The following is a list of revenue and procedure codes for use by nursing homes to submit claims for nursing home services.
| Allowable Revenue Codes for Non-Developmentally Disabled Nursing Home Members | |||
|---|---|---|---|
| Service | Revenue Code | Revenue Code Description | Required Condition Code |
| Accommodation | 0192 | Subacute Care level II - Comprehensive Care: Moderate nursing intervention + Disability. | |
| Hospital Bedhold | 0185 | Leave of Absence - Nursing Home (for Hospitalization). Charges for holding a room while the member is temporarily away from the provider. | |
| Therapeutic Leave | 0183 | Leave of Absence - Therapeutic Leave. Charges from holding a room while the member is temporarily away from the provider. | |
| Allowable Revenue Codes for Developmentally Disabled Nursing Home Members | |||
| Service | Revenue Code | Revenue Code Description | Required Condition Code |
| Accommodation - DD1A member | 0190 | Subacute Care - General Classification + Disability. | A5 |
| Accommodation - DD1B member | 0194 | Subacute Care Level IV - Intensive Care: Extensive nursing and technical intervention + Disability. | A5 |
| Accommodation - DD2 member | 0193 | Subacute Care Level III - Complex Care: Moderate to extensive nursing intervention + Disability. | A5 |
| Accommodation - DD3 member | 0192 | Subacute Care Level II - Comprehensive Care: Moderate nursing intervention + Disability. | A5 |
| Hospital Bedhold | 0185 | Leave of Absence - Nursing Home (for Hospitalization). Charges for holding a room while the member is temporarily away from the provider. | A5 |
| Therapeutic Leave | 0183 | Leave of Absence - Therapeutic Leave. Charges from holding a room while the member is temporarily away from the provider. | A5 |
| Allowable Revenue Codes for Other Nursing Home Members | |||
| Service | Revenue Code | Revenue Code Description | Required Condition Code |
| Accommodation - brain injured member | 0199 | Subacute Care - Other + Disability. | A5 |
| Accommodation - intensive brain injured member | 0199 | Subacute Care - Other. | X0 |
| Allowable Revenue Codes for Ancillary Services | |||
| Service | Revenue Code | Revenue Code Description | Required Condition Code |
| Laboratory | 0300 | Laboratory - General classification. Charges for the performance of diagnostic and routine clinical laboratory tests. | |
| X-ray | 0320 | Radiology - General classification. Charges for diagnostic radiology services provided for the examination and care of members. Includes taking, processing, and interpreting radiographs and flourographs. | |
| Private Room Rate | 0110 | Room and Board - Private (Medical or General) - General classification. Routine service charges for single bed rooms. | |
| Ventilator, AIDS, ARC | 0946 | Other Therapeutic Services - Complex Medical Equipment - Routine. Charges for other therapeutic services not otherwise categorized. | |
| AIDS/ARC | 0940 | Other Therapeutic Services - General Classification. Charges for other therapeutic services not otherwise categorized. | |
| Other Covered Nursing Home Services (Billed on the 1500 Health Insurance Claim Form) | |||
| Service | Procedure Code | Procedure Code Description | |
| Vaccine | 90656 | Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use. | |
| Vaccine | 90658 | Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use. | |
| Vaccine | 90732 | Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed member dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use. | |
| Non-emergency Transportation | A0120 | Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems, [base rate] | |
| Non-emergency Transportation | S0215 | Non-emergency transportation; mileage [one dollar per mile] | |
| Telemedicine originating site facility fee | Q3014 | Telehealth originating site facility fee. | |
| Medically Necessary Noncovered Services | |||
| Service | Revenue Code | Revenue Code Description | Required Condition Code |
| Noncovered vision services | 0962 | Professional fees - Ophthalmology. | |
| Noncovered dental services | 0969 | Professional fees - Other. | |
| Other noncovered services | 0999 | Patient convenience items - Other. | |