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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyIowa Medicaid CPT/D code modifier update | OpenPay…
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    CurrentIowa Department of Health and Human ServicesPolicy N/A

    Iowa Medicaid Addendum B — CPT and Dental Code Listing (modifier placeholders)

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    Provides a listing of CPT and dental D codes with modifier placeholders for Iowa Medicaid Addendum B, updated for use effective January 1, 2025; intended for provider billing reference (no coverage criteria included in this excerpt).

    Policy Summary
    PayerIowa Department of Health and Human Services
    PolicyIowa Medicaid Addendum B — CPT and Dental Code Listing (modifier placeholders)
    Policy CodePolicy N/A
    Change TypeInformational update (code/modifier listing)
    Effective DateJan 1, 2025
    Last ReviewJan 1, 2025
    Next Review DateN/A
    Key ActionUse the provided CPT/D and HCPCS code lists with 'Modifier = .' placeholders when submitting Iowa Medicaid claims for dates of service on or after January 1, 2025.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    20+chunks with listings
    Modifier = .modifier placeholder
    hundredsapprox. codes shown
    partialdocument part

    Coverage / Code Listings (Informational)

    Billing code list (informational)

    Code listing for billing purposes (no explicit coverage rules in this excerpt).

    Sequential CPT/CPT‑like codes are listed with a modifier placeholder 'Modifier = .' for billing; this excerpt does not state medical necessity or coverage conditions.

    Code listing — no criteria in this fragment

    This section presents a sequence of procedure codes with an associated modifier field; no explicit coverage criteria or limits are provided in this fragment.

    Procedure codes (e.g., 27675, 27676, 27680…) are enumerated with 'Modifier = .' following each code; no medical necessity or coverage requirements are included in these chunks.

    Modifier assignment list

    Modifier assignments for listed procedure codes (excerpt).

    Policy Summary
    PayerIowa Department of Health and Human Services
    PolicyIowa Medicaid Addendum B — CPT and Dental Code Listing (modifier placeholders)
    Policy CodePolicy N/A
    Change TypeInformational update (code/modifier listing)
    Effective DateJan 1, 2025
    Last ReviewJan 1, 2025
    Next Review DateN/A
    Key ActionUse the provided CPT/D and HCPCS code lists with 'Modifier = .' placeholders when submitting Iowa Medicaid claims for dates of service on or after January 1, 2025.
    SourceLink
    On This Page
    Coverage / Code Listings (Informational)CPT / HCPCS / Modifier ExamplesWhat Providers Need To KnowNotation and Copyright
    Each listed procedure code in these chunks (for example 33851, 33999, 43400) is followed by a modifier field shown as 'Modifier = .' indicating a placeholder for the modifier value; no coverage rules accompany these assignments.

    Procedure code listing (informational)

    This extract provides a raw enumerated list of procedure codes paired with modifier annotations; no coverage criteria or clinical limitations are provided in these chunks.

    Procedure codes such as 43255, 43400, 55705 (and many others shown across these chunks) are listed with 'Modifier = .' placeholders; the excerpt does not define prior authorization, documentation, or clinical criteria.

    No criteria

    No coverage criteria present in this excerpt; only code-modifier listings.

    Numerous CPT procedure codes (e.g., 67015, 67450, 68115…) are listed with 'Modifier = .'; no medical necessity criteria or coverage limits are specified in this fragment.

    Procedure code listing (partial)

    Listed procedure codes and modifier indicator.

    Laboratory and pathology CPT/HCPCS codes (for example 81020, 81105, 81216…) are listed with a modifier placeholder 'Modifier = .'; this listing does not include coverage criteria.

    No coverage rules in excerpt

    No coverage rules in excerpt.

    These chunks continue the sequential listing of procedure codes with 'Modifier = .' placeholders (e.g., 86977, 87253, 87478); no coverage or medical necessity rules are present in the excerpt.

    Billing/coding list (informational)

    This segment provides code entries but does not include explicit coverage criteria or limitations within these chunks.

    Codes including 94774, 95249, 95700 and others are shown with 'Modifier = .' placeholders for billing; the excerpt provides no medical necessity criteria.

    Code list (informational)

    Procedure codes shown with modifier placeholders—no explicit coverage determinations included in this part.

    A‑, B‑, C‑, D‑series and other HCPCS/CPT codes (for example A6231, D3220) are listed with 'Modifier = .'; the document fragment does not define coverage conditions.

