NA
NA
NA
NA
NA
NA
C
NA
NA
C
C
C
NC
C
NA
COV SVC
N
-
HCPCS REQ
C
NC
UNITS REQ
N
COV SVC
C
-
Y
Y
Y
Y
Y
Y
HCPCS REQ
C
C
C
C
C
C
SNF - NRSG FAC
NA
NA
NA
-
HOSPICE
-
UNITS REQ
Y
Y
Y
N
N
N
-
NA
NA
NA
COV SVC
C
C
C
C
C
C
PDN
-
INPATIENT
NC
NC
NA
-
HCPCS REQ
Y
Y
Y
Y
Y
Y
NA
NA
NA
UNITS REQ
C
NC
NC
C
C
C
NC
C
C
HOME HEALTH
NA
NA
NA
-
COV SVC
Y
Y
Y
Y
Y
Y
C
NA
NA
C
C
C
NC
C
C
RATE/HCPCS
REQ
Y
Y
-
UNITS REQ
OPPS
Y
Y
-
OPH
Y
Y
-
COV SVC
HCPCS REQ
C
C
NC
NC
NC
NC
C
C
NC
HCPCS REQ
UNITS REQ
094X
0940
0941
COV SVC
091X
0910
0911
0912
0913
0914
0915
0916
0917
0918
0919
092X
0920
0921
0922
0923
0924
0925
0926-8
0929
093X
BH/MILIEU THERAPY
BH/PLAY THERAPY
BH/ACTIVITY THERAPY
BH/INTENS OP/PSYCH
BH/INTENS OP/CHEM DEP
BH/COMMUNITY
RESERVED
BEHAVIORAL HEALTH
TREATMENTS/SERVICES - EXTENSION
OF 090X
RESERVED
BH/REHAB
BH/PARTIAL HOSP
BH/PARTIAL INTENSV
BH/INDIV RX
BH/GROUP RX
BH/FAMILY RX
BH/BIOFEED
BH/TESTING
BH/OTHER
OTHER DIAGNOSTIC SERVICES
OTHER DX SVCS
PERI VASCUL LAB
EMG
PAP SMEAR
ALLERGY TEST
PREG TEST
RESERVED
OTHER DX SVCS
MEDICAL REHAB DAY PROGRAM
Other Therapeutic Services (also see
095X, ext of 094X)
OTHER RX SVCS
RECREATION RX
UNITS REQ
0902
0903
0904
0905
0906
0907
0908-9
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
100x
101X to
209X
210x
RESERVED
ALTERNATIVE THERAPY SERVICES
Rev. 12/3/15
NA
NA
NA
NA
NA
NA
NA
NA
PDN
-
-
SNF - NRSG FAC
NA
NA
NA
NA
NA
NA
NA
NA
-
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NC
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
-
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
-
NA
NA
NA
NA
NA
NA
NC
NC
NC
NC
NC
NC
NA
NA
Page 18 of 19
-
-
-
-
-
Special Notes
T5 = Title V
* = FIDS Beds
HCPCS REQ
HCPCS REQ
HOME HEALTH
NA
NA
NA
NA
NA
NA
NA
NA
-
UNITS REQ
UNITS REQ
-
COV SVC
COV SVC
HOSPICE
-
NA
HCPCS REQ
NA
NA
NA
NA
NA
NA
NA
NA
UNITS REQ
INPATIENT
NA
C
N
N
NA
NA
NA
NC
NA
NA
-
COV SVC
HCPCS REQ
Y
Y
Y
NA
NA
NA
NA
NA
NA
NA
NC
NC
NC
NC
RATE/HCPCS
REQ
OPPS
Y
Y
Y
UNITS REQ
Pkg
C
NC
NC
NC
NC
C
C
COV SVC
HCPCS REQ
UNITS REQ
0980
0981
0982
0983
0984
0985
0986
0987
0988
0989
099X
COV SVC
098X
-
HCPCS REQ
097X
OPH
N
-
UNITS REQ
096x
C
NC
NA
NA
NA
NA
NA
C
COV SVC
095X
EDUC/TRAINING
CARDIAC REHAB
DRUG REHAB
ALCOHOL REHAB
CMPLX MED EQUIP-ROUT
CMPLX MED EQUIP-ANC
PULMONARY REHAB
OTHER
Other Therapeutic Services (extension of
094X)
PROFESSIONAL FEES (also see 097x
and 098x)
PROFESSIONAL FEES (extension of
096X)
PROFESSIONAL FEES (extension of
096X & 097X)
RESERVED (use 0960 for General
Classification)
PRO FEE/ER
PRO FEE/OUTPT
PRO FEE/CLINIC
PRO FEE/SOC SVC
PRO FEE/EKG
PRO FEE/EEG
PRO FEE/HOS VIS
PRO FEE/CONSULT
PRO FEE/PVT NURSE
PATIENT CONVENIENCE ITEMS
BEHAVIORAL HEALTH
ACCOMMODATIONS
UNITS REQ
0942
0943
0944
0945
0946
0947
0948
0949
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
-
C = Covered
NC = NonCovered
NA = Not Applicable
A = Activation
Pkg = Packaged
Units/Required (covered svcs)
Y = Yes N = No
HCPCS (or Rate for IP) Req
Y = Yes N = No
V = Valid, Not Required
REVENUE CODE TABLE
The Revenue Code descriptions and code ranges are subject to change by National Uniform Billing Codes (NUBC) direction and does not supersede MDHHS published policy
Table changes will be date specific and identified by revision date. Specific changes are noted in red.
OPH
211X to
309x
310x
311x to
999x
NC
NC
RESERVED
NC
NC
-
INPATIENT
HOSPICE
HOME HEALTH
PDN
SNF - NRSG FAC
-
Page 19 of 19
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
COV SVC
RATE/HCPCS
REQ
UNITS REQ
COV SVC
HCPCS REQ
OPPS
RESERVED
ADULT CARE
Rev. 12/3/15
UNITS REQ
COV SVC
HCPCS REQ
UNITS REQ
STANDARD ABBREVIATION
COV SVC
Revenue
Code
Special Note
Use for Dates of
Use for Dates of
Services on or before Services on and after
4/1/2007
3/31/2007
Special Notes
T5 = Title V
* = FIDS Beds