List of HCPCS codes for: Private Payer Codes (S-codes) - Group S0

HCPCS Code	Short Description	Long Description
S0012	Butorphanol tartrate, nasal	Butorphanol tartrate, nasal spray, 25 mg
S0013	Esketamine, nasal spray	Esketamine, nasal spray, 1 mg
S0014	Tacrine hydrochloride, 10 mg	Tacrine hydrochloride, 10 mg
S0017	Injection, aminocaproic acid	Injection, aminocaproic acid, 5 grams
S0020	Injection, bupivicaine hydro	Injection, bupivicaine hydrochloride, 30 ml
S0021	Injection, cefoperazone sod	Injection, cefoperazone sodium, 1 gram
S0023	Injection, cimetidine hydroc	Injection, cimetidine hydrochloride, 300 mg
S0028	Injection, famotidine, 20 mg	Injection, famotidine, 20 mg
S0030	Injection, metronidazole	Injection, metronidazole, 500 mg
S0032	Injection, nafcillin sodium	Injection, nafcillin sodium, 2 grams
S0034	Injection, ofloxacin, 400 mg	Injection, ofloxacin, 400 mg
S0039	Injection, sulfamethoxazole	Injection, sulfamethoxazole and trimethoprim, 10 ml
S0040	Injection, ticarcillin disod	Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams
S0073	Injection, aztreonam, 500 mg	Injection, aztreonam, 500 mg
S0074	Injection, cefotetan disodiu	Injection, cefotetan disodium, 500 mg
S0077	Injection, clindamycin phosp	Injection, clindamycin phosphate, 300 mg
S0078	Injection, fosphenytoin sodi	Injection, fosphenytoin sodium, 750 mg
S0080	Injection, pentamidine iseth	Injection, pentamidine isethionate, 300 mg
S0081	Injection, piperacillin sodi	Injection, piperacillin sodium, 500 mg
S0088	Imatinib 100 mg	Imatinib, 100 mg
S0090	Sildenafil citrate, 25 mg	Sildenafil citrate, 25 mg
S0091	Granisetron 1mg	Granisetron hydrochloride, 1 mg (for circumstances falling under the medicare statute, use q0166)
S0092	Hydromorphone 250 mg	Injection, hydromorphone hydrochloride, 250 mg (loading dose for infusion pump)
S0093	Morphine 500 mg	Injection, morphine sulfate, 500 mg (loading dose for infusion pump)
S0104	Zidovudine, oral, 100 mg	Zidovudine, oral, 100 mg
S0106	Bupropion hcl sr 60 tablets	Bupropion hcl sustained release tablet, 150 mg, per bottle of 60 tablets
S0108	Mercaptopurine 50 mg	Mercaptopurine, oral, 50 mg
S0109	Methadone oral 5mg	Methadone, oral, 5 mg
S0117	Tretinoin topical 5 g	Tretinoin, topical, 5 grams
S0119	Ondansetron 4 mg	Ondansetron, oral, 4 mg (for circumstances falling under the medicare statute, use hcpcs q code)
S0122	Inj menotropins 75 iu	Injection, menotropins, 75 iu
S0126	Inj follitropin alfa 75 iu	Injection, follitropin alfa, 75 iu
S0128	Inj follitropin beta 75 iu	Injection, follitropin beta, 75 iu
S0132	Inj ganirelix acetat 250 mcg	Injection, ganirelix acetate, 250 mcg
S0136	Clozapine, 25 mg	Clozapine, 25 mg
S0137	Didanosine, 25 mg	Didanosine (ddi), 25 mg
S0138	Finasteride, 5 mg	Finasteride, 5 mg
S0139	Minoxidil, 10 mg	Minoxidil, 10 mg
S0140	Saquinavir, 200 mg	Saquinavir, 200 mg
S0142	Colistimethate inh sol mg	Colistimethate sodium, inhalation solution administered through dme, concentrated form, per mg
S0144	Inj, propofol, 10 mg	Injection, propofol, 10 mg
S0145	Peg interferon alfa-2a/180	Injection, pegylated interferon alfa-2a, 180 mcg per ml
S0148	Peg interferon alfa-2b/10	Injection, pegylated interferon alfa-2b, 10 mcg
S0155	Epoprostenol dilutant	Sterile dilutant for epoprostenol, 50 ml
S0156	Exemestane, 25 mg	Exemestane, 25 mg
S0157	Becaplermin gel 1%, 0.5 gm	Becaplermin gel 0.01%, 0.5 gm
S0160	Dextroamphetamine	Dextroamphetamine sulfate, 5 mg
S0164	Injection pantroprazole	Injection, pantoprazole sodium, 40 mg
S0166	Inj olanzapine 2.5mg	Injection, olanzapine, 2.5 mg
S0169	Calcitrol	Calcitrol, 0.25 microgram
S0170	Anastrozole 1 mg	Anastrozole, oral, 1 mg
S0171	Bumetanide 0.5 mg	Injection, bumetanide, 0.5 mg
