S Codes

S0012

Butorphanol tartrate, nasal spray, 25 mg

S0014

Tacrine hydrochloride, 10 mg

S0017

Injection, aminocaproic acid, 5 grams

S0020

Injection, bupivicaine hydrochloride, 30 ml

S0021

Injection, cefoperazone sodium, 1 gram

S0023

Injection, cimetidine hydrochloride, 300 mg

S0028

Injection, famotidine, 20 mg

S0030

Injection, metronidazole, 500 mg

S0032

Injection, nafcillin sodium, 2 grams

S0034

Injection, ofloxacin, 400 mg

S0039

Injection, sulfamethoxazole and trimethoprim, 10 ml

S0040

Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams

S0073

Injection, aztreonam, 500 mg

S0074

Injection, cefotetan disodium, 500 mg

S0077

Injection, clindamycin phosphate, 300 mg

S0078

Injection, fosphenytoin sodium, 750 mg

S0080

Injection, pentamidine isethionate, 300 mg

S0081

Injection, piperacillin sodium, 500 mg

S0088

Imatinib, 100 mg

S0090

Sildenafil citrate, 25 mg

S0091

Granisetron hydrochloride, 1 mg (for circumstances falling under the medicare statute, use q0166)

S0092

Injection, hydromorphone hydrochloride, 250 mg (loading dose for infusion pump)

S0093

Injection, morphine sulfate, 500 mg (loading dose for infusion pump)

S0104

Zidovudine, oral, 100 mg

S0106

Bupropion hcl sustained release tablet, 150 mg, per bottle of 60 tablets

S0108

Mercaptopurine, oral, 50 mg

S0109

Methadone, oral, 5 mg

S0117

Tretinoin, topical, 5 grams

S0119

Ondansetron, oral, 4 mg (for circumstances falling under the medicare statute, use hcpcs q code)

S0122

Injection, menotropins, 75 iu

S0126

Injection, follitropin alfa, 75 iu

S0128

Injection, follitropin beta, 75 iu

S0132

Injection, ganirelix acetate, 250 mcg

S0136

Clozapine, 25 mg

S0137

Didanosine (ddi), 25 mg

S0138

Finasteride, 5 mg

S0139

Minoxidil, 10 mg

S0140

Saquinavir, 200 mg

S0142

Colistimethate sodium, inhalation solution administered through dme, concentrated form, per mg

S0144

Injection, propofol, 10 mg

S0145

Injection, pegylated interferon alfa-2a, 180 mcg per ml

S0148

Injection, pegylated interferon alfa-2b, 10 mcg

S0155

Sterile dilutant for epoprostenol, 50 ml

S0156

Exemestane, 25 mg

S0157

Becaplermin gel 0.01%, 0.5 gm

S0160

Dextroamphetamine sulfate, 5 mg

S0164

Injection, pantoprazole sodium, 40 mg

S0166

Injection, olanzapine, 2.5 mg

S0169

Calcitrol, 0.25 microgram

S0170

Anastrozole, oral, 1 mg

S0171

Injection, bumetanide, 0.5 mg

S0172

Chlorambucil, oral, 2 mg

S0174

Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)

S0175

Flutamide, oral, 125 mg

S0176

Hydroxyurea, oral, 500 mg

S0177

Levamisole hydrochloride, oral, 50 mg

S0178

Lomustine, oral, 10 mg

S0179

Megestrol acetate, oral, 20 mg

S0182

Procarbazine hydrochloride, oral, 50 mg

S0183

Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)

S0187

Tamoxifen citrate, oral, 10 mg

S0189

Testosterone pellet, 75 mg

S0190

Mifepristone, oral, 200 mg

S0191

Misoprostol, oral, 200 mcg

S0194

Dialysis/stress vitamin supplement, oral, 100 capsules

S0195

Pneumococcal conjugate vaccine, polyvalent, intramuscular, for children from five years to nine years of age who have not previously received the vaccine

S0197

Prenatal vitamins, 30-day supply

S0199

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

S0201

Partial hospitalization services, less than 24 hours, per diem

S0207

Paramedic intercept, non-hospital-based als service (non-voluntary), non-transport

