SECTION 7 FREE-STANDING DIALYSIS SERVICES Effective 10/1/09

10-144 CH. 101 MAINECARE BENEFITS MANUAL CHAPTER III SECTION 7 FREE-STANDING DIALYSIS SERVICES Effective 7/26/10

HCPCS *** MAXIMUM CODE CODE DESCRIPTION ALLOWANCE

0821 90999 HEMODIALYSIS/COMPOSITE BY REPORT

0825 90993, 90989 SUPPORT SERVICES (HEMODIALYSIS BY REPORT

0831 90999 PERITONEAL DIALYSIS/COMPOSITE BY REPORT

0835 90993, 90989 SUPPORT SERVICES (IP) BY REPORT

0841 90999 CAPD/COMPOSITE BY REPORT

0845 90993, 90989 SUPPORT SERVICES/CAPD BY REPORT

0849 90945 OTHER CAPD DIALYSIS BY REPORT

0851 90999 CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) BY REPORT

0855 90993, 90989 SUPPORT SERVICES (CCPD) BY REPORT

0634 * EPO- INJECTION, EPOETIN ALFA, UNDER 10,000 UNITS BY REPORT

0635 * EPO- INJECTION, EPOETIN ALFA, ABOVE 10,000 UNITS

0636** ARANESP- INJECTION, DARBEPOETIN ALFA, 1 MCG BY REPORT

* Providers must also put HCPCS Q4081 on claim form. * * Providers must also put HCPCS JO882 on claim form.

*** These HCPCS codes will become effective upon implementation of MIHMS. (APA Office Note: This occurred on September°1, 2010.)