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CurrentIowa Department of Health and Human ServicesPolicy N/A

Iowa Medicaid CY2021 Addendum B — CPT codes and modifier listings

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Addendum B listing of CPT, HCPCS and dental procedure codes with modifier placeholders for Iowa Medicaid, updated for October 1, 2021; this part contains code/modifier tables and copyright notices and does not state coverage criteria.

Policy Summary

PayerIowa Department of Health and Human Services

PolicyIowa Medicaid CY2021 Addendum B — CPT codes and modifier listings

Policy CodePolicy N/A

Change TypeAddendum update (code list only)

Effective DateOct 1, 2021

Last ReviewOct 1, 2021

Next Review DateN/A

Key ActionUse the provided code and 'Modifier = .' listings when billing Iowa Medicaid; no prior authorization or additional billing instructions are included in this part.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+Chunks with code/modifier listings

hundredsProcedure codes enumerated

partialDocument part

yesIncludes dental codes

Coverage Criteria and Stance

Coverage information not present in this part

This part contains coded listings; no explicit coverage criteria or payment rules are present in the extracted portion.

No coverage criteria, limitations, or medical necessity rules are specified in this excerpt; the content is an enumerated list of procedure codes with modifier placeholders.

Code-to-modifier mapping (partial)

This segment is a billing code table mapping numerous CPT/HCPCS codes to a modifier marker. No explicit coverage criteria, limitations, or medical necessity rules are included in these chunks.

Listed entries map procedure codes to a 'Modifier = .' placeholder (modifier value not provided); no coverage or medical necessity conditions are stated.

Coding-only listing (no coverage rules present)

No explicit coverage criteria in this window; content is a code/modifier listing.

Policy Summary

PayerIowa Department of Health and Human Services

PolicyIowa Medicaid CY2021 Addendum B — CPT codes and modifier listings

Policy CodePolicy N/A

Change TypeAddendum update (code list only)

Effective DateOct 1, 2021

Last ReviewOct 1, 2021

Next Review DateN/A

Key ActionUse the provided code and 'Modifier = .' listings when billing Iowa Medicaid; no prior authorization or additional billing instructions are included in this part.

SourceLink

On This Page

CPT, HCPCS, and Modifier Listings

CPT codes with modifiers (partial listing)CPT

0001A	Modifier listed (placeholder in addendum)
0002A	Modifier listed (placeholder in addendum)
00100	Modifier listed (placeholder in addendum)

Sample codes from enumerated listCPT

0648T	Procedure code listed with Modifier = .
10004	Procedure code listed with Modifier = .
11000	Procedure code listed with Modifier = .

Enumerated CPT/HCPCS procedure codes and modifiersCPT

24358	Procedure code listed with modifier placeholder
25020	Procedure code listed with modifier placeholder
26160	Procedure code listed with modifier placeholder
27100	Procedure code listed with modifier placeholder
3085F	Procedure code/Modifier listed
31257	Procedure code listed at end of excerpt

Partial CPT code list from Addendum B (chunks 54-73)CPT

3021F	Procedure code listed with modifier placeholder
30300	Procedure code listed with modifier placeholder
31299	Procedure code listed with modifier placeholder
37200	Procedure code listed with modifier placeholder

Sample codes from list (not exhaustive in this chunk)CPT

36570	Procedure code listed with modifier placeholder
37140	Procedure code listed with modifier placeholder
37200	Procedure code listed with modifier placeholder

Enumerated procedure codes/modifiers (partial list — continuation)mixed

46916	Modifier/code listed in sequence (as shown in document)
49999	Modifier/code listed in sequence (as shown in document)
61597	Modifier/code listed in sequence (as shown in document)

Enumerated CPT/Procedure codesCPT

multiple CPT codes (see list)

Procedural codes enumerated across chunks 108–127 with modifier placeholders.

Example codes from the sequenceCPT

74251
74261
74262
74263
74270

Assorted CPT/HCPCS codes listedmixed

83497	Immunohematology/related procedure (listed with modifier)
83500	Clinical chemistry procedure (listed with modifier)
84100	Specific laboratory test examples (from list)
89220	Embryology/microbiology procedural codes (from list)
90619	Vaccine code example (from list)
92002	Ophthalmological procedure examples (from list)

Sample codes from enumerated listmixed

90882
99202
A0021

Sample of listed HCPCS A-codesHCPCS

A0225
A0380
A0382
A0384
A0390

Sample of listed dental (D-) codesCPT

D0120
D0140
D0150
D0210
D1110

Sample codes from listCPT

D0351	Procedural dental code listed with modifier placeholder
D1110	Procedural dental code listed with modifier placeholder
D2393	Procedural dental code listed with modifier placeholder
E0100	DME/orthotic/prosthetic code listed with modifier placeholder
E0748	DME/orthotic/prosthetic code listed with modifier placeholder

HCPCS E- and G- codesHCPCS

No codes listed

G-codes (partial)CPT

G9147	G-code listed with modifier placeholder
G9192	G-code listed with modifier placeholder

H- and J-codes (partial)HCPCS

H0003	H-code listed with modifier placeholder
J0120	J-code listed with modifier placeholder

J-codes continuation (partial)HCPCS

J3300	J-code listed with modifier placeholder
J7197	J-code listed with modifier placeholder

Sample J-code group (complete list continues in document)HCPCS

J3301
J3302
J3303

Sample K-code group (complete list continues in document)HCPCS

K0001
K0002
K0003

Sample L-code group (complete list continues in document)HCPCS

L0112
L0113
L0120

Modifier notation

Modifier notation usedMany procedure and HCPCS/CPT codes in this addendum are followed by the literal text 'Modifier = .' which indicates a modifier field is associated with the code in the listing.

Examples including modifier notationExamples from the listing include codes such as 24358, 36570, and 90882 each followed by 'Modifier = .'.

Implication for billingThe 'Modifier = .' entry in the table serves as a placeholder in the addendum indicating where a modifier value should appear on claims; the specific modifier value is not provided in this excerpt.

Modifier presence

Modifier presence across documentAll listed codes in the referenced segments consistently show a 'Modifier = .' placeholder following each code (e.g., sequences beginning with 36570 and 90882 and G-codes in later chunks).

Sections exhibiting placeholder patternChunks containing procedural CPT codes (e.g., chunk 72), behavioral/clinical codes (chunk 162), and G-codes (chunk 234) all demonstrate the same 'Modifier = .' pattern.

No specific modifier values providedThe excerpted addendum does not specify actual modifier letters/numbers in these listings; the dot functions as the shown placeholder.

Modifier notation (placeholder format)

Literal placeholder formatThe document uses the literal string 'Modifier = .' immediately after each code (for example: '24358, Modifier = .' and 'G9147, Modifier = .').

Applies to CPT, HCPCS and G-codesThe 'Modifier = .' notation appears across CPT procedure code sequences and HCPCS code groups (including G-codes), indicating a consistent placeholder convention in the addendum.

Provider action impliedProviders should supply the appropriate modifier on claims where applicable; the addendum listing itself shows only the placeholder rather than the modifier value.

Modifier placeholder and listed codes

Specific codes called out in briefThe brief and source explicitly include codes 0002A and 00100 among the CPT entries and indicate multiple CPT codes across the listing (e.g., 24358, 36570, 90882, G9147) each followed by 'Modifier = .'.

Multiple CPT codes presentThe addendum enumerates hundreds of CPT/HCPCS codes across chunks; examples in the extract include 24358, 36570, 74251, 83497, 90882 and many others, all with 'Modifier = .' placeholders.

Modifier field represented as dotAcross the excerpt the modifier field is shown as a single dot ('.') after 'Modifier =', representing an unspecified/placeholder modifier value in the published table.

Billing and Provider Notes

Note

Code appendix only — no provider action instructions

This section is a code appendix that lists CPT, HCPCS, dental (D-), DME (E-), J-, K- and L- codes with an associated modifier placeholder shown as 'Modifier = .'. No prior authorization, step therapy, denial-risk, documentation, or billing action instructions are provided in these chunks — the content is strictly a code/modifier listing for Iowa Medicaid Addendum B (Updated October 1, 2021).

Billing Rule

Procedure code list — modifier placeholders present

Enumerated CPT/HCPCS procedure codes are listed with each entry followed by 'Modifier = .' indicating a modifier field applies but the specific modifier value is shown as a placeholder; the listing does not include authorization, documentation, billing-rule, or step-therapy instructions.

Examples shown: 0648T, 10004, 10010 (each followed by 'Modifier = .').
'Modifier = .' is used repeatedly to indicate a modifier placeholder for the listed codes.

Billing Rule

Procedure code listing — no authorization guidance

This fragment continues the enumerated procedure-code listing where each code is followed by 'Modifier = .' — there are no prior authorization, documentation, denial-risk, billing-rule, or step-therapy directives included in this excerpt.

Examples shown: 24358, 25020, 25315 (each followed by 'Modifier = .').
'Modifier = .' denotes a placeholder for a modifier value in the addendum listing.

Billing Rule

Procedure codes and modifiers (partial)

A partial list of CPT/procedure codes is provided with each code annotated 'Modifier = .' to indicate an associated modifier field; the fragment does not specify which modifier(s) apply or any provider billing or authorization actions.

Examples shown: 3021F, 30300, 36570, 37182 (each followed by 'Modifier = .').

Billing Rule

Procedure codes and modifiers (continuation)

This continuation lists CPT procedure codes with the literal placeholder 'Modifier = .' after each code; no instructions on modifier values, prior authorization, documentation, denial risk, or step therapy appear in this excerpt.

Examples shown: 37182, 37200, 37500 (each followed by 'Modifier = .').

Billing Rule

Procedure code/modifier list (continuation)

Sequential CPT procedure codes are listed with 'Modifier = .' placeholders indicating modifier applicability; this continuation does not include any prior authorization, documentation, denial-risk, billing-rule, or step-therapy directives.

Examples shown: 46916, 47542, 61458 (each followed by 'Modifier = .').

Billing Rule

Code appendix — modifier placeholders only

This code appendix fragment lists procedure codes with 'Modifier = .' placeholders to denote modifier fields; the fragment contains no explicit prior authorization, documentation, denial-risk, billing-rule, or step-therapy instructions.

Examples shown: 74251, 83497 (each followed by 'Modifier = .').

Billing Rule

Procedure code list excerpt — modifier marker only

Enumerated CPT/HCPCS procedure codes in this excerpt each include the notation 'Modifier = .' indicating a modifier field is associated; no authorization, documentation, billing-rule, denial-risk, or step-therapy guidance is provided here.

Examples shown: 83500, 88300 (each followed by 'Modifier = .').

Billing Rule

Code modifier list (partial) — no action guidance

This fragment enumerates CPT/HCPCS codes each followed by 'Modifier = .' to indicate modifier applicability; the listing does not include any provider-required actions such as prior authorization, documentation, denial-risk, billing rules, or step therapy.

Examples shown: 90882, 91301, 92002 (each followed by 'Modifier = .').

Billing Rule

HCPCS A-code list — modifier placeholders

This sequence lists HCPCS A-codes and other HCPCS procedure codes with 'Modifier = .' markers; the excerpt is for code reference only and does not state any authorization, documentation, denial-risk, billing rule, or step therapy requirements.

Examples shown: A0225, A0380, A9280 (each followed by 'Modifier = .').

Billing Rule

Dental codes — modifier placeholders (partial)

Dental procedure (D) codes are listed with 'Modifier = .' placeholders indicating where modifier values belong on claims; no coverage or prior authorization instructions are contained in this fragment.

Examples shown: D0351, D0701 (each followed by 'Modifier = .').
The document includes a copyright notice for dental codes (see chunk 0).

Billing Rule

DME codes — modifier placeholders

Durable medical equipment (E) codes are enumerated with 'Modifier = .' shown after each code to indicate an associated modifier field; the fragment contains no provider action instructions such as prior authorization, documentation, denial-risk, or step therapy.

Examples shown: E0105, E0955 (each followed by 'Modifier = .').

Billing Rule

HCPCS E- and G- codes — modifier notation

HCPCS E- and G- codes are listed with a repeated 'Modifier = .' notation for each code, indicating modifier placeholders; this excerpt provides coding reference only and does not specify modifier values or any provider billing or authorization actions.

Examples shown: E0955, G9290 (each followed by 'Modifier = .').

Billing Rule

J-code modifier listing (partial)

HCPCS J-codes are listed with 'Modifier = .' annotations indicating modifier placeholders; no authorization, documentation, denial-risk, billing rules, or step-therapy instructions accompany this list in the excerpt.

Examples shown: J0121, J3301 (each followed by 'Modifier = .').

Billing Rule

K-code modifier listing (partial)

K-codes are enumerated with the literal placeholder 'Modifier = .' after each code to denote an associated modifier field; this fragment does not provide specific modifier values or any prior authorization, documentation, or step-therapy guidance.

Examples shown: K0017, K0884 (each followed by 'Modifier = .').
K-code groups appear across chunks 259–261 with repeated modifier placeholders.

Billing Rule

L-code modifier listing (partial)

L-codes are presented with 'Modifier = .' placeholders indicating a modifier field should be reported on claims; the excerpt provides no further billing rules, prior authorization, documentation, denial-risk, or step-therapy instructions.

Examples shown: L0112, L0120 (each followed by 'Modifier = .').

Documentation Required

Modifier notation — 'Modifier = .' placeholder

The listing uses the literal notation 'Modifier = .' consistently to show that a modifier field is associated with each listed code; the document extract does not define the dot beyond indicating it is a placeholder and does not provide the actual modifier values in this fragment.

'Modifier = .' appears repeatedly across the addendum code listings to denote a modifier placeholder.
No specific modifier values are provided in the shown excerpts; the dot is a placeholder in the table.

Note

Modifier and Copyright Notices

inv-53: Copyright notices

Document identificationIowa Medicaid Calendar Year (CY) 2021 Addendum B — Updated for October 1, 2021.

inv-54: Modifier = .

Notation definition'Modifier = .' indicates the modifier field is shown as a literal dot in the table for codes in this listing segment.

Example codesExamples include 0648T, Modifier = . and 10004, Modifier = . in the enumerated list.

Coverage contextThis excerpt lists codes with the placeholder modifier notation; it does not define coverage or acceptable modifier values.

inv-55: Modifier = .

Placeholder usage'Modifier = .' is used as a placeholder after procedure codes to indicate an associated modifier field without specifying the modifier value in this extract.

Example clusterEntries such as '24358, Modifier = .' and neighboring codes in the same chunk follow this pattern.

Provider noteRefer to the complete addendum or payer billing guidance for the required modifier values when submitting claims.

inv-56: Modifier placeholder

Repeated placeholder'Modifier = .' appears repeatedly across multiple chunks, indicating a consistent placeholder convention where specific modifiers are not provided in this excerpt.

Examples across chunksSee codes in chunks 54 and 73 (e.g., 3021F, Modifier = . ; 37182, Modifier = .) showing the same placeholder pattern.

Implication for billingClaims requiring modifiers should reference the full policy to determine the actual modifier values; this extract only signals modifier applicability.

inv-57: 'Modifier = .' indicates a modifier field is associated with the listed procedure code (specific modifier value not provided in this segment).

Association indicatedThe annotation 'Modifier = .' indicates a modifier field is associated with the listed procedure code; the specific modifier value is not provided in this segment.

Example entriesMultiple vascular and catheter-related codes (e.g., 36570, Modifier = .) are shown with this marker.

Next stepConsult the full addendum or Iowa Medicaid billing instructions for the specific modifier to use on claims.

inv-58: Modifier / Procedure code list

Modifier/procedure mappingThis segment functions as a modifier/procedure code list where each procedure code is followed by 'Modifier = .' to mark modifier applicability.

Example codesCodes in this chunk include 46916, Modifier = . and a series of biliary/gastrointestinal procedure codes with the same notation.

No coverage guidanceThe excerpt provides coding notation only and does not state coverage rules or modifier specifics.

inv-59: Modifier placeholder

Modifier placeholder reiteratedEntries of the form '<code>, Modifier = .' appear across this chunk, reiterating that modifier fields are present but unspecified in the extract.

Illustrative codesExamples include 74251, Modifier = . and 75774, Modifier = . in this sequence.

Documentation adviceFor specific modifier values required for claims, consult the complete addendum or payer billing guidelines.

inv-60: Modifier placeholder

Modifier placeholder useThe listing shows G-codes followed by 'Modifier = .' indicating a placeholder modifier field for each HCPCS G-code in this excerpt.

Example entriesG9147, Modifier = . ; G9148, Modifier = . ; G9149, Modifier = . are shown in sequence.

Action for claimsDetermine the appropriate modifier from the full policy or payer guidance prior to claim submission; the excerpt does not supply the modifier values.

inv-61: Code list / modifier applicability

Notation conventionAcross the G-code listings, 'Modifier = .' is used consistently after each code to denote the modifier field without specifying the modifier.

Series continuationChunk 235 continues the G-code sequence with the same placeholder pattern (e.g., G9290, Modifier = . through G9393, Modifier = .).

Provider instructionRefer to the complete addendum for explicit modifier assignments; this section only flags where modifiers apply.

inv-62: modifier notation

J-code modifier notationHCPCS J-codes in this excerpt are listed with 'Modifier = .' indicating a placeholder in the modifier field for each J-code.

ExamplesJ3301, Modifier = . ; J3302, Modifier = . ; J3303, Modifier = . are shown as part of the J-code list.

Billing implicationSpecific modifiers for these J-codes are not provided here; consult the full addendum or payer guidance for correct modifier use.

inv-63: Modifier = .

Modifier placeholder repeatedMany CPT procedure entries in this chunk end with 'Modifier = .', signaling a modifier field is associated but unspecified in this excerpt.

Sample entriesCodes such as 61458, Modifier = . and 61500, Modifier = . illustrate the pattern.

Administrative noteThis listing is a code appendix portion of the addendum and does not define the dot or list specific modifier values within these chunks.

inv-64: Modifier placeholder

Modifier placeholder in lab codesLaboratory and related procedure codes (e.g., 83497, Modifier = . ; 83500, Modifier = .) are presented with the placeholder modifier notation.

Pattern consistencyThe 'Modifier = .' pattern persists across diverse code groups in this extract, including laboratory, vaccine, and ophthalmology codes.

Next step for accuracyConfirm required modifier values with the full policy table or billing instructions before submission.

inv-65: HCPCS code list / modifier notation

HCPCS E-code notationHCPCS E-codes in this excerpt are listed with 'Modifier = .' indicating a placeholder modifier field for each E-code entry.

ExamplesE0955, Modifier = . ; E0956, Modifier = . ; E0957, Modifier = . appear in the E-code sequence.

Provider actionUse the full addendum or Iowa Medicaid billing guidance to identify the specific modifier to apply when billing these E-codes.

inv-66: Modifier = .

G-code modifier placeholder'Modifier = .' is used repeatedly after G-codes in the listing, indicating placeholder modifier fields for each G-code.

Example sequenceG9147, Modifier = . through G9289, Modifier = . are included in the G-code list.

Claim submission noteThis excerpt does not supply explicit modifier values; confirm with the complete addendum for correct billing modifiers.

inv-67: Modifier = .

Document update dateUpdated for October 1, 2021 (Addendum B to Iowa Medicaid CY2021).

Copyright repetitionThe copyright statements for CPT and dental codes are repeated multiple times at the start of the document extract.

Rights noticeApplicable FARS/DFARS Apply as noted in the copyright statement.