S0208

Paramedic intercept, hospital-based als service (non-voluntary), non-transport

S0209

Wheelchair van, mileage, per mile

S0215

Non-emergency transportation; mileage, per mile

S0220

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

S0221

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

S0250

Comprehensive geriatric assessment and treatment planning performed by assessment team

S0255

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

S0257

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)

S0260

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

S0265

Genetic counseling, under physician supervision, each 15 minutes

S0270

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

S0271

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

S0272

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

S0273

Physician visit at member's home, outside of a capitation arrangement

S0274

Nurse practitioner visit at member's home, outside of a capitation arrangement

S0280

Medical home program, comprehensive care coordination and planning, initial plan

S0281

Medical home program, comprehensive care coordination and planning, maintenance of plan

S0285

Colonoscopy consultation performed prior to a screening colonoscopy procedure

S0302

Completed early periodic screening diagnosis and treatment (epsdt) service (list in addition to code for appropriate evaluation and management service)

S0310

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

S0311

Comprehensive management and care coordination for advanced illness, per calendar month

S0315

Disease management program; initial assessment and initiation of the program

S0316

Disease management program, follow-up/reassessment

S0317

Disease management program; per diem

S0320

Telephone calls by a registered nurse to a disease management program member for monitoring purposes; per month

S0340

Lifestyle modification program for management of coronary artery disease, including all supportive services; first quarter / stage

S0341

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

S0342

Lifestyle modification program for management of coronary artery disease, including all supportive services; fourth quarter / stage

S0353

Treatment planning and care coordination management for cancer, initial treatment

S0354

Treatment planning and care coordination management for cancer, established patient with a change of regimen

S0390

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

S0395

Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic

S0400

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

S0500

Disposable contact lens, per lens

S0504

Single vision prescription lens (safety, athletic, or sunglass), per lens

S0506

Bifocal vision prescription lens (safety, athletic, or sunglass), per lens

S0508

Trifocal vision prescription lens (safety, athletic, or sunglass), per lens

S0510

Non-prescription lens (safety, athletic, or sunglass), per lens

S0512

Daily wear specialty contact lens, per lens

S0514

Color contact lens, per lens

S0515

Scleral lens, liquid bandage device, per lens

S0516

Safety eyeglass frames

S0518

Sunglasses frames

S0580

Polycarbonate lens (list this code in addition to the basic code for the lens)

S0581

Nonstandard lens (list this code in addition to the basic code for the lens)

S0590

Integral lens service, miscellaneous services reported separately

S0592

Comprehensive contact lens evaluation

S0595

Dispensing new spectacle lenses for patient supplied frame

S0596

Phakic intraocular lens for correction of refractive error

S0601

Screening proctoscopy

S0610

Annual gynecological examination, new patient

S0612

Annual gynecological examination, established patient

S0613

Annual gynecological examination; clinical breast examination without pelvic evaluation

S0618

Audiometry for hearing aid evaluation to determine the level and degree of hearing loss

S0620

Routine ophthalmological examination including refraction; new patient

S0621

Routine ophthalmological examination including refraction; established patient

S0622

Physical exam for college, new or established patient (list separately in addition to appropriate evaluation and management code)

S0630

Removal of sutures; by a physician other than the physician who originally closed the wound

S0800

Laser in situ keratomileusis (lasik)

S0810

Photorefractive keratectomy (prk)

S0812

Phototherapeutic keratectomy (ptk)

S1001

Deluxe item, patient aware (list in addition to code for basic item)

S1002

Customized item (list in addition to code for basic item)

S1015

Iv tubing extension set

S1016

Non-pvc (polyvinyl chloride) intravenous administration set, for use with drugs that are not stable in pvc e.g., paclitaxel

S1030

Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use cpt code)

S1031

Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use cpt code)

S1034

Artificial pancreas device system (e.g., low glucose suspend (lgs) feature) including continuous glucose monitor, blood glucose device, insulin pump and computer algorithm that communicates with all of the devices

S1035

Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device system

S1036

Transmitter; external, for use with artificial pancreas device system

S1037

Receiver (monitor); external, for use with artificial pancreas device system

S1040

Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

S1090