    Modifier listing — no coverage criteria in this fragment

    Listing of codes with modifier entries; no explicit coverage criteria provided in this fragment.

    Dental procedure codes (e.g., D3220, D4266) and related D‑series entries are listed with a modifier placeholder 'Modifier = .'; no medical necessity or coverage rules accompany the list.

    Modifier listing

    Billing list of codes and modifier placeholders (no coverage rules included in these chunks).

    Selected HCPCS/G/J/H and other codes (for example G9105, G9246, J2770) are enumerated with 'Modifier = .' after each code, indicating modifier usage for billing; this excerpt contains no prior authorization or medical necessity criteria.

    CPT / HCPCS / Modifier Examples

    Sample CPT codes with modifiers (partial)CPT
    0001FModifier placeholder
    0001UModifier placeholder
    0002MModifier placeholder
    0002UModifier placeholder
    Sample CPT codes with modifiers (partial) - continuedCPT
    No codes listed
    Sample codes from listCPT
    0552T
    10004
    17111
    Partial CPT code list from chunks 36-55CPT
    21122CPT code listed with placeholder for modifier
    21315CPT code listed with placeholder for modifier
    22505CPT code listed with placeholder for modifier
    22856CPT code listed with placeholder for modifier
    24100CPT code listed with placeholder for modifier
    25000CPT code listed with placeholder for modifier
    26100CPT code listed with placeholder for modifier
    27000CPT code listed with placeholder for modifier
    27400CPT code listed with placeholder for modifier
    27826CPT code listed with placeholder for modifier
    1–10 of 11
    1/2
    Orthopedic and related surgical codes (sample from listing)CPTCovered
    27675Procedure code listed with modifier placeholder
    27676Procedure code listed with modifier placeholder
    27680Procedure code listed with modifier placeholder
    Sample of listed CPT/HCPCS codes with modifier fieldCPT
    33851Procedure code listed with Modifier = .
    33999Procedure code listed with Modifier = .
    43400Procedure code listed with Modifier = .
    Example procedure codes from listingCPT
    43255Procedure code listed with modifier indicator
    43832Procedure code listed with modifier indicator
    55899Procedure code listed with modifier indicator
    Sample of listed procedure codesCPTCovered
    54417Procedure code listed with a modifier placeholder
    54420Procedure code listed with a modifier placeholder
    54430Procedure code listed with a modifier placeholder
    54435Procedure code listed with a modifier placeholder
    54437Procedure code listed with a modifier placeholder
    54438Procedure code listed with a modifier placeholder
    54440Procedure code listed with a modifier placeholder
    54450Procedure code listed with a modifier placeholder
    54500Procedure code listed with a modifier placeholder
    54505Procedure code listed with a modifier placeholder
    Sample of listed CPT codes (section continues across chunks)CPT
    67015
    67025
    67027
    67028
    67030
    67031
    67036
    67039
    67040
    67041
    Laboratory and pathology CPT/HCPCS codes (partial list)CPTCovered
    81020
    81105
    81200
    81336
    81490
    82009
    82300
    82507
    82930
    83001
    1–10 of 22
    1/3
    Sample of listed procedure codesCPT
    86977
    86978
    86985
    86999
    sample codes from this chunk (partial list)mixed
    94774CPT/HCPCS code listed with modifier placeholder
    99213CPT evaluation and management code included in listing
    A0420HCPCS/A-code listed
    99499CPT/HCPCS code listed
    Sample codes from A-, B-, C-, D- series listed in this partmixed
    A6231
    A6566
    B4100
    C1600
    D0140
    Codes with modifier columnmixed
    D3220Dental procedure code listed with modifier field
    D4266Dental procedure code listed with modifier field
    D7520Dental procedure code listed with modifier field
    E0100Durable medical equipment/service HCPCS code listed with modifier field
    E1830Durable medical equipment/service HCPCS code listed with modifier field
    E2298Durable medical equipment/service HCPCS code listed with modifier field
    Sample codes from long listHCPCS
    E1357HCPCS code listed with modifier placeholder
    G0010G-code listed with modifier placeholder
    G9354G-code listed with modifier placeholder
    Selected examples from listed codesmixed
    G9105G-code listed with modifier placeholder
    G9999G-code listed with modifier placeholder
    H0003H-code listed with modifier placeholder
    J0120J-code listed with modifier placeholder
    J2806J-code listed with modifier placeholder
    fragment_position
    Fragment positionPart 4 of 15
    Source contextChunk shows sequential CPT/HCPCS entries in this part of the addendum
    Implication for providersThis extract is a partial segment of the full Addendum B listing — consult the complete addendum for other parts
    Listing completeness
    Listing completenessSequential blocks of procedure codes with modifiers spanning chunks 90-109 (partial, not exhaustive)
    What is includedNumerous CPT procedure codes each followed by 'Modifier = .' placeholders
    ActionUse this as a billing code reference only; not a statement of coverage criteria
    modifier notation
    Modifier notationDisplayed as 'Modifier = .' indicating a placeholder for modifier values
    Document usageModifier field shown as a dot after each code throughout the listing
    Provider actionApply the appropriate modifier in claims per coding rules; the addendum shows where modifiers are recorded
    document part
    Document partPartial code listing (not exhaustive) — this segment is one part of a multi-part addendum
    Coverage implicationThis extract provides code/modifier pairs but does not assert coverage rules or medical necessity criteria
    Reference instructionConsult other parts of Addendum B for the complete listing and any related guidance
    modifier presence
    Modifier presenceAll listed codes include an explicit modifier field placeholder ('.') following the code
    ConsistencyThe modifier placeholder appears across CPT, HCPCS and dental D-code series in the addendum
    Billing noteA modifier value is expected or may be specified elsewhere; providers must supply the correct modifier on claims
    modifier placeholder
    Modifier placeholder formEach listed code is shown followed by 'Modifier = .' indicating a placeholder for the modifier value
    InterpretationThe dot represents an empty/placeholder modifier field; actual modifier(s) must be applied per coding rules
    Where appliedUsed throughout G-, J-, H-, CPT, HCPCS and dental code ranges in this extract

    What Providers Need To Know

    Billing Rule

    CPT/Dental code list — Addendum B

    Iowa Medicaid Addendum B lists CPT and dental procedure codes with a modifier placeholder for billing; the addendum was updated for January 1, 2025.

    Billing Rule

    Code list excerpt (Modifier = .)

    This excerpt enumerates CPT/HCPCS codes each shown with the notation "Modifier = .", indicating a modifier field placeholder accompanying each listed code.

    Billing Rule

    Procedure code/modifier list (partial)

    Continuation of the procedure code table showing CPT codes each followed by "Modifier = ." to indicate where a modifier value is recorded for billing.

    Billing Rule

    Procedure code and modifier listing (partial)

    Section enumerates procedure codes with an adjacent "Modifier =" placeholder (e.g., 27675, Modifier = .), signifying modifiers are associated with each code in the addendum.

    Billing Rule

    Procedure code modifier assignments (excerpt)

    Lists numerous procedure codes each followed by the text "Modifier = ." indicating the modifier value for each listed code is shown as a placeholder in this excerpt.

    Billing Rule

    Procedure codes and modifier indicators

    Examples in this segment show procedure codes with associated modifier placeholders (for example, "43255, Modifier = ."), consistent across the listing.

    Billing Rule

    Procedure code list (modifier placeholders)

    This portion enumerates many procedure codes with an adjacent "Modifier = ." placeholder; no prior authorization, step therapy, or documentation rules are specified in these chunks.

    Billing Rule

    Procedure codes with placeholder modifier

    Numerous CPT procedure codes are listed here each followed by "Modifier = .", indicating an unspecified or placeholder modifier value intended for use in claims.

    Billing Rule

    Laboratory/Pathology code list (partial)

    Partial laboratory and pathology code listing showing CPT/HCPCS lab/path codes each followed by "Modifier = ." as the modifier placeholder.

    Billing Rule

    Procedure code list with modifier placeholders

    Procedure and HCPCS/CPT codes in this excerpt are presented with a "Modifier =" column where many modifier entries are left blank (shown as ".").

    Billing Rule

    Procedure code list (partial)

    Partial segment listing procedure codes with an explicit "Modifier = ." placeholder following each code for billing record purposes.

    Billing Rule

    Procedure code modifier listing

    This section lists HCPCS, CPT and dental procedure codes with a modifier field shown as "Modifier = ." alongside each code.

    Billing Rule

    Modifier listing (no auth rules in this fragment)

    The addendum consistently shows a modifier placeholder expressed as "Modifier = ." for listed procedure codes; this fragment does not specify modifier values or authorization rules.

    Billing Rule

    HCPCS/G-code modifier notation

    HCPCS and G‑codes are enumerated with the notation "Modifier = ." after each code, indicating a modifier placeholder in the listing.

    Billing Rule

    Modifier-coded procedure list (excerpt)

    Selected G-, J-, H- and other codes are shown with a modifier placeholder "." following each code, indicating modifier values are specified as a placeholder in this excerpt.

    Notation and Copyright

    CPT/D codes copyright notice
    CPT/D codes copyrightCPT codes and descriptions copyright 2020 American Medical Association; dental D codes copyright 2020 American Dental Association
    Effective date noteAddendum updated for January 1, 2025
    Rights statementAll Rights Reserved. Applicable FARS/DFARS Apply.
    Modifier = .
    Modifier = .Appears immediately after listed codes (example: 0552T, Modifier = .)
    MeaningServes as a placeholder indicating where a specific modifier value would be recorded
    Document usageRepeated across multiple code entries in this section
    Modifier = .
    Modifier = .Shown after CPT codes in the listing (example: 21122, Modifier = .)
    ScopeApplies to surgical/procedural CPT codes in this extract
    Provider instructionEnter appropriate modifier on claims consistent with coding guidelines
    Modifier = .
    Modifier = .Appears after orthopedic procedure codes (example: 27675, Modifier = .)
    Consistent notationUsed uniformly across listed procedure ranges
    ImplicationIndicates modifier information is associated with each code, though specific modifiers are not provided here
    Modifier = . <number>
    Modifier = . <number>Modifier placeholder appears alongside sequential numeric codes (example pattern: 33851, Modifier = .)
    Example usageObserved across cardiovascular/related procedure code series in the extract
    Action for billersSupply the correct modifier value when submitting claims per payer and coding guidance
    'Modifier =' text following each procedure code indicates where modifier information is intended to be associated with the code in the full document.
    Modifier association text'Modifier =' text follows each procedure code to indicate where modifier information is intended to be recorded
    Document roleThis shows how modifier metadata is linked to individual codes in the addendum table
    Provider guidanceModifiers must be selected and appended according to coding rules; the addendum marks the modifier field location
    Modifier placeholder
    Modifier placeholderRepeated placeholder 'Modifier = .' shown after ophthalmology and related codes (example: 67015, Modifier = .)
    Coverage noteThe listing pairs codes with modifier placeholders but does not define coverage conditions in this excerpt
    Provider actionRefer to payer billing rules for appropriate modifier selection
    Modifier = .
    Modifier = .Appears in a procedure code modifier list for laboratory/microbiology/pathology and related codes (example: 86977, Modifier = .)
    List characteristicEach entry is a code followed by the modifier field marker
    Billing implicationProviders must supply applicable modifiers on claims; the addendum marks where they belong
    Procedure code modifier list
    Procedure code modifier listMultiple procedure codes are listed each followed by 'Modifier = .' indicating a modifier field for each code
    ExamplesEntries include 94774, 94775, etc., each with 'Modifier = .'
    UseServes as billing reference; does not supply the specific modifier values in this fragment
    Modifier = . (placeholder indicating modifier(s) may apply)
    Modifier = . (placeholder indicating modifier(s) may apply)Shown after numerous HCPCS/A-code entries (example: A6231, Modifier = .)
    ScopeApplies across A-, B-, C-, D-, and other HCPCS code series in the extract
    Provider instructionDetermine and submit the correct modifier per coding and payer requirements
    Modifier placeholder
    Modifier placeholderDental procedure codes are listed with 'Modifier = .' after each code (example: D3220, Modifier = .)
    ImplicationIndicates where modifiers for dental codes would be applied in claims
    Billing noteProviders should include the appropriate dental modifier when submitting claims to Iowa Medicaid
    Modifier field placeholder
    Modifier field placeholderVarious HCPCS E- and G-codes show 'Modifier = .' indicating a modifier field placeholder
    InterpretationPlaceholder denotes that modifier information is expected though not specified here
    ActionApply correct modifiers per HCPCS coding guidance and payer rules when billing
    Modifier = .
    Modifier = .Appears throughout G-code listings as the modifier placeholder (example: G9105, Modifier = .)
    Document roleMarks the modifier column for these procedure codes in the addendum
    Provider guidanceConfirm and include the appropriate modifier when submitting claims
    Modifier = .
    Modifier = .Consistently used after numeric procedure codes to indicate modifier placeholder (example cluster: 33851, Modifier = .)
    PatternThe placeholder is repeated across many contiguous chunks indicating uniform table formatting
    Provider implicationModifiers must be provided on claims; consult full addendum or payer guidance for specific modifier rules