S0172	Chlorambucil 2 mg	Chlorambucil, oral, 2 mg
S0174	Dolasetron 50 mg	Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)
S0175	Flutamide 125 mg	Flutamide, oral, 125 mg
S0176	Hydroxyurea 500 mg	Hydroxyurea, oral, 500 mg
S0177	Levamisole 50 mg	Levamisole hydrochloride, oral, 50 mg
S0178	Lomustine 10 mg	Lomustine, oral, 10 mg
S0179	Megestrol 20 mg	Megestrol acetate, oral, 20 mg
S0182	Procarbazine, oral	Procarbazine hydrochloride, oral, 50 mg
S0183	Prochlorperazine 5 mg	Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)
S0187	Tamoxifen 10 mg	Tamoxifen citrate, oral, 10 mg
S0189	Testosterone pellet 75 mg	Testosterone pellet, 75 mg
S0190	Mifepristone, oral, 200 mg	Mifepristone, oral, 200 mg
S0191	Misoprostol, oral, 200 mcg	Misoprostol, oral, 200 mcg
S0194	Vitamin suppl 100 caps	Dialysis/stress vitamin supplement, oral, 100 capsules
S0195	Pneumo vaccine 5-9 yrs	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	Prenatal vitamins, 30-day supply
S0199	Med abortion inc all ex drug	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 serv	Partial hospitalization services, less than 24 hours, per diem
S0207	Paramedicintercep nonhospals	Paramedic intercept, non-hospital-based als service (non-voluntary), non-transport
S0208	Paramed intrcept nonvol	Paramedic intercept, hospital-based als service (non-voluntary), non-transport
S0209	Wc van mileage per mi	Wheelchair van, mileage, per mile
S0215	Nonemerg transp mileage	Non-emergency transportation; mileage, per mile
S0220	Medical conference by physic	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, 60 min	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	Comp geriatr assmt team	Comprehensive geriatric assessment and treatment planning performed by assessment team
S0255	Hospice refer visit nonmd	Hospice referral visit (advising patient and family of care options) performed by nurse, social worker, or other designated staff
S0257	End of life counseling	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	H&p for surgery	History and physical (outpatient or office) related to surgical procedure (list separately in addition to code for appropriate evaluation and management service)
S0265	Genetic counsel 15 mins	Genetic counseling, under physician supervision, each 15 minutes
S0270	Home std case rate 30 days	Physician management of patient home care, standard monthly case rate (per 30 days)
S0271	Home hospice case 30 days	Physician management of patient home care, hospice monthly case rate (per 30 days)
S0272	Home episodic case 30 days	Physician management of patient home care, episodic care monthly case rate (per 30 days)
S0273	Md home visit outside cap	Physician visit at member's home, outside of a capitation arrangement
S0274	Nurse practr visit outs cap	Nurse practitioner visit at member's home, outside of a capitation arrangement
S0280	Medical home, initial plan	Medical home program, comprehensive care coordination and planning, initial plan
S0281	Medical home, maintenance	Medical home program, comprehensive care coordination and planning, maintenance of plan
S0285	Cnslt before screen colonosc	Colonoscopy consultation performed prior to a screening colonoscopy procedure
S0302	Completed epsdt	Completed early periodic screening diagnosis and treatment (epsdt) service (list in addition to code for appropriate evaluation and management service)
S0310	Hospitalist visit	Hospitalist services (list separately in addition to code for appropriate evaluation and management service)
S0311	Comp mgmt care coord adv ill	Comprehensive management and care coordination for advanced illness, per calendar month
S0315	Disease management program	Disease management program; initial assessment and initiation of the program
