HCPCS Range Miscellaneous Provider Services

• 1 Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs ( S0199 )

• 2 Partial hospitalization services, less than 24 hours, per diem ( S0201 )

• 3 Paramedic intercept, non-hospital-based ALS service (non-voluntary), non-transport ( S0207 )

• 4 Paramedic intercept, hospital-based ALS service (non-voluntary), non-transport ( S0208 )

• 5 Wheelchair van, mileage, per mile ( S0209 )

• 6 Non-emergency transportation; mileage, per mile ( S0215 )

• 7 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient is present); approximately 30 minutes ( S0220 )

• 8 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient is present); approximately 60 minutes ( S0221 )

• 9 Comprehensive geriatric assessment and treatment planning performed by assessment team ( S0250 )

• 10 Hospice referral visit (advising patient and family of care options) performed by nurse, social worker, or other designated staff ( S0255 )

• 11 Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate (list separately in addition to code for appropriate evaluation and management service) ( S0257 )

• 12 History and physical (outpatient or office) related to surgical procedure (list separately in addition to code for appropriate evaluation and management service) ( S0260 )

• 13 Genetic counseling, under physician supervision, each 15 minutes ( S0265 )

• 14 Physician management of patient home care, standard monthly case rate (per 30 days) ( S0270 )

• 15 Physician management of patient home care, hospice monthly case rate (per 30 days) ( S0271 )

• 16 Physician management of patient home care, episodic care monthly case rate (per 30 days) ( S0272 )

• 17 Medical home program, comprehensive care coordination and planning, initial plan ( S0280 )

• 18 Medical home program, comprehensive care coordination and planning, maintenance of plan ( S0281 )

• 19 Completed early periodic screening diagnosis and treatment (EPSDT) service (list in addition to code for appropriate evaluation and management service) ( S0302 )

• 20 Hospitalist services (list separately in addition to code for appropriate evaluation and management service) ( S0310 )

• 21 Disease management program; initial assessment and initiation of the program ( S0315 )

• 22 Disease management program, follow-up/reassessment ( S0316 )

• 23 Disease management program; per diem ( S0317 )

• 24 Telephone calls by a registered nurse to a disease management program member for monitoring purposes; per month ( S0320 )

• 25 Lifestyle modification program for management of coronary artery disease, including all supportive services; first quarter / stage ( S0340 )

• 26 Lifestyle modification program for management of coronary artery disease, including all supportive services; second or third quarter / stage ( S0341 )

• 27 Lifestyle modification program for management of coronary artery disease, including all supportive services; fourth quarter / stage ( S0342 )

• 28 Treatment planning and care coordination management for cancer, initial treatment ( S0353 )

• 29 Treatment planning and care coordination management for cancer, established patient with a change of regimen ( S0354 )

• 30 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (e.g., diabetes), per visit ( S0390 )

• 31 Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic ( S0395 )

• 32 Global fee for extracorporeal shock wave lithotripsy treatment of kidney stone(s) ( S0400 )

• 33 Physician visit at member's home, outside of a capitation arrangement ( S0273 )

• 34 Nurse practitioner visit at member's home, outside of a capitation arrangement ( S0274 )

• 35 Colonoscopy consultation performed prior to a screening colonoscopy procedure ( S0285 )

• 36 Comprehensive management and care coordination for advanced illness, per calendar month ( S0311 )