|
Revenue Code
|
Description
|
Comments
|
|
Pharmacy
|
|
B-250
|
General classification
|
|
|
B-251
|
Generic drugs
|
|
|
B-252
|
Non-generic drugs
|
|
|
B-253
|
Take Home drugs
|
Not a benefit
|
|
B-254
|
Drugs incident to other diagnostic services
|
|
|
B-255
|
Drugs incident to radiology
|
|
|
B-256
|
Experimental drugs
|
Not a benefit
|
|
B-257
|
Nonprescription drugs
|
|
|
B-258
|
IV solutions
|
|
|
B-259
|
Other pharmacy
|
|
|
B-451
|
Emergency room - Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) emergency medical screening services
|
|
|
B-630
|
Drugs requiring specific identification
|
HCPCS code required
|
|
B-631
|
Single source drug
|
HCPCS code required
|
|
Pharmacy
|
|
B-632
|
Multiple source drug
|
HCPCS code required
|
|
B-633
|
Restrictive prescription
|
HCPCS code required
|
|
B-634
|
Erythropoietin (EPO) less than 10,000 units
|
HCPCS code required
|
|
B-635
|
Erythropoietin (EPO) 10,000 or more units
|
HCPCS code required
|
|
B-636
|
Drugs requiring detailed coding
|
HCPCS code required
|
|
B-637
|
Self-administrable drugs
|
Not a benefit
|
|
Intravenous (IV) Therapy
|
|
B-260
|
General classification
|
|
|
B-261
|
Infusion pump
|
|
|
B-262
|
IV therapy/pharmacy services
|
|
|
B-263
|
IV therapy/drug/supply delivery
|
|
|
B-264
|
IV therapy/supplies
|
|
|
B-269
|
Other IV therapy
|
|
|
Medical/Surgical Supplies and Devices
|
|
B-270
|
General classification
|
|
|
B-271
|
Nonsterile supply
|
|
|
B-272
|
Sterile supply
|
|
|
B-273
|
Take-home supplies
|
Not a benefit
|
|
B-274
|
Prosthetic/orthotic devices
|
HCPCS code required
|
|
B-275
|
Pacemaker
|
|
|
B-276
|
Intraocular lens
|
|
|
B-277
|
Oxygen-take-home
|
|
|
B-278
|
Other implants
|
HCPCS code required
|
|
B-279
|
Other supplies/devices
|
HCPCS code required
|
|
B-620
|
Medical/surgical supplies
|
HCPCS code required
|
|
B-621
|
Supplies incident to radiology
|
|
|
B-622
|
Supplies incident to other diagnostic services
|
|
|
B-623
|
Surgical dressings
|
|
|
B-624
|
Food and Drug Administration (FDA) investigational devices
|
Not a benefit
|
|
Oncology
|
|
B-280
|
General classification
|
|
|
B-289
|
Other oncology
|
|
|
Laboratory
|
|
B-300
|
General classification
|
HCPCS code required
|
|
B-301
|
Chemistry
|
HCPCS code required
|
|
B-302
|
Immunology
|
HCPCS code required
|
|
B-303
|
Renal client (home)
|
HCPCS code required
|
|
B-304
|
Nonroutine dialysis
|
HCPCS code required
|
|
B-305
|
Hematology
|
HCPCS code required
|
|
B-306
|
Bacteriology and microbiology
|
HCPCS code required
|
|
B-307
|
Urology
|
HCPCS code required
|
|
Laboratory
|
|
B-309
|
Other laboratory
|
HCPCS code required
|
|
Laboratory Pathological
|
|
B-310
|
General classification
|
HCPCS code required
|
|
B-311
|
Cytology
|
HCPCS code required
|
|
B-312
|
Histology
|
HCPCS code required
|
|
B-314
|
Biopsy
|
HCPCS code required
|
|
B-319
|
Other pathology
|
HCPCS code required
|
|
Radiology-Diagnostic
|
|
B-320
|
General classification
|
HCPCS code required
|
|
B-321
|
Angiocardiography
|
HCPCS code required
|
|
B-322
|
Arthrography
|
HCPCS code required
|
|
B-323
|
Arteriography
|
HCPCS code required
|
|
B-324
|
Chest X-ray
|
HCPCS code required
|
|
B-329
|
Other diagnostic radiology
|
HCPCS code required
|
|
Radiology-Therapeutic
|
|
B-330
|
General classification
|
HCPCS code required
|
|
B-331
|
Chemotherapy-injected
|
HCPCS code required
|
|
B-332
|
Chemotherapy-oral
|
HCPCS code required
|
|
B-333
|
Chemotherapy-radiation therapy
|
HCPCS code required
|
|
B-335
|
Chemotherapy-IV
|
HCPCS code required
|
|
B-339
|
Other therapeutic radiology
|
HCPCS code required
|
|
Nuclear Medicine
|
|
B-340
|
General classification
|
HCPCS code required
|
|
B-341
|
Diagnostic
|
HCPCS code required
|
|
B-342
|
Therapeutic
|
HCPCS code required
|
|
B-349
|
Other nuclear medicine
|
HCPCS code required
|
|
Computed Tomography (CT) Scan
|
|
B-350
|
General classification
|
HCPCS code required
|
|
B-351
|
Head scan
|
HCPCS code required
|
|
B-352
|
Body scan
|
HCPCS code required
|
|
B-359
|
Other CT scans
|
HCPCS code required
|
|
Operating Room Services
|
|
B-360
|
General classification
|
|
|
B-361
|
Minor surgery
|
|
|
B-369
|
Other operating room services
|
|
|
Anesthesia
|
|
B-370
|
General classification
|
|
|
B-371
|
Anesthesia incident to radiology
|
|
|
B-372
|
Anesthesia incident to other diagnostic services
|
|
|
B-374
|
Acupuncture
|
Not a benefit
|
|
B-379
|
Other anesthesia
|
|
|
Blood
|
|
Blood
|
|
B-380
|
General classification
|
HCPCS code required
|
|
B-381
|
Packed red cells
|
HCPCS code required
|
|
B-382
|
Whole blood
|
HCPCS code required
|
|
B-383
|
Plasma
|
HCPCS code required
|
|
B-384
|
Platelets
|
HCPCS code required
|
|
B-385
|
Leucocytes
|
HCPCS code required
|
|
B-386
|
Other components
|
HCPCS code required
|
|
B-387
|
Other derivatives (cryoprecipitates)
|
HCPCS code required
|
|
B-389
|
Other blood
|
HCPCS code required
|
|
Blood Storage and Processing
|
|
B-390
|
General classification
|
|
|
B-391
|
Blood administration
|
Not a benefit
|
|
B-399
|
Other blood storage and processing
|
Not a benefit
|
|
Other Imaging Services
|
|
B-400
|
General classification
|
HCPCS code required
|
|
B-401
|
Diagnostic mammography
|
HCPCS code required
|
|
B-402
|
Ultrasound
|
HCPCS code required
|
|
B-403
|
Screening mammography
|
HCPCS code required
|
|
B-404
|
Positron emission tomography
|
HCPCS code required
|
|
B-409
|
Other imaging services
|
HCPCS code required
|
|
Respiratory Services
|
|
B-410
|
General classification
|
|
|
B-412
|
Inhalation services
|
|
|
B-413
|
Hyperbaric oxygen therapy
|
|
|
B-419
|
Other respiratory services
|
HCPCS code required
|
|
Physical Therapy (PT)
|
|
B-420
|
General classification
|
HCPCS code required
|
|
B-421
|
Visit charge
|
HCPCS code required
|
|
B-422
|
Hourly charge
|
HCPCS code required
|
|
B-423
|
Group rate
|
HCPCS code required
|
|
B-424*
|
Evaluation or re-evaluation
|
HCPCS code required
|
|
B-429
|
Other PT
|
HCPCS code required
|
|
Occupational Therapy (OT)
|
|
B-430
|
General classification
|
HCPCS code required
|
|
B-431
|
Visit charge
|
HCPCS code required
|
|
B-432
|
Hourly charge
|
HCPCS code required
|
|
B-433
|
Group rate
|
HCPCS code required
|
|
B-434
|
Evaluation or re-evaluation
|
HCPCS code required
|
|
B-439
|
Other OT
|
HCPCS code required
|
|
Speech-Language Pathology
|
|
B-440
|
General classification
|
HCPCS code required
|
|
B-441
|
Visit charge
|
HCPCS code required
|
|
Speech-Language Pathology
|
|
B-442
|
Hourly charge
|
HCPCS code required
|
|
B-443
|
Group rate
|
HCPCS code required
|
|
B-444*
|
Evaluation or re-evaluation
|
HCPCS code required
|
|
B-449
|
Other speech-language pathology
|
HCPCS code required
|
|
Emergency Room
|
|
B-450
|
General classification
|
|
|
B-451
|
Emergency room - EMTALA screening
|
|
|
B-456
|
Urgent care
|
|
|
B-459
|
Other emergency room
|
|
|
Pulmonary Function
|
|
B-460
|
General classification
|
HCPCS code required
|
|
B-469
|
Other pulmonary function
|
HCPCS code required
|
|
Audiology
|
|
B-470
|
General classification
|
HCPCS code required
|
|
B-471
|
Diagnostic
|
HCPCS code required
|
|
B-472
|
Treatment
|
HCPCS code required
|
|
B-479
|
Other Audiology
|
HCPCS code required
|
|
Cardiology
|
|
B-480
|
General classification
|
HCPCS code required
|
|
B-481
|
Cardiac cath lab
|
HCPCS code required
|
|
B-482
|
Stress test
|
HCPCS code required
|
|
B-489
|
Other cardiology
|
HCPCS code required
|
|
Clinic
|
|
B-510
|
General classification
|
|
|
B-511
|
Chronic pain center
|
|
|
B-512
|
Dental clinic
|
|
|
B-513
|
Psychiatric clinic
|
|
|
B-514
|
Obstetrics-Gynecology (OB-GYN) clinic
|
|
|
B-515
|
Pediatric clinic
|
|
|
B-516
|
Urgent Care clinic
|
|
|
B-517
|
Family Practice clinic
|
|
|
B-519
|
Other clinic
|
|
|
Freestanding Clinic
|
|
B-520
|
General classification
|
|
|
B-523
|
Family practice clinic
|
|
|
B-526
|
Urgent care clinic
|
|
|
B-529
|
Other freestanding clinic
|
|
|
Magnetic Resonance Technology (MRT)
|
|
B-610
|
General classification
|
HCPCS code required
|
|
B-611
|
Magnetic resonance imaging (MRI) brain (including brainstem)
|
HCPCS code required
|
|
B-612
|
MRI spinal cord (including spine)
|
HCPCS code required
|
|
Magnetic Resonance Technology (MRT)
|
|
B-619
|
Other MRT
|
HCPCS code required
|
|
Cast Room
|
|
B-700
|
General classification
|
|
|
B-709
|
Other cast room
|
|
|
Recovery Room
|
|
B-710
|
General classification
|
|
|
B-719
|
Other recovery room
|
|
|
Labor Room/Delivery
|
|
B-720
|
General classification
|
|
|
B-721
|
Labor
|
|
|
B-722
|
Delivery
|
|
|
B-723
|
Circumcision
|
|
|
B-724
|
Birthing center
|
|
|
B-729
|
Other labor room/delivery
|
|
|
Electrocardiogram (EKG/ECG)
|
|
B-730
|
General classification
|
HCPCS code required
|
|
B-731
|
Holter monitor
|
HCPCS code required
|
|
B-732
|
Telemetry
|
HCPCS code required
|
|
B-739
|
Other EKG/ECG
|
HCPCS code required
|
|
Electroencephalogram (EEG)
|
|
B-740
|
General classification
|
HCPCS code required
|
|
B-749
|
Other EEG
|
HCPCS code required
|
|
Gastrointestinal Services
|
|
B-750
|
General classification
|
|
|
B-759
|
Other gastrointestinal
|
|
|
Treatment or Observation Room
|
|
B-760
|
General classification
|
|
|
B-761
|
Treatment room
|
|
|
B-762
|
Observation room
|
|
|
B-769
|
Other treatment/observation room
|
|
|
Preventive Care Services
|
|
B-770
|
General classification
|
HCPCS code required
|
|
B-771
|
Vaccine administration
|
HCPCS code required
|
|
B-779
|
Other preventive care services
|
HCPCS code required
|
|
Lithotripsy
|
|
B-790
|
General classification
|
HCPCS code required
|
|
B-799
|
Other lithotripsy
|
HCPCS code required
|
|
Other Diagnostic Services
|
|
B-920
|
General classification
|
HCPCS code required
|
|
B-921
|
Peripheral vascular lab
|
HCPCS code required
|
|
B-922
|
Electromyelogram
|
HCPCS code required
|
|
B-923
|
Pap smear
|
HCPCS code required
|
|
Other Diagnostic Services
|
|
B-924
|
Allergy test
|
HCPCS code required
|
|
B-925
|
Pregnancy test
|
HCPCS code required
|
|
B-929
|
Other diagnostic service
|
HCPCS code required
|
|
|