S0316	Follow-up/reassessment	Disease management program, follow-up/reassessment
S0317	Disease mgmt per diem	Disease management program; per diem
S0320	Rn telephone calls to dmp	Telephone calls by a registered nurse to a disease management program member for monitoring purposes; per month
S0340	Lifestyle mod 1st stage	Lifestyle modification program for management of coronary artery disease, including all supportive services; first quarter / stage
S0341	Lifestyle mod 2 or 3 stage	Lifestyle modification program for management of coronary artery disease, including all supportive services; second or third quarter / stage
S0342	Lifestyle mod 4th stage	Lifestyle modification program for management of coronary artery disease, including all supportive services; fourth quarter / stage
S0353	Cancer treatmentplan initial	Treatment planning and care coordination management for cancer, initial treatment
S0354	Cancer treatment plan change	Treatment planning and care coordination management for cancer, established patient with a change of regimen
S0390	Rout foot care per visit	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 ft	Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic
S0400	Global eswl kidney	Global fee for extracorporeal shock wave lithotripsy treatment of kidney stone(s)
S0500	Dispos cont lens	Disposable contact lens, per lens
S0504	Singl prscrp lens	Single vision prescription lens (safety, athletic, or sunglass), per lens
S0506	Bifoc prscp lens	Bifocal vision prescription lens (safety, athletic, or sunglass), per lens
S0508	Trifoc prscrp lens	Trifocal vision prescription lens (safety, athletic, or sunglass), per lens
S0510	Non-prscrp lens	Non-prescription lens (safety, athletic, or sunglass), per lens
S0512	Daily cont lens	Daily wear specialty contact lens, per lens
S0514	Color cont lens	Color contact lens, per lens
S0515	Scleral lens liquid bandage	Scleral lens, liquid bandage device, per lens
S0516	Safety frames	Safety eyeglass frames
S0518	Sunglass frames	Sunglasses frames
S0580	Polycarb lens	Polycarbonate lens (list this code in addition to the basic code for the lens)
S0581	Nonstnd lens	Nonstandard lens (list this code in addition to the basic code for the lens)
S0590	Misc integral lens serv	Integral lens service, miscellaneous services reported separately
S0592	Comp cont lens eval	Comprehensive contact lens evaluation
S0595	New lenses in pts old frame	Dispensing new spectacle lenses for patient supplied frame
S0596	Phakic iol refractive error	Phakic intraocular lens for correction of refractive error
S0601	Screening proctoscopy	Screening proctoscopy
S0610	Annual gynecological examina	Annual gynecological examination, new patient
S0612	Annual gynecological examina	Annual gynecological examination, established patient
S0613	Ann breast exam	Annual gynecological examination; clinical breast examination without pelvic evaluation
S0618	Audiometry for hearing aid	Audiometry for hearing aid evaluation to determine the level and degree of hearing loss
S0620	Routine ophthalmological exa	Routine ophthalmological examination including refraction; new patient
S0621	Routine ophthalmological exa	Routine ophthalmological examination including refraction; established patient
S0622	Phys exam for college	Physical exam for college, new or established patient (list separately in addition to appropriate evaluation and management code)
S0630	Removal of sutures	Removal of sutures; by a physician other than the physician who originally closed the wound
S0800	Laser in situ keratomileusis	Laser in situ keratomileusis (lasik)
S0810	Photorefractive keratectomy	Photorefractive keratectomy (prk)
S0812	Phototherap keratect	Phototherapeutic keratectomy (ptk)