Chapter 8: Billing Instructions

Transcription

I N D I A N A
H E A L T H
C O V E R A G E
P R O G R A M S
P R O V I D E R
M A N U A L
Chapter 8:
Billing Instructions
Library Reference Number: PRPR10004
8-1
Published: January 23, 2014 (as amended 4/1/14)
Policies and Procedures as of September 1, 2013 (amended to include CMS-1500 Version 02/12 claim form revisions effective 4/1/14)
Version: 13.2
Chapter 8
Indiana Health Coverage Programs Provider Manual
Current Dental Terminology (CDT) is copyrighted by the American Dental Association. 2012 American Dental Association. All rights
reserved.
Current Procedural Terminology (CPT) is copyright 2012 American Medical Association. All rights reserved. CPT® is a registered
trademark of the American Medical Association.
8-2
Version: 13.2
Chapter 8
Chapter 8: Revision History
Version
Date
Reason for Revisions
Completed By
1.0
September 1999
Policies and procedures are
current as of March 1, 1999
New Manual
EDS Document
Management Unit
2.0
June 2001
current as of June 1, 2000
Chapters 1, 2, 3, 6, 7, 8, 9, 10, 13, 14, and
Appendix A
EDS Document
Management Unit
3.0
April 2002
current as of August 1, 2001
All Chapters
EDS Client
Services and
EDS Publications
Unit
4.0
April 2003
current as of April 1, 2002
All Chapters
EDS Client
Services Unit
5.0
July 2004
current as of January 1, 2004
All Chapters
EDS Client
Services Unit
5.1
February 2005
current as of January 1, 2005
All Chapters
EDS Publications
Unit
6.0
December 2006
current as of April 1, 2006
All Chapters
EDS Publications
Unit
Quarterly Update
EDS Publications
Unit
7.0
7.1
October 2007
Policies and procedures as of
October 1, 2007
Semiannual Update
EDS Provider
Relations and
Publications Units
8.0
August 2008
May 1, 2008
Semiannual Update
EDS Provider
Relations and
Publications Units
8.1
February 2009
November 1, 2008
Semiannual Update
EDS Provider
Relations and
Publications Units
9.0
December 2009
May 1, 2009
Semiannual Update
EDS Provider
Relations and
Publications Units
9.1
April 22, 2010
November 1, 2009
Semiannual Update
HP Provider
Relations and
Publications Units
8-3
Version: 13.2
Chapter 8
Version
Date
Completed By
10.0
August 26, 2010
May 1, 2010
Semiannual Update
HP Provider
Relations and
Publications Units
10.1
January 11, 2011
November 1, 2010
Semiannual Update
HP Provider
Relations and
Publications Units
11.0
August 31, 2011
Published: December 29, 2011
Semiannual Update
HP Provider
Relations and
Publications Units
12.0
Policies and Procedures as of
February 1, 2012
Published: May 8, 2012
Semiannual Update
HP Provider
Relations and
Publications Units
13.0
August 9, 2012
Published: July 9, 2013
Semiannual Update
HP Provider
Relations and
Publications Units
13.1
September 1, 2013
Published: January 23, 2014
Semiannual Update
HP Provider
Relations and
Publications Units
•
Updated Introduction to Billing
Instructions: General Information
section
•
Updated Ordering Claim Forms section
•
Updated National Correct Coding
Initiative section
•
Updated National Drug Code Billing
section
•
Updated Companion Guides section
•
Updated Report Type Code section
•
Updated Use of ICD Procedure Codes
Restricted for UB-04 Billers section
•
Updated UB-04 Claim Form Locator
Descriptions table
•
Updated Home Health Reimbursement
section
•
Updated Hospital Discharge section
•
Updated Birthing Centers section
•
Removed Exempt Hospitals section
•
Updated Provider Preventable
Conditions section
•
Updated Leave Days section
•
Added Bariatric Age Restriction section
•
Updated Treatment Room Visits section
•
Updated Emergency Services section
8-4
Version: 13.2
Chapter 8
Version
Date
•
Updated Code Auditing Methodologies
for Hospitals section
•
Updated UB-04 Crossover and
Medicare Replacement Billing
Procedures section
•
Updated NCCI/Code Auditing
Explanation of Benefits Codes section
•
Removed Special Consideration for Edit
4181 section
•
Updated Ordering, Prescribing, and
Referring Providers section
•
Updated CMS-1500, Version 08-05
Claim Form Locator Descriptions table
•
Removed Waiver section (under
Modifiers)
•
Updated CMS-1500 Modifiers table
- Updated JE and K3 descriptions
•
Updated Package B section
•
Updated IHCP Members section
•
Updated Drug-Related Medical Supplies
and Medical Devices section
•
Updated Manually Priced Supplies,
DME, and HME section
•
Updated Ancillary and Therapy Billing
for LTC Facility Residents section
•
Updated Home Infusion – Parenteral
and Enteral Therapy Services section
•
Updated Humidifiers, Nonheated or
Heated section
•
Updated A4927 – Nonsterile Gloves, per
100 section
•
Updated Wheelchair – Seat Cushions
section
•
Updated Family Planning: Coverage
and Billing Procedures section
- Added S4993 code to CPT Codes for
Contraceptive Supplies table
- Updated Limits and Restrictions for
Depo-Provera Contraceptive
Injection section
•
Added Histrelin Implant (Supprelin LA)
section
Completed By
8-5
Version: 13.2
Chapter 8
Version
Date
•
Updated Injections: Coverage and
Billing Procedures section
•
Updated CPT Codes for
Chemodenervation for use with Botox
and Myobloc Injections table
•
Updated Compounds – Professional
Claim Types section
•
Updated CPT Codes for HER-2/neu
Gene Detection Test table
•
Updated Outpatient Mental Health
section
- Added code 90899
•
Updated Acute Partial Hospitalization
section
•
Updated Applicable Service Codes
section
•
Updated Limitations and Restrictions
section
•
Updated Psychiatric Residential
Treatment Facilities: Coverage
Provisions section
•
Updated Risk-based Managed Care
section
•
Updated Smoking Cessation Treatment
Services section
- Updated Reimbursement section
- Removed Pharmacy Providers and
Smoking Cessation Products sections
•
Updated Obstetrical Delivery and
Postpartum Care Billing section
•
Updated Coverage Criteria for 17P
Injections section
•
Updated Adoption of Modifiers for
Replacement Eyeglasses section
•
Updated Podiatric Services section
•
Updated School Corporation Services
section
•
Updated MRT CPT Procedure Codes
table
- Replaced S0201 with H0035
•
Updated Dental Extractions section
•
Removed Dental Cap section
Completed By
8-6
Version: 13.2
Chapter 8
Version
13.2
Date
September 1, 2013
Published: January 23, 2014
Special Update 4/1/14
•
Removed Spend-down and the Dental
Cap section
•
Updated Spend-down and Benefit Limits
section
•
Removed Dental Cap for Dentures,
Relines, and Repairs section
•
Updated Periodontal Root Planing and
Scaling section
•
Updated Billing a Member for
Noncovered Services section
•
Updated Multiple Restorations
Reimbursement section
•
Updated Home and Community-Based
Services Waiver Billing Guidelines
section
•
Updated Oral and Injectable
Contraceptives section
•
Updated Limitations section
•
Updated Consent for Sterilization Form
Instructions section
•
Updated Description of Fields on the
CMS-1500 Claim Form section
- Removed CMS-1500 claim form and
completion instructions for Version
08/05
- Replaced with claim form and
completion instruction for new CMS1500, Version 02/12, effective for all
claims received on or after April 1,
2014
Completed By
8-7
Version: 13.2
Chapter 8
Table of Contents
Chapter 8: Revision History .......................................................................... 8-3
Table of Contents ............................................................................................ 8-8
Section 1: Introduction to Billing Instructions ........................................... 8-19
General Information ................................................................................... 8-19
Ordering Claim Forms................................................................................ 8-20
National Provider Identifier and One-to-One Match .................................. 8-20
National Correct Coding Initiative ............................................................. 8-21
Claims Submitted via Web interChange ................................................ 8-22
Types of Services Billed on Each Claim Form .......................................... 8-22
Diagnosis Codes ......................................................................................... 8-24
Modifiers ................................................................................................ 8-24
National Drug Code Billing ................................................................... 8-25
Procedure Code Partial Units ................................................................. 8-25
Date of Service Definition ..................................................................... 8-25
Electronic Standards ................................................................................... 8-25
Companion Guides ................................................................................. 8-26
Paper Attachment Requirements ................................................................ 8-26
Paper Attachments with Electronic Claims ............................................ 8-26
Report Type Code .................................................................................. 8-27
Claim Notes ................................................................................................ 8-29
Number of Details ...................................................................................... 8-29
Section 2: UB-04 Billing Instructions .......................................................... 8-31
Providers Using the UB-04 Claim Form .................................................... 8-31
Using Modifiers for Outpatient Hospital Billing ................................... 8-31
Billing a Continuation Claim Using the UB-04 Claim Form ................. 8-32
Ordering, Prescribing, and Referring Physician Billing Requirements ...... 8-32
Claims Processing Changes To Be Implemented................................... 8-32
Use of ICD Procedure Codes Restricted for UB-04 Billers........................ 8-33
UB-04 Claim Form Requirements .............................................................. 8-33
Description of Fields on the UB-04 Claim Form ................................... 8-33
Diagnostic and Therapeutic Codes Not Reimbursable ........................... 8-60
Single Procedure Code with Multiple NDCs ......................................... 8-61
Compounds – Outpatient/Outpatient Crossover..................................... 8-61
Birthing Centers ......................................................................................... 8-61
Home Health Services ................................................................................ 8-62
Coverage ................................................................................................ 8-62
Billing Procedures .................................................................................. 8-62
Unit of Service ....................................................................................... 8-63
Overhead Rate ........................................................................................ 8-63
Home Health Reimbursement ................................................................ 8-64
Registered Nurse Delegation to Home Health Aides ............................. 8-64
Multiple Visit Billing ............................................................................. 8-64
Partial Units of Service .......................................................................... 8-65
Hospital Discharge ................................................................................. 8-65
Hospice Care Coverage .............................................................................. 8-69
Revenue Codes....................................................................................... 8-69
Physician Services under Revenue Codes 651 through 655 .................. 8-73
Physician Services under Revenue Code 657 ........................................ 8-73
8-8
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Table of Contents
Prior-Authorized Physician Services ..................................................... 8-74
Hospice Contracts with Other Entities for Hospice-related Services ..... 8-74
Volunteer Physician Services ................................................................. 8-74
Emergency Services ............................................................................... 8-74
Concurrent Hospice and Curative Care Services for Children ............... 8-74
Billing the Programs as the Payer of Last Resort ................................... 8-75
Medicare and Traditional Medicaid Eligibility Changes during the Month8-76
IHCP-Only – Hospice Member Who Becomes Medicare-Eligible in
Nursing Facility ..................................................................................... 8-76
Dually Eligible Medicare/Traditional Medicaid – Member in a Nursing
Facility Who Becomes IHCP-Only ........................................................ 8-77
Billing a Continuation Claim Using the UB-04 Claim Form ................. 8-77
Hospice Provider Reimbursement Terms .............................................. 8-77
Inpatient Hospital Services ......................................................................... 8-79
Coverage ................................................................................................ 8-79
Prior Authorization for Elective Hospital Inpatient Admissions ........... 8-79
Unit and Age Limitations on Inpatient Neonatal and Pediatric Critical Care
Services ...................................................................................................... 8-90
Stereotactic Radiosurgery........................................................................... 8-91
Ventricular Assist Devices ......................................................................... 8-91
Noncovered Services .............................................................................. 8-92
Prior Authorization ................................................................................ 8-92
Coding and Billing Instructions ............................................................. 8-92
Long-Term Acute Care Facility Services ................................................... 8-94
Long-Term Acute Care Facilities ........................................................... 8-94
Package C............................................................................................... 8-94
Nursing Facility Services ........................................................................... 8-94
Coverage ................................................................................................ 8-94
Member Liability ................................................................................... 8-95
Leave Days............................................................................................. 8-95
Autoclosure Billing ................................................................................ 8-96
Medicare Crossover Payment Policy ..................................................... 8-97
Nursing Facilities Not Medicare-Certified ............................................. 8-97
Intermediate Care Facility for Individuals with Intellectual Disability Services8-98
Type of Bill ............................................................................................ 8-98
Leave Days............................................................................................. 8-98
Outpatient Services .................................................................................... 8-99
Coverage ................................................................................................ 8-99
Billing Procedures ................................................................................ 8-100
Package B Billing ..................................................................................... 8-100
Notification of Pregnancy Billing ............................................................ 8-101
Outpatient Surgeries ................................................................................. 8-101
Surgical Revenue Codes ........................................................................... 8-101
Implantable DME ..................................................................................... 8-103
Corneal Tissue .......................................................................................... 8-104
Pacemakers ............................................................................................... 8-104
Implantable Cardioverter Defibrillators ................................................... 8-104
Prior authorization................................................................................ 8-104
Covered indications.............................................................................. 8-104
Implantable Cardioverter Defibrillators for Pediatric Members and
Members with Congenital Heart Disease ............................................. 8-106
Billing instructions ............................................................................... 8-108
8-9
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Table of Contents
Phrenic Nerve Stimulator (Breathing Pacemaker) ................................... 8-109
Prior Authorization .............................................................................. 8-109
Coding and Billing Instructions ........................................................... 8-109
Coverage Issues ................................................................................... 8-110
Device Monitoring ............................................................................... 8-111
Spinal Cord Stimulators ........................................................................... 8-111
Spinal Cord Stimulation Prior Authorization Criteria .......................... 8-111
Three- to Seven-Day Trial Stimulation Period..................................... 8-112
Permanent SCS Implantation ............................................................... 8-112
Intractable Angina ................................................................................ 8-115
Billing Requirements ........................................................................... 8-116
Patient-Activated Event Recorder – Implantable Loop Recorder ............ 8-116
Coverage .............................................................................................. 8-116
Reimbursement and Billing Instructions .............................................. 8-117
Device Monitoring ............................................................................... 8-118
Coverage Criteria ................................................................................. 8-118
Intraocular Lenses .................................................................................... 8-118
NeuroCybernetic Prosthesis System – Vagus Nerve Stimulator .............. 8-119
Coverage Criteria for the NCP System ................................................ 8-119
Diagnosis and Procedure Codes ........................................................... 8-119
Physician Billing Instructions .............................................................. 8-121
Bariatric Age Restriction .......................................................................... 8-122
Treatment Room Visits ............................................................................ 8-123
Emergency Services ................................................................................. 8-123
Add-on Services ....................................................................................... 8-124
Stand-alone Services ................................................................................ 8-126
Stand-alone Laboratory Services .............................................................. 8-128
Billing and Coverage Policies Low Osmolar Contrast Materials ............. 8-128
Code Auditing Methodologies for Hospitals ....................................... 8-129
Stand-alone Radiology Services ............................................................... 8-129
Stand-alone Chemotherapy and Radiation Services ................................. 8-129
Stand-alone Renal Dialysis Services ........................................................ 8-130
Composite Rate for Method I Dialysis ................................................. 8-130
Billing Guidelines ................................................................................ 8-131
Type of Bill Codes ............................................................................... 8-132
Diagnosis Codes................................................................................... 8-132
Revenue Codes..................................................................................... 8-132
Transportation Services ............................................................................ 8-133
Outpatient Mental Health ......................................................................... 8-134
Partial Units of Service ........................................................................ 8-135
Filing UB-04 Crossover Claims ............................................................... 8-135
Processing Crossover Claims ............................................................... 8-135
Attachments for UB-04 Paper Claims or 837I Transaction Submissions8-136
UB-04 Crossover and Medicare Replacement Billing Procedures ...... 8-136
Billing Medicare Denied Services ............................................................ 8-137
837I Electronic Transaction ..................................................................... 8-138
Companion Guides ............................................................................... 8-138
Diagnosis Codes................................................................................... 8-138
Additional UB-04 and 837I Admission and Duration Changes ........... 8-138
Section 3: Telemedicine .............................................................................. 8-139
Overview .................................................................................................. 8-139
Definitions ................................................................................................ 8-139
Provider or Service Requirements ............................................................ 8-139
8-10
Version: 13.2
Chapter 8
Table of Contents
Conditions of Payment ............................................................................. 8-140
Hub Site Services and Billing Requirements ........................................... 8-140
Spoke Site Services and Billing Requirements ........................................ 8-141
Documentation Standards......................................................................... 8-141
Special Considerations ............................................................................. 8-141
Managed Care Considerations .................................................................. 8-142
Section 4: CMS-1500 and 837P Transaction Billing Instructions .......... 8-143
Introduction .............................................................................................. 8-143
Providers Using the CMS-1500 Claim Form or the 837P Transaction ..... 8-143
General Information ................................................................................. 8-144
Claims Submission Addresses ............................................................. 8-145
National Correct Coding Initiative ........................................................... 8-145
Claims Processing and Mass Adjustments ........................................... 8-145
Code Auditing Methodologies for Physicians...................................... 8-145
NCCI/Code Auditing Explanation of Benefits Codes .......................... 8-146
NCCI Column I/Column II Edits ......................................................... 8-148
Mutually Exclusive (ME) Edits ........................................................... 8-148
Medical Unlikely Edits (MUE) ............................................................ 8-149
Ordering, Prescribing, and Referring Providers ....................................... 8-149
CMS-1500 Paper Claim Form Requirements ........................................... 8-149
Billing and Rendering Provider Numbers ............................................ 8-149
Description of Fields on the CMS-1500 Claim Form .......................... 8-150
837P Electronic Transaction .................................................................... 8-157
Diagnosis Codes................................................................................... 8-157
Modifiers .................................................................................................. 8-157
Use of Modifiers .................................................................................. 8-158
Using Modifiers with Pathology Codes ............................................... 8-159
Place of Service Codes ............................................................................. 8-179
U Modifiers .............................................................................................. 8-181
Use of Span Dates on the CMS-1500 Claim Form .............................. 8-181
Substitute Physicians and Locum Tenens ................................................. 8-181
Substitute Physicians............................................................................ 8-181
Locum Tenens Physicians .................................................................... 8-182
Translation Services in Care Select .......................................................... 8-182
Anesthesia Services .................................................................................. 8-182
Coverage and Billing Procedures ......................................................... 8-182
Care Coordination Services ...................................................................... 8-194
Chiropractic Services ............................................................................... 8-194
Comprehensive Outpatient Rehabilitation Facility .................................. 8-205
Billing .................................................................................................. 8-206
Diabetes Self-Care Management Training Services ................................. 8-206
Practitioners Eligible to Provide Services ............................................ 8-206
Procedure Codes and Units of Service ................................................. 8-208
Diabetic Test Strips .............................................................................. 8-208
Drug-Related Medical Supplies and Medical Devices ......................... 8-210
Durable Medical Equipment and Home Medical Equipment ................... 8-212
Casting Supplies................................................................................... 8-226
Continuous Passive Motion – Continuous Passive Motion Device ..... 8-227
Cranial Remolding Orthosis ................................................................. 8-227
Home Infusion – Parenteral and Enteral Therapy Services .................. 8-228
8-11
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Table of Contents
Home Infusion – Parenteral and Enteral Nutrition Pumps ................... 8-229
Clarification on Billing Food Thickener, HCPCS Code B4100 ........... 8-230
Humidifiers, Nonheated or Heated ...................................................... 8-230
Incontinence, Ostomy, and Urological Mail Order Supplies ............... 8-231
A4927 – Nonsterile Gloves, per 100 .................................................... 8-234
A4930 – Gloves, Sterile, per Pair......................................................... 8-234
General Guidelines Applicable to Nonsterile and Sterile Gloves ........ 8-234
Orthopedic or Therapeutic Footwear ................................................... 8-235
Osteogenic Bone Growth Stimulators .................................................. 8-236
Oximetry .............................................................................................. 8-236
Oxygen and Home Oxygen Equipment ............................................... 8-237
Oxygen – Portable Systems ................................................................. 8-240
Nebulizer with Compressor.................................................................. 8-240
Phototherapy (Bilirubin Light) ............................................................. 8-240
Pneumograms ....................................................................................... 8-240
Prosthetic Devices ................................................................................ 8-241
ThAIRapy Vest™ ................................................................................ 8-241
Trend Event Monitoring and Apnea Monitors ..................................... 8-241
Ventricular Assist Devices ................................................................... 8-242
Wheelchairs – Motorized ..................................................................... 8-244
Wheelchairs – Nonmotorized ............................................................... 8-245
Wheelchair – Power Seating ................................................................ 8-245
Wheelchair – Seat Cushions................................................................. 8-245
Wheelchair Accessories ....................................................................... 8-245
Documentation Required for Medical Supplies and Equipment .......... 8-246
Emergency Department Physicians .......................................................... 8-247
Evaluation and Management Services ...................................................... 8-248
Consultations ............................................................................................ 8-249
Office Consultation .............................................................................. 8-249
Inpatient Consultation .......................................................................... 8-250
Hospital Observation or Inpatient Care Services ................................. 8-250
Family Planning ....................................................................................... 8-252
Managed Care Program Considerations ............................................... 8-254
Family Planning Services – New Eligibility Program ......................... 8-254
Federally Qualified Health Centers and Rural Health Clinics .................. 8-254
Federally Qualified Health Centers ...................................................... 8-254
Rural Health Clinics ............................................................................. 8-255
Service Coverage ................................................................................. 8-255
FQHC and RHC Covered Services ...................................................... 8-255
Service Definition ................................................................................ 8-258
HealthWatch/EPSDT Services ................................................................. 8-259
Examination Procedure and Diagnosis Codes...................................... 8-259
Managed Care Considerations ............................................................. 8-261
Histrelin Implant (Supprelin LA) ............................................................. 8-261
Description of Service .......................................................................... 8-261
Reimbursement Requirements ............................................................. 8-262
Prior Authorization Requirements ....................................................... 8-262
Billing Requirements ........................................................................... 8-262
Hearing Aids ............................................................................................ 8-263
8-12
Version: 13.2
Chapter 8
Table of Contents
Hearing Aid Purchase .......................................................................... 8-263
Hearing Aid Reimbursement................................................................ 8-263
Hearing Aid Dispensing Fee ................................................................ 8-264
Maintenance and Repair ....................................................................... 8-264
Replacement ......................................................................................... 8-265
Audiology Services .............................................................................. 8-265
Augmentative Communication Devices ................................................... 8-266
Reimbursement .................................................................................... 8-266
Authorization ....................................................................................... 8-267
Trial Period .......................................................................................... 8-267
Rental versus Purchase ......................................................................... 8-267
Repair and Replacement ...................................................................... 8-268
Rehabilitation Engineering................................................................... 8-268
Pneumatic Artificial Voicing Systems ..................................................... 8-268
Purchase ............................................................................................... 8-268
Home and Community-Based Services Waiver Programs ....................... 8-268
Attendant Care Services, Respite Home Health Aide Services, and Medicaid
Prior Authorization for Home Health Aide Services ................................ 8-269
Injections .................................................................................................. 8-272
Compounds – Professional Claim Types ............................................. 8-275
Botulinum Toxin Coverage and Billing Procedures ............................ 8-275
Vaccines for Children Program ............................................................ 8-277
Laboratory Services .................................................................................. 8-277
Clinical Diagnostic Laboratory Procedures ......................................... 8-278
Professional and Technical Components ............................................. 8-280
Hospital Outpatient Defined ................................................................ 8-280
Independent Diagnostic Testing Facility.............................................. 8-280
Specimen Collection ............................................................................ 8-280
Handling Conveyance .......................................................................... 8-281
Lab Panels ............................................................................................ 8-281
Interpretation of Clinical Laboratory Services ..................................... 8-281
Breast Cancer Testing .......................................................................... 8-281
Billing Requirements and Prior Authorization Criteria for Genetic Testing
for Breast and Ovarian Cancer ............................................................. 8-282
Lead Testing......................................................................................... 8-284
Medical and Surgical Supplies ................................................................. 8-284
Limitations on Coverage ...................................................................... 8-284
Manually Priced Supplies .................................................................... 8-285
Medicare Part B Crossover Claims .......................................................... 8-285
Medicare and Medicaid Reimbursement .............................................. 8-286
Mental Health Services ............................................................................ 8-286
Outpatient Mental Health ..................................................................... 8-287
Bridge Appointments ........................................................................... 8-289
Package C............................................................................................. 8-291
Medicaid Rehabilitation Option Services ............................................ 8-291
8-13
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Chapter 8
Table of Contents
Coverage of Mental Health Codes for Children’s Health Insurance
Program ................................................................................................ 8-295
Psychiatric Residential Treatment Facilities ........................................ 8-297
Screening and Brief Intervention Services ........................................... 8-301
Mid-Level Practitioner Services ............................................................... 8-301
Smoking Cessation Treatment Services ................................................... 8-302
Newborn Services .................................................................................... 8-304
Presumptive Eligibility – Package P ........................................................ 8-305
Presumptive Eligibility Requirements ................................................. 8-306
Qualified Provider ................................................................................ 8-306
Obstetrical Services .................................................................................. 8-318
Antepartum Care Policy ....................................................................... 8-318
Billing for Antepartum Visits............................................................... 8-318
Antepartum Tests and Screenings Schedule ........................................ 8-319
Placental Alpha Microglobulin-1 (PAMG-1) Test ............................... 8-323
Salivary Estriol Test for Preterm Labor Risk Assessment ................... 8-323
Sonography .......................................................................................... 8-324
Echography .......................................................................................... 8-324
First Trimester Fetal Nuchal Translucency Ultrasound ....................... 8-324
Obstetrical Delivery and Postpartum Care Billing ............................... 8-326
Birthing Center Professional Services.................................................. 8-327
Other Outpatient Office Visits ............................................................. 8-327
Normal Pregnancy................................................................................ 8-327
Multiple Births ..................................................................................... 8-327
High-Risk Pregnancy ........................................................................... 8-328
Additional Antepartum Visits .............................................................. 8-332
Reimbursement .................................................................................... 8-333
Pregnancy Services Billing Considerations ......................................... 8-333
Hoosier Healthwise Package B – Pregnancy and Urgent Care Only ... 8-333
Proton Treatment Billing ..................................................................... 8-334
Coverage Criteria for 17P Injections .................................................... 8-334
Process for Completion of the Notification of Pregnancy.................... 8-335
Ophthalmological Services ....................................................................... 8-336
Date of Service Definition ................................................................... 8-336
Vision Coding and the Vision Services Code Set ................................ 8-336
Coverage for Ophthalmologic Uses of HCPCS Code J3300 ............... 8-337
Vision Procedures Limited to One Unit ............................................... 8-337
Eye Examinations ................................................................................ 8-339
Orthoptic or Pleoptic Training, Vision Training, and Therapies Coverage
Criteria ................................................................................................. 8-340
Lenses .................................................................................................. 8-341
Frames .................................................................................................. 8-343
Adoption of Modifiers for Replacement Eyeglasses ............................ 8-343
Written Correspondence ...................................................................... 8-344
Billing a Member for Services that have Exceeded Benefit Limitations8-345
Vision Services and Managed Care ..................................................... 8-345
8-14
Version: 13.2
Chapter 8
Table of Contents
Podiatric Services ..................................................................................... 8-345
Second Opinions .................................................................................. 8-346
Office Visits ......................................................................................... 8-346
Surgical Services .................................................................................. 8-347
Laboratory and X-ray Services ............................................................ 8-347
Doppler Evaluations ............................................................................. 8-348
Radiology Services ................................................................................... 8-348
Utilization Criteria ............................................................................... 8-349
Computerized Tomography Scans ....................................................... 8-350
PET Scans ............................................................................................ 8-350
Radionuclide Bone Scans ..................................................................... 8-350
Upper Gastrointestinal Studies ............................................................. 8-350
Hospice Providers ................................................................................ 8-351
Renal Dialysis Physician Services............................................................ 8-351
School Corporation Services .................................................................... 8-352
Covered Services.................................................................................. 8-353
Surgical Services ...................................................................................... 8-355
Split Care ............................................................................................. 8-356
Therapy Services ...................................................................................... 8-359
Outpatient ............................................................................................. 8-364
Hippotherapy........................................................................................ 8-364
Traumatic Brain Injury......................................................................... 8-364
Transportation Services ............................................................................ 8-365
Advanced Life Support – ALS ............................................................. 8-365
Basic Life Support – BLS .................................................................... 8-365
Commercial or Common Ambulatory Service – CAS ......................... 8-366
Nonambulatory Service (Wheelchair Van) – NAS .............................. 8-366
Taxi ...................................................................................................... 8-366
Rotary Air Ambulance Transportation ................................................. 8-366
Retroactive Eligibility .......................................................................... 8-369
Definition of a Trip .............................................................................. 8-369
Multiple Destinations ........................................................................... 8-369
Transportation Origin and Destination Modifiers ................................ 8-370
Clarification of Requirements for Transportation Prior Authorization 8-370
Twenty One-Way Trip Limitation and Exemptions ............................. 8-371
Emergency Transportation Services..................................................... 8-371
Hospital Admission or Discharge ........................................................ 8-371
Members on Renal Dialysis or Members Residing in Nursing Homes 8-371
Mileage ................................................................................................ 8-372
Mileage Units and Rounding ............................................................... 8-373
Multiple Passengers ............................................................................. 8-373
Accompanying Parent or Attendant ..................................................... 8-374
Additional Attendant ............................................................................ 8-374
Waiting Time ....................................................................................... 8-375
Ambulance Transportation Services .................................................... 8-375
Level of Service Rendered Versus Level of Response ........................ 8-376
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Table of Contents
Ambulance Mileage ............................................................................. 8-377
Neonatal Ambulance Transportation ................................................... 8-377
Oxygen and Oxygen Supplies .............................................................. 8-377
Member Copayments ........................................................................... 8-377
Exemptions to Copayments for Transportation Services ..................... 8-378
Federal Guidelines for Copayment Policy ........................................... 8-378
Package C Transportation Services ...................................................... 8-379
Risk-Based Managed Care Hoosier Healthwise Services .................... 8-379
Noncovered Transportation Services ................................................... 8-379
Documentation Requirements for Transportation Services ................. 8-379
Registration Requirements ................................................................... 8-380
Transportation Code Sets ..................................................................... 8-381
Nonambulatory Service Provider ......................................................... 8-382
Ambulance (ALS and BLS) Provider .................................................. 8-382
Air Ambulance ..................................................................................... 8-383
Taxi Provider ....................................................................................... 8-384
Family Member Transportation Provider ............................................. 8-384
Bus Provider......................................................................................... 8-384
Vaccines for Children ............................................................................... 8-384
Eligible Members ................................................................................. 8-385
Provider Enrollment in the VFC Program ............................................ 8-385
Vaccines for Children Forms ............................................................... 8-385
Vaccine Storage ................................................................................... 8-386
VFC Vaccine Coverage and Billing Procedures .................................. 8-386
Reporting Individual Cases of Varicella (Chickenpox) ....................... 8-388
VFC and HealthWatch ......................................................................... 8-388
Provider-Purchased Vaccine ................................................................ 8-388
Third Party Liability............................................................................. 8-389
Package C............................................................................................. 8-390
Children and Hoosiers Immunization Registry Program ..................... 8-390
Medical Review Team Billing Procedures ............................................... 8-391
MRT Reimbursement for Transportation ............................................. 8-392
MRT Procedure Codes ......................................................................... 8-392
Pre-Admission Screening Resident Review Billing Procedures .............. 8-398
Section 5: Dental Claim Form Billing Instructions.................................. 8-401
Introduction .............................................................................................. 8-401
Providers Using the Dental Claim Form .................................................. 8-401
ADA 2006 Paper Claim Form Requirements ........................................... 8-401
Rendering NPI Required ...................................................................... 8-401
Date of Service Definition ................................................................... 8-402
Out-of-State Providers ......................................................................... 8-402
ADA 2006 Dental Claim Form Fields ................................................. 8-402
Description of Fields on the ADA 2006 Dental Claim Form ................... 8-403
837D Electronic Transaction .................................................................... 8-407
Billing Procedures .................................................................................... 8-408
Current Dental Terminology Procedure Codes .................................... 8-408
Dental Extractions ................................................................................ 8-408
Package B Billing................................................................................. 8-408
Package E Billing ................................................................................. 8-408
Attachments .............................................................................................. 8-411
Return to Provider Letter ..................................................................... 8-411
Paper Claims with Attachments ........................................................... 8-411
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Table of Contents
Services Associated with Dental Services for Hoosier Healthwise RBMC
Networks .............................................................................................. 8-412
Member Eligibility Verification and Billing for Dental Services ........ 8-413
Spend-down .............................................................................................. 8-413
Spend-down and Benefit Limits ........................................................... 8-413
Dental Service Limitations ....................................................................... 8-414
Orthodontics ......................................................................................... 8-414
Prophylaxis .......................................................................................... 8-415
Topical Fluoride Treatment.................................................................. 8-415
Periodontal Root Planing and Scaling .................................................. 8-416
Oral Evaluations ................................................................................... 8-417
General Anesthesia .............................................................................. 8-418
D9420 – Hospital Call-Services Provided in Hospital Setting ............. 8-418
Radiographs ......................................................................................... 8-418
Emergency Services ............................................................................. 8-419
Supernumerary Tooth Extractions ............................................................ 8-419
Permanent Dentition ............................................................................ 8-419
Primary Dentition ................................................................................. 8-419
Dentures and Partials Coverage................................................................ 8-420
Dentures and Partials ........................................................................... 8-420
Billing a Member for Noncovered Services ......................................... 8-422
Valid Tooth Numbers ............................................................................... 8-426
Sealants .................................................................................................... 8-426
Tooth Surface Procedure Codes ............................................................... 8-426
Multiple Restorations Reimbursement ..................................................... 8-427
Section 6: Home and Community-Based Services Waiver Billing Guidelines8-429
Introduction .............................................................................................. 8-429
Eligibility for HCBS Waiver Services...................................................... 8-429
Waiver Authorization ........................................................................... 8-430
Environmental Modifications............................................................... 8-430
Special Processing Required for Home and Community-Based Services
Overlapping Hospice Level of Care or Long-Term Care Discharge Dates8-432
Billing Instructions ................................................................................... 8-432
Waiver Providers Use LPI ................................................................... 8-432
Paid Claim Adjustments ........................................................................... 8-436
Section 7: Family Planning Eligibility Program ...................................... 8-437
Reimbursement requirements ................................................................... 8-438
Member eligibility .................................................................................... 8-438
Description of Services ............................................................................ 8-438
Annual Examinations and Office Visits ............................................... 8-438
Contraception ....................................................................................... 8-439
Sterilization .......................................................................................... 8-439
STIs and STDs ..................................................................................... 8-440
Pap Smears ........................................................................................... 8-440
Billing and Reimbursement Requirements ............................................... 8-441
General Information ............................................................................. 8-441
Diagnosis Codes................................................................................... 8-442
Evaluation and Management (E/M) Codes .......................................... 8-447
Contraceptive Supplies ........................................................................ 8-451
Oral and Injectable Contraceptives ...................................................... 8-451
Contraceptive Devices ......................................................................... 8-451
Intrauterine Devices ............................................................................. 8-452
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Table of Contents
Vaginal Ring and Hormone Patch ........................................................ 8-452
Contraceptive Implants ........................................................................ 8-453
Norplant Systems ................................................................................. 8-453
Sterilization and Sterilization-related Procedures ................................ 8-453
Hysteroscopic Sterilizations ................................................................. 8-454
Tubal Ligation ...................................................................................... 8-455
Vasectomy............................................................................................ 8-455
Anesthesia for Sterilization .................................................................. 8-456
Sexually Transmitted Diseases and Infections (STDs and STIs) ......... 8-456
Radiology Services .............................................................................. 8-464
Laboratory Procedures ......................................................................... 8-465
Surgical Procedures.............................................................................. 8-467
Section 8: Informed Consent Claim Attachment Instructions ............... 8-471
Abortions and Related Services................................................................ 8-471
Documentation Requirements .............................................................. 8-471
Medical Abortion by Oral Ingestion of Medication ............................. 8-473
Sterilization and Hysterectomy ................................................................ 8-475
Sterilizations ........................................................................................ 8-475
Limitations ........................................................................................... 8-475
Informed Consent ................................................................................. 8-478
Retroactive Eligibility or Failure to Provide Proof of Eligibility ......... 8-478
Consent Forms ..................................................................................... 8-479
Documentation Requirements .............................................................. 8-479
Consent for Sterilization Form Instructions ......................................... 8-479
Hysterectomy Billing ........................................................................... 8-482
Section 9: Healthcare Common Procedure Coding System Codes ........ 8-486
Fee Schedule ............................................................................................ 8-486
HCPCS Codes Requiring Attachments .................................................... 8-486
Index ............................................................................................................ 8-513
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Chapter 8
Section 1: Introduction to Billing Instructions
General Information
Note: See Chapter 9: IHCP Pharmacy Services Benefit of this manual for
pharmacy billing information. The NCPDP Drug Claim Form (Version D.0)
and Compound Prescription Claim Form (Version D.0), along with related
billing instructions, are available under the Pharmacy Services quick link at
indianamedicaid.com.
This chapter provides a comprehensive explanation of billing instructions for each claim form used by
the Indiana Health Coverage Programs (IHCP).
The IHCP uses the following claim forms:
•
UB-04 Claim Form
•
CMS-1500 Claim Form
•
American Dental Association (ADA) 2006 Claim Form
•
National Council for Prescription Drug Programs (NCPDP) Drug Claim Form
•
Indiana Medicaid Compound Prescription Claim Form
Note: Claims related to Hoosier Healthwise risk-based managed care (RBMC)
plans may use the forms listed where applicable. Contact the appropriate
managed care entity (MCE) for specific instructions.
Providers can also bill claims using the 837I, 837P, or 837D transactions. This chapter includes
specific guidelines for each of these transaction types.
The explanation of each claim form includes the following:
•
Types of providers using the form
•
Form sample
•
Field descriptions and field requirements
•
Field coding information
•
Unique billing instructions for each type of service billed on the form
Providers can find detailed information about covered services and policy guidelines in the Indiana
Administrative Code (IAC) on the web at state.in.us.
Some supplemental programs have substantial requirements that are too lengthy to be included in this
chapter. The supplemental provider manual for each program contains information about these
programs. The IHCP supplemental provider manuals are available for download from the Manuals
page on indianamedicaid.com:
•
590 Program Provider Manual
•
HealthWatch/Early and Periodic Screening, Diagnosis, and Testing (EPSDT) Provider Manual
•
Healthy Indiana Plan (HIP) Reimbursement Manual
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•
Home and Community-Based Services Waiver Provider Manual
•
Hospice Provider Manual
•
Medicaid Rehabilitation Option (MRO) Provider Manual
•
Right Choices Program Policy Manual
•
Qualified Provider Presumptive Eligibility Manual
Ordering Claim Forms
Providers can order UB-04, CMS-1500, and ADA 2006 Dental claim forms from a standard form
supply company. They can also download and print UB-04 and CMS-1500 version 08-05 forms from
the Centers for Medicare & Medicaid Services (CMS) website at cms.hhs.gov. HP does not distribute
supplies of these forms.
Providers can download drug and compound prescription claim forms under the Pharmacy Services
quick link at indianamedicaid.com .
National Provider Identifier and One-to-One Match
Providers are encouraged to bill with the National Provider Identifier (NPI) only. Providers’ IHCP
Legacy Provider Identifier (LPI) may appear on the claim but will not be used to process the claim. All
healthcare providers must report their NPI on all claims and establish a one-to-one match with the
service location where the patient was treated, or the claim will be denied. Only atypical provider
claims are exempt from this requirement.
Three data elements are used for the standard NPI crosswalk:
•
Billing NPI
•
Billing taxonomy code
•
Billing provider office service location ZIP Code + 4 on file in IndianaAIM
The crosswalk attempts to establish a one-to-one match with the following data elements in the
following sequence:
•
NPI only
•
NPI to billing taxonomy
•
NPI to billing provider office service location ZIP Code + 4
•
NPI to billing provider office service location five-digit ZIP Code
•
NPI to billing taxonomy and five-digit ZIP Code
Note: Providers can view their provider profile on the Web interChange.
Additional information about the Web interChange can be found in
Chapter 3: Electronic Solutions of this manual.
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Chapter 8
National Correct Coding Initiative
On January 27, 2011, the IHCP began processing CMS-1500 professional claims received with a date
of service on or after October 1, 2010, through National Correct Coding Initiative (NCCI) code editing.
This includes NCCI Column I and Column II, Mutually Exclusive (ME) edits, and Medically Unlikely
Edits (MUEs) for professional claims. The implementation date for outpatient claim bill types 13X and
83X was April 1, 2011. Providers are to monitor all communications for further information.
The CMS developed the NCCI to promote national correct coding methodologies and to control
improper coding leading to inappropriate payment. The correct coding policies were created based on
coding conventions derived from a variety of sources, such as the American Medical Association’s
(AMA’s) Current Procedural Terminology (CPT ®1) Guidelines, coding guidelines developed by
national societies, analysis of standard medical and surgical practices, and a review of current coding
practices.
Healthcare legislation passed into law (H.R. 3962) requires Medicaid programs to incorporate
compatible methodologies of the NCCI into their claims processing systems. Section 6507 –
Mandatory State Use of National Correct Coding Initiative – of H.R.3962 mandates that NCCI
methodologies must be in effect for claims filed on or after October 1, 2010. Therefore, the IHCP
implemented three basic coding concepts required by NCCI editing to the IndianaAIM claims
processing system:
•
NCCI Column I and Column II Edits – When the NCCI was first established, the “Column
I/Column II Correct Coding Edit Table” was termed the “Comprehensive/Component Edit Table.”
Although the Column II code is often a component of a more comprehensive Column I code, this
relationship is not true for many edits. In the latter type of edit, the code pair edit simply represents
two codes that should not be reported together.
•
ME Edits – Many procedure codes cannot be reported together because they are mutually
exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same
anatomic site or same patient encounter.
•
Medically Unlikely Edits – A Medically Unlikely Edit (MUE) for a Healthcare Common
Procedure Coding System (HCPCS)/CPT code is the maximum number of units of service under
most circumstances allowable by the same provider for the same beneficiary on the same date of
service.
NCCI-specific files and the NCCI Policy Manual, as well as other publications related to NCCI claim
editing, are located on the Medicaid.gov website at medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html. Providers not
familiar with NCCI claim editing are encouraged to access this site for educational materials and to
download NCCI Column I/II, ME, and MUE files. For explanation of benefits (EOB) codes related to
NCCI, see the EOB Codes Related to NCCI/Code Auditing table.
For information regarding the Claims Administrative Review and Appeals procedures, see Chapter 10:
Claims Processing Procedures, Section 6 of this manual.
1
CPT copyright2012 American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association.
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Claims Submitted via Web interChange
Providers that submit claims via Web interChange may view those claims within two hours of
submission via the Claim Inquiry function. As a result of NCCI editing, there may be rare events when
claims will not be available for viewing within the usual two-hour time frame. If the delay is longer
than 24 hours, providers may contact HP Customer Assistance to determine the reason for the delay.
When performing an electronic void of a claim that was subject to NCCI auditing, providers must wait
until the following day to resubmit claims related to the voided claim.
Types of Services Billed on Each Claim Form
Tables 8.1 to 8.3 illustrate the types of services billed on each claim form.
Table 8.1 – UB-04 Claim Form
Provider Types
Types of Services
Ambulatory surgical centers (ASCs)
Outpatient surgical services
Birthing center
Normal pregnancy delivery services (vaginal only)
End-stage renal disease (ESRD) clinics
Renal dialysis services
Home health agencies (HHAs)
Home health services
Hospices
Hospice facility services (except waiver services)
Hospitals
Inpatient facility services (acute, psychiatric, and
rehabilitation)
Outpatient facility services
Outpatient radiological services (technical
component)
Outpatient laboratory services (technical
component)
Long-term care (LTC) facilities
Nursing facility (NF) services
Intermediate care facility for individuals with
intellectual disability (ICF/IID, formerly ICF/MR)
facility services
Community residential facility for the
developmentally disabled (CRF/DD) facility
services (this type of facility may also be called a
small ICF/IID)
Long Term Acute Care (LTAC)
Rehabilitation hospital facilities
Rehabilitation facility services
Traumatic brain injury services
Table 8.2 – CMS-1500 Claim Form
Provider Types
Advanced practice nurses
Types of Services
Midwife services
Nurse practitioner services
Nurse anesthetist services
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Provider Types
Types of Services
Audiologists
Audiology services
Case managers
Care coordination services
Chiropractors
Chiropractic services
Clinics
Family planning services
Federally Qualified Health Center (FQHC) services
Medical services
Nurse practitioner services
Rural health clinic (RHC) services
Therapy services
Surgical services
Certified registered nurse anesthetists
(CRNAs)
Nurse anesthetist services
Comprehensive outpatient rehabilitation
facilities
Outpatient rehabilitation
Dentists
Oral surgery (using CPT or HCPCS code)
Durable medical equipment (DME) and
home medical equipment (HME) dealers
DME/HME
Medical supplies
Oxygen
Freestanding radiology facilities
Radiological services, professional component, technical
component, or global component
Hearing aid dealers
Hearing aids
Independent diagnostic testing facilities
Laboratory services – Diagnostic testing only
Laboratories
Laboratory services – Professional component
Mental health providers
Medicaid Rehabilitation Option (MRO) services
Outpatient mental health services
Mid-level practitioners
Anesthesiology assistant services
Physician assistant services
Advanced practice nurse credentialed in psychiatric or
mental health nursing
Opticians
Optical services
Optometrists
Optometric services
Physicians – Doctor of medicine (MD)
and doctor of osteopathy (DO)
Anesthesia services
Laboratory services
Medical services – Professional component
Mental health services
Radiological services
Surgical services
Podiatrists
Podiatric services
Public health agencies
Medical services
Psychiatric Residential Treatment
Facilities (PRTF)
Behavioral health residential treatment
School corporations
Therapy services – Physical, occupational, speech, and
mental health
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Chapter 8
Provider Types
Types of Services
Therapists
Therapy services – Physical, occupational, speech, and
audiology
Transportation providers
Transportation services
Waiver providers
Waiver services
Table 8.3 – ADA 2006 Dental Claim Form
Provider Types
Types of Services
Dentists
Dental services
Medical clinics
Dental services
Dental clinics
Dental services
Other dental providers
Dental services
This section describes revisions to paper claim submission requirements that are applicable to more
than one claim type. These changes are required to bring paper claim requirements into compliance
with Health Insurance Portability and Accountability Act (HIPAA) electronic claim transaction
requirements.
Diagnosis Codes
With the implementation of the new ASC X12 version of the HIPAA 5010, the transaction requirement
for primary diagnosis codes was changed from situational to required for 837 claim transactions.
Effective April 1, 2012, this billing requirement also applies to all IHCP paper and Web interChange
claim submissions.
This change affects even providers that were previously exempt from submitting diagnosis codes
specific to transportation, waiver, and DME services. Transportation and waiver providers should bill
diagnosis code 7999 as the primary diagnosis code for claim submissions when the actual diagnosis is
not known. DME providers must obtain the primary diagnosis code from the physician who ordered
the DME supplies or equipment.
Claims submitted to the IHCP without a valid diagnosis code will be denied.
Modifiers
The paper CMS-1500 and UB-04 claim forms and the electronic 837P and 837I transactions accept
four modifiers per procedure code. There are currently no modifiers approved for use with the Current
Dental Terminology (CDT®2) code set on the dental claim form. More information on modifier use can
be found in the CMS-1500 and 837P Transaction Billing Instructions: Modifiers section in this
chapter.
2
CDT copyright 2012 American Dental Association. All rights reserved.
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Chapter 8
National Drug Code Billing
The Federal Deficit Reduction Act of 2005 mandates that the IHCP require the submission of National
Drug Codes (NDCs) on claims submitted with certain procedure codes for physician-administered
drugs. This mandate affects all providers submitting electronic or paper claims for procedure-coded
drugs. Because the State may pay up to the 20% Medicare B copayment for dually eligible individuals,
the NDC is also required on Medicare crossover and Medicare Replacement Plan claims for all
applicable procedure codes.
Please contact your vendor to make the necessary software changes.
The NDC is required on the CMS-1500 paper claim form, Web interChange, and 837P electronic
transactions for submission on all claims. Requirements for the CMS-1500 paper claim form are
explained in Section 4 of this chapter.
The NDC is required on the UB-04 paper claim form, Web interChange, and 837I electronic
transactions for submission on all claims. Requirements for the UB-04 paper claim form are explained
in Section 2 of this chapter. All providers are encouraged to monitor future bulletins and banner pages
for updates about NDC reporting.
The IHCP is not changing reimbursement policy pertaining to procedure-coded, physicianadministered drugs at this time. Claims for such drugs continue to be priced by using the submitted
procedure code and procedure code units. The sole exception is that manually priced J and Q codes are
priced using the submitted NDC.
Procedure Code Partial Units
The ADA 2006 and CMS-1500 paper claim forms and the 837 Dental (837D) and 837P transactions
allow partial units for procedure codes that accommodate fractional units. Each procedure code
quantity allows for two decimal places when submitting partial units.
Note: Providers can submit CPT and HCPCS codes on the UB-04 claim form or
837I transaction using only whole units.
Date of Service Definition
All claims must reflect a date of service. The date of service is the date the specific services were
actually supplied, dispensed, or rendered to the patient. For example, when rendering services for
space maintainers or dentures, the date of service must reflect the date the appliance or denture is
delivered to the patient. This requirement is applicable to all IHCP-covered services.
Electronic Standards
HIPAA specifically names several electronic standards that must be followed when certain healthcare
information is exchanged. These standards are published as National Electronic Data Interchange
Transaction Set Implementation Guides. They are commonly called Implementation Guides (IGs). An
addendum to most IGs has been published and must be used to properly implement each transaction.
The IGs are available for download through the Washington Publishing Company website at wpcedi.com.
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Chapter 8
Companion Guides
The IHCP has developed technical companion guides to assist application developers during the
implementation process. Information contained in the IHCP Companion Guides is intended only to
supplement the adopted IGs and provide guidance and clarification as it applies to the IHCP. The
IHCP Companion Guides are never intended to modify, contradict, or reinterpret the rules established
by the IGs.
The IHCP Companion Guides are located on indianamedicaid.com in the EDI Solutions section.
The NCPDP Payer Sheet is located under the Pharmacy Services quick link at indianamedicaid.com.
Paper Attachment Requirements
The IHCP accepts paper attachments with electronic claims (837I, 837P, and 837D). Web interChange
claims follow the same attachment requirements.
Paper Attachments with Electronic Claims
When an 837 or Web interChange claim transaction requires the submission of additional
documentation, providers can submit the documentation as a paper attachment. When a provider elects
to send a paper attachment with an 837 or Web interChange transaction, the provider must include the
following information:
•
Attachment Transmission Code – Required to indicate whether an electronic claim has paper
documentation to support the billed services. This code defines the timing and transmission method
or format of reports and how they are sent. Attachment Transmission Code, Data Element 756, on
the 837 transaction provides this value. The IHCP accepts paper attachments for electronic or paper
claims only by mail. This Attachment Transmission Code is BM (by mail).
•
Attachment Report Type Code – Indicates the type of attachment that the provider is sending to the
IHCP to support the 837 or Web interChange claim data. The code indicates the title or contents of
a document, report, or supporting item. Enter this code in Report Type Code, Data Element 755.
For a complete listing of Attachment Report Type Codes, see the specific 837 or Web interChange
claim transaction implementation guide.
•
Attachment control number (ACN) – This code identifies each attachment. The ACN is created by
the provider and can be numbers, letters, or a combination of letters and numbers. ACNs can be up
to 30 characters in length. Enter this code in Attachment Control Number, Data Element 67.
Providers must adhere to the following instructions when submitting paper attachments for electronic
claims:
•
Each paper attachment submitted for an 837 or Web interChange transaction must include a
provider-assigned ACN. Assign a unique ACN for each type of attachment within a claim. Write
the corresponding ACN on each page of the document. Once an ACN has been used, it cannot be
used again, even if the same claim is resubmitted at a later date.
•
Providers must send an IHCP Claims Attachment Cover Sheet for attachments associated with a
specific claim. Each claim must have its own attachment cover sheet. Providers can find a copy of
the IHCP Claim Attachment Cover Sheet on indianamedicaid.com in the Forms section. The
provider must complete the following information on the IHCP Claims Attachment Cover Sheet:
- Billing provider name, service location address and ZIP Code + 4
- Billing provider NPI or LPI and service location
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Chapter 8
 Only atypical providers may use LPI and service location
Dates of service on the claim
IHCP member identification number (RID)
ACN for each attachment associated with the claim
Number of pages associated with each attachment (not including the cover page)
•
Providers can submit a maximum of 20 ACNs with each attachment cover sheet.
•
The ACN must be unique per document type. Documents cannot be shared between claims.
•
Attachments not processed within 45 calendar days of the date posted on the provider’s Remittance
Advice will be denied. Providers must mail paper attachments to the IHCP at the following
address:
HP Claims Attachments
P.O. Box 7259
Indianapolis, IN 46207
The HP Claims Support Unit reviews each Claims Attachment Cover Sheet for completeness and
accuracy of the number of ACNs to the number of attachments. If errors are found, HP returns the
cover sheet and attachments to the provider for correction and resubmission. If the provider does not
mail the attachments within 45 days of claim submission, the claims are automatically denied. If the
provider has submitted the attachments, but one specific attachment needed for processing is missing
from the batch, the claim or service line denies.
Report Type Code
For processing, providers must also use the report type code indicating the type of attachment that they
are sending. Report type codes are as follows:
•
03 – Report Justifying Treatment Beyond Utilization Guidelines
•
04 – Drugs Administered
•
05 – Treatment Diagnosis
•
06 – Initial Assessment
•
07 – Functional Goals
•
08 – Plan of Treatment
•
09 – Progress Report
•
10 – Continued Treatment
•
11 – Chemical Analysis
•
13 – Certified Test Report
•
15 – Justification for Admission
•
21 – Recovery Plan
•
A3 – Allergies/Sensitivities Document
•
A4 – Autopsy Report
•
AM – Ambulance Certification
•
AS – Admission Summary
•
B2 – Prescription
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•
B3 – Physician Order
•
B4 – Referral Order
•
BR – Benchmark Testing Results
•
BS – Baseline
•
BT – Blanket Test Results
•
CB – Chiropractic Justification
•
CK – Consent Form(s)
•
CT – Certification
•
D2 – Drug Profile Document
•
DA – Dental Models
•
DB – Durable Medical Equipment Prescription
•
DG – Diagnostic Report
•
DJ – Discharge Monitoring Report
•
DS – Discharge Summary
•
EB – Explanation of Benefits
•
HC – Health Certificate
•
HR – Health Clinic Records
•
I5 – Immunization Record
•
IR – State School Immunization Records
•
LA – Laboratory Results
•
M1 – Medical Record Attachment
•
MT – Models
•
NN – Nursing Notes
•
OB – Operative Notes
•
OC – Oxygen Content Averaging Report
•
OD – Orders and Treatment Document
•
OE – Objective Physical Examination Document
•
OX – Oxygen Therapy Certification
•
OZ – Support Data for Claim
•
P4 – Pathology Report
•
P5 – Patient Medical History Document
•
P6 – Periodontal Charts
•
PE – Parental or Enteral Certification
•
PN – Physical Therapy Notes
•
PO – Prosthetics or Orthotic Certifications
•
PQ – Paramedical Results
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•
PY – Physician’s Report
•
PZ – Physical Therapy Certification
•
RB – Radiology Films
•
RR – Radiology Reports
•
RT – Report of Tests and Analysis Report
•
RX – Renewable Oxygen Content Averaging Report
•
SG – Symptoms Document
•
V5 – Death Certificate
•
XP – Photographs
Chapter 8
Claim Notes
IndianaAIM accepts claim note information in electronic 837 claim transactions and retrieves the
information for review during processing. This feature reduces the number of attachments that must be
sent with claims. Also, in some instances, use of the claim note may assist with the adjudication of
claims.
For example, when postoperative care is performed within one day of surgery, providers can submit
supporting information in the claim note segment rather than sending an attachment. For complete
details of claim notes accepted, see Chapter 10: Claims Processing Procedures, Section 2 of this
manual.
When a provider submits claims electronically via an 837 transaction or Web interChange claim
submission, the following is true for claim notes:
•
At the header level, the IHCP accepts 20 claim notes for the 837D transaction, 10 claim notes for
the 837I transaction, and one claim note for the 837P transaction.
•
At the detail level, the IHCP allows 10 claim notes on the 837D transaction and one claim note on
the 837P transaction.
•
The IHCP does not support detail-level claim notes on the 837I transaction.
•
Claim note codes identify the functional area or purpose for which the note applies:
- ADD – Additional Information
Note: The IHCP does not accept all types of claim notes as documentation and
providers should submit claim notes to Indiana Medicaid ONLY if the notes
relate to any of the situations described in this section.
Number of Details
IndianaAIM complies with HIPAA standards for details as follows:
•
837I – 450 details (the maximum number of details for Medicare)
•
837D – 50 details
•
837P – 50 details
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Chapter 8
Note: The IHCP accepts as many as 5,000 Claim (CLM) segments per ST – SE.
Web interChange also accommodates these limitations.
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Chapter 8
Section 2: UB-04 Billing Instructions
Providers Using the UB-04 Claim Form
The following types of providers use the UB-04 claim form when billing services to the Indiana Health
Coverage Programs (IHCP):
•
Ambulatory surgical center (ASC)
•
Birthing center
•
End-stage renal disease (ESRD) clinic
•
Home health agency (HHA)
•
Hospice provider
•
Hospital
•
Long-term care (LTC) facility
•
Rehabilitation hospital facility
Note: Hospital pharmacy take-home, direct care services performed by a
physician, and transportation services provided in a hospital are not billed
on a UB-04 claim form.
Using Modifiers for Outpatient Hospital Billing
Modifiers may be appended to Healthcare Common Procedure Coding System (HCPCS)/Current
Procedural Terminology (CPT) codes only when clinical circumstances justify the use of the modifier.
Institutional claims must incorporate the correct use of modifiers. A modifier should not be appended
to an HCPCS/CPT code solely to bypass Component Rebundling auditing. The use of modifiers affects
the accuracy of claims billing, reimbursement, and Component Rebundling auditing. If multiple units
of the same procedure are performed during the same session, the provider should roll all the units to a
single line, unless otherwise specified in medical policy.
The Centers for Medicare & Medicaid Services (CMS) provides carriers with guidance and
instructions on the correct coding of claims and use of modifiers through manuals, transmittals, and the
CMS website. Providers can access the CMS website at medicaid.gov. The American Medical
Association’s (AMA’s) CPT Assistant newsletter and Coding with Modifiers reference manual are
other valuable resources for correct modifier usage.
The IHCP implemented enhanced code auditing into the claims processing system. This enhanced code
auditing supports the Office of Medicaid Policy and Planning’s (OMPP’s) effort to promote and
enforce correct coding efforts for more appropriate and accurate program reimbursement.
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Chapter 8
Billing a Continuation Claim Using the UB-04 Claim Form
Providers can prepare a continuation claim, which is a claim with more than one UB-04 claim form
completed as if it is one claim to be processed for payment by the IHCP. Continuation claims cannot
contain more than 66 detail lines or be more than three pages long. Providers must complete the
continuation claim as follows:
•
Mark the UB-04 claim form page numbers in the area provided on line 23.
•
Complete the first 22 lines on page one of the UB-04 claim form.
•
Do not subtotal the first page of the claim. Total only the last page of the continuation claim, or
IndianaAIM reads the claim as two claims rather than one.
•
Complete the subsequent UB-04 claim forms for the remaining dates of service of the month.
•
Provide a grand total for the continuation claim on the last page of the UB-04 claim form in the
space provided at the bottom of field locator 47.
Ordering, Prescribing, and Referring Physician Billing
Requirements
A new category of enrollment has been created: ordering, prescribing, and referring (OPR) provider.
Providers already enrolled as IHCP providers do not need to do anything new. Providers not otherwise
enrolled as IHCP providers can enroll as OPR providers. This new OPR provider category is
appropriate for practitioners who:
•
May occasionally see an IHCP member who needs additional services or supplies that will be
covered by the Medicaid program.
•
Do not want to be enrolled as an IHCP provider.
•
Do not plan to submit claims to the IHCP for payment of services rendered.
Claims Processing Changes To Be Implemented
For dates of service on and after October 1, 2012, when providers with the following specialties submit
claims for services or supplies that require an order, prescription, or referral, the submitting providers
will be required to include the National Provider Identifier (NPI) of the provider that ordered,
prescribed, or referred the services or supplies.
The IHCP’s claims processing will monitor whether the OPR provider is enrolled in the IHCP. Claims
will deny if the OPR provider is not enrolled.
Table 8.4 – Entering OPR Information on Claim Form
Claim Form
Field Locator
UB-04
78 if not already listed in fields 76 or 77
837I Institutional EDI Batch Transaction
Loop 2310B Operating Provider
NM101 = 72 NM109 = NPI
837I Institutional EDI Batch Transaction
Loop 2310C Other Operating Provider
NM101 = ZZ NM109 = NPI
Web interChange – Institutional Claims
Other Prov NPI field
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Use of ICD Procedure Codes Restricted for UB-04 Billers
Beginning January 1, 2013, the IHCP will restrict the use of International Classification of Diseases
(ICD) procedure codes on institutional claims to the reporting of inpatient procedures. Institutional
claims, other than inpatient, inpatient crossover, and inpatient crossover Medicare Replacement Plan
claims, with dates of service on or after January 1, 2013, that are billed with ICD procedure codes will
deny with explanation of benefits (EOB) 4072 − ICD procedure code not allowed for claim type billed.
Please verify and resubmit claim as appropriate. Claims that deny with EOB code 4072 should be
corrected to remove ICD procedure codes and resubmitted for reimbursement consideration.
UB-04 Claim Form Requirements
This section provides a brief overview of the requirements to complete the UB-04 claim form.
Noncompliant UB-04 paper claims are returned to the provider.
For instructions about National Provider Identifier (NPI) requirements, see the National Provider
Identifier and One-to-One Match section.
Description of Fields on the UB-04 Claim Form
This section explains the completion of the UB-04 claim form. Some information is required to
complete the claim form, while other information is optional.
Note: These instructions apply to the IHCP guidelines only and are not intended to
replace instructions issued by the National Uniform Billing Committee
(NUBC). The NUBC instruction manual can be accessed at the NUBC
website at nubc.org.
The UB-04 paper claim form does not have a designated signature field. Therefore, all providers must
have the Claim Certification Statement for Signature on File form with the IHCP for the UB-04 claim
form to be processed.
The Claim Certification Statement for Signature on File form can be obtained on the Forms page at
Table 8.5 indicates in bold type if a field is required or required, if applicable. Optional and Not
applicable information is displayed in normal type. Specific instructions applicable to a particular
provider type are included. The table describes each form locator by referring to the number found in
the left corner of each box on the UB-04 claim form. These boxes contain the data elements.
The chart provides basic information about UB-04 claim fields. Where necessary, the chart notes
specific directions applicable to a particular provider type:
•
Accommodation rates are always in units of full days.
•
A day begins at midnight and ends 24 hours later.
•
Any part of a day, including the day of admission, counts as a full day, except the following:
- The day of discharge is not counted as a day unless the member is readmitted by midnight on
the same day.
- The day of death is the day of discharge and is not counted.
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•
Chapter 8
A period of inpatient care that includes at least one night in a hospital and is reimbursable under the
IHCP is considered an inpatient stay; however, if fewer than 24 hours, then outpatient observation
should be billed.
Providers should use the UB-04 billing manual conventions unless otherwise specified. Table 8.5 gives
field information for the UB-04 claim form. Table 8.6 lists revenue codes with descriptions.
Table 8.5 – UB-04 Claim Form Locator Descriptions
Form Field
Narrative Description/Explanation
PLEASE REMIT PAYMENT TO – Enter the billing provider office service location name,
address, and the expanded ZIP Code+4 format. Required.
1
Note: If the Postal Service provides an expanded ZIP Code for a geographic
area, this expanded ZIP Code must be entered on the claim form.
2
UNLABELED FIELD – Not applicable.
3a
PATIENT CONTROL NO. – Enter the internal patient tracking number. Optional.
3b
MEDICAL RECORD NUMBER – Enter the number assigned to the patient’s medical or health
record by the provider. Optional.
4
TYPE OF BILL – Enter the code indicating the specific type of bill. This three-digit code requires
one digit from each of the following categories in the following sequence and all positions must be
fully coded. Required.
Hospice bill type is 822.
•
First position – Type of Facility
•
Second position – Bill Classification
•
Third position – Frequency
Note: See the NUBC website at nubc.org/become.html for a current list of Type of
Bill codes. The NUBC maintains this code set, which is considered an
external code set by HIPAA requirements. Therefore, the IHCP is not
responsible for updating the type of bill code set. It is the provider’s
responsibility to monitor the changes made to this external code set.
5
FED. TAX NO. – Not applicable.
6
STATEMENT COVERS PERIOD, FROM/THROUGH – Enter the beginning and ending service
dates included on this bill. For all services rendered on a single day, use the FROM and THROUGH
dates. Indicate dates in MMDDYY format, such as 122506. Required.
7
8a
PATIENT IDENTIFIER – Not applicable.
Report recipient ID in field 60.
8b
PATIENT NAME – Last name, first name, and middle initial of the member. Required.
9a
PATIENT ADDRESS – STREET – Enter the member’s street address. Optional.
9b
PATIENT ADDRESS – CITY – Enter the member’s city. Optional.
9c
PATIENT ADDRESS – STATE – Enter the member’s two-alpha character state abbreviation.
Optional.
9d
PATIENT ADDRESS – ZIP CODE – Enter the member’s ZIP Code. Optional.
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9e
PATIENT ADDRESS – COUNTRY CODE – Enter the three-character country code, if other than
USA. Optional.
10
BIRTHDATE – Enter the member’s date of birth in an MMDDYY format. Optional.
11
SEX – Enter the member’s gender. M for male, F for female. Optional.
12
ADMISSION DATE – Enter the date the patient was admitted to inpatient care in a MMDDYY
format. Required for inpatient and LTC.
13
ADMISSION HOUR – Enter the hour during which the patient was admitted for inpatient care.
Required for inpatient.
Admission Hour Code Structure
Code
14
Time Frame a.m.
Code
Time Frame p.m.
00
12 a.m. – 12:59 a.m.
12
12 p.m. – 12:59 p.m.
01
1 a.m. – 1:59 a.m.
13
1 p.m. – 1:59 p.m.
02
2 a.m. – 2:59 a.m.
14
2 p.m. – 2:59 p.m.
03
3 a.m. – 3:59 a.m.
15
3 p.m. – 3:59 p.m.
04
4 a.m. – 4:59 a.m.
16
4 p.m. – 4:59 p.m.
05
5 a.m. – 5:59 a.m.
17
5 p.m. – 5:59 p.m.
06
6 a.m. – 6:59 a.m.
18
6 p.m. – 6:59 p.m.
07
7 a.m. – 7:59 a.m.
19
7 p.m. – 7:59 p.m.
08
8 a.m. – 8:59 a.