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2012 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4. Outpatient Hospital (Medical/Surgical Acute Care Outpatient Facility) : 4.5 Claims Filing and Reimbursement : 4.5.5 Outpatient Hospital Revenue Codes

4.5.5
UB‑04 CMS-1450 revenue codes must be used to submit claims for outpatient hospital facility services. In some instances, a HCPCS procedure code is required in addition to the revenue code for accurate claims processing:
Drugs incident to other diagnostic services
Medical/surgical supplies and devices- other implants
Laboratory- bacteriology/microbiology
Radiology- diagnostic angiocardiography
Blood- other derivatives (cryopricipitates)
Other imaging services- diagnostic mammography
Other imaging services- screening mammography
Physical therapy- evaluation/reevaluation
Occupational therapy- evaluation/reevaluation
Speech-language pathology- evaluation/reevaluation
Blood- other derivatives (cryopricipitates)
Other imaging services- diagnostic mammography
Other imaging services- screening mammography
Physical therapy- evaluation/reevaluation
Occupational therapy- evaluation/reevaluation
Speech-language pathology- evaluation/reevaluation
Magnetic resonance imaging- general classification
Magnetic resonance imaging- brain (incl brain stem)
Magnetic resonance imaging- spinal cord (incl spine)

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.