Medicare Non Covered HCPCS Codes

This Contain 5 Character HCPCS level II, Interim, and 3 Character HIPPA compliant revenue codes used for billing. but interim codes are not used to bill MCR, it included in assist provider in determining the type of services (ToS) not covered by MCR.

 

Codes	Description	When to Bill Medi-Cal Directly
G0154, G0156, S5130, S5165, S5170, S9470, T2003, T2022, T2025, T2026, T2028, T2029	AIDS Waiver	Always
A0430, A0431, X0510 – X0522	Air Ambulance	Any non-emergency TAR-authorized service
A0800, A0999, X0002 – X0020, X0030 – X0036	Ambulance	Any non-emergency TAR-authorized service
X0200 – X0222, X0400 – X0416	Ambulance/Medical Transportation	Always
V5008, V5010, X4526 – X4528, X4532, X4542	Audiology	Always
X4500 – X4524, X4530, X4534 – X4540, X4544, X4546, Z0316	Audiology	If for hearing aid evaluation.  Enter “hearing aid evaluation” in the Reserved for Local Use field (Box 19) of the CMS-1500 claim form.
Z6200 – Z6210, Z6300 – Z6308, Z6400 – Z6414, Z6500	Comprehensive Perinatal Services Program (CPSP)	Always
E0181, E0184 – E0190, E0193, E0194, E0196 – E0199, E0277, E0371 – E0373	Decubitus Care Equipment	On the UB-04, if the facility type code is 26 (Skilled Nursing – Intermediate Care Level II/NF-B), 25 (Skilled Nursing – Intermediate Care Level II/NF-A), or 27 (Skilled Nursing – Subacute).  On the CMS-1500, if the Place of Service code is 31 (Nursing Facility Level B), 32 (Nursing Facility Level A) or 99 (Other).
Z0318	Directly Observed Therapy (DOT)	Always
A9281, E0240 – E0248, E0273, E0602 – E0604, E0618, E0619, E0625	DME	Always
E0600, E0958, E0959, E0961, E0967, E0970, E0971, E0974, E0978, E0979, E0983, E0984, E0992, E1028, E1065, E1091, E1225 – E1228, E1296 – E1298, E1902, E2000, E2360, E2362, E2364, E2373, E2500 – E2599, K0009, K0014, K0064, K0070, K0108, K0739, K0740, K0868 – K0898	DME	On the UB-04, if the facility type code is other than 33 (Home Health – Outpatient) or 14, 24, 34, 44, 54, 64, 74, 75 or 89.  On the CMS-1500, if the Place of Service code is other than 12 (Home) or 99 (Other).

E0950 – E1110, E1161 – E1298, E2201 – E2397, E2601 – E2621, K0002 – K0195, K0733 – K0737, K0800 – K0898 Note:  All codes falling within the listed ranges may not be Medi-Cal benefits.  Please refer to the Durable Medical Equipment (DME):  Billing Codes and Reimbursement Rates section for the covered code list.	DME	On the CMS-1500, if the Place of Service code is 31 (Nursing Facility Level B).
A9900, E1399	DME – Unlisted	On the UB-04, if the facility type code is other than 33 (Home Health – Outpatient) or 14, 24, 34, 44, 54, 64, 74, 75 or 89.  On the CMS-1500, if the Place of Service code is other than 12 (Home) or 99 (Other).
Z5802, Z5804, Z5806, Z5814, Z5816, Z5820, Z5999	Early and Periodic Screening, Diagnosis and Treatment (EPSDT)	If services are part of Medicare non-covered treatment.
Z9700 – Z9703	Expanded Access to Primary Care (EAPC) Program	Always
G9012, H0045, S5111, S5160, S5161, S9122, S9123, S9124, T1005, T1016, T1019, T2017, T2033, T2035	HCBS Waiver	Always
V5014, V5020 – V5080, V5120 – V5190, V5210 – V5230, V5264, V5265, V5267, V5298	Hearing Aids	Always
H0014	Heroin Detoxification (21-Day Only)	Always
Z7100 – Z7106, Z7108	Hospice Care Services	If recipient has Part B-only Medicare coverage.
658	Hospice Room and Board	Always
A4335, A4520, A4554, A6250, T4521 – T4537, T4540 – T4543	Incontinence Medical Supplies	Always
A4230 – A4232, A9274	Insulin Infusion Pump Supplies	Always
Z7506 – Z7514	Operating/Recovery Room Services	If services are part of Medicare non-covered dental treatment.
L0982, L1710, L1730, L2360, L2780, L3100, L3208 – L3214, L3251 – L3255, L3260, L3265, L3300 – L3520, L3560 – L3595, L3610, L3630	Orthotics	Always

A4615, A4619, A4620, E0424, E0425, E0430 – E0435, E0439 – E0444, E1390 – E1392		Oxygen Delivery Systems and Supplies	On the CMS-1500, if the Place of Service code is 32 (Nursing Facility Level A) or 31 (Nursing Facility Level B).  If the Place of Service code is 99 (Other), services are included in the per diem rate and are not separately reimbursable by Medicare or Medi-Cal.
L8001, L8002, L8010, L8100 – L8180, L8230		Prosthetics	Always
X9544, X9546		Psychology Services	Always
X4300 – X4312, X4320		Speech Therapy	Always
X9900 – X9920		Subacute, Physician	Always
S0500, S0512, S0514, V2500, V2501, V2510, V2511, V2513, V2520, V2521, V2523		Vision Services – Contact lenses, per lens	If diagnosis is other than aphakia (ICD-9-CM codes 379.3 – 379.34 or 743.35), or pseudophakia (ICD-9-CM code V43.1).
	S0516, V2020, V2025	Vision Services – Eyeglass Frames	If diagnosis is other than aphakia (ICD-9-CM codes 379.3 – 379.34 or 743.35) or pseudophakia (ICD-9-CM code V43.1).
V2100 – V2499, V2781 – V2783		Vision Services – Ophthalmic Lenses (billed only in non-FOL Counties: 40 (San Luis Obispo), 41 (San Mateo), and 42 (Santa Barbara)	If diagnosis is other than aphakia (ICD-9-CM codes 379.3 – 379.34 or 743.35) or pseudophakia (ICD-9-CM code V43.1).
V2599		Vision Services – Bandage Contact Lenses	If diagnosis is other than aphakia (ICD-9-CM codes 379.3 – 379.34 or 743.35) or pseudophakia (ICD-9-CM code V43.1).
V2600, V2610, V2615		Vision Services – Low Vision Aids	Always
	V2702 – V2755, V2760 – V2762, V2799	Vision Services – Eye Appliance, Miscellaneous billed only in non-Fabricating Optical Laboratory (FOL) Counties: 40 (San Luis Obispo), 41 (San Mateo), and 42 (Santa Barbara)	If diagnosis is other than aphakia (ICD-9-CM codes 379.3 – 379.34 or 743.35) or pseudophakia (ICD-9-CM code V43.1).
V2770		Vision Services – Occluder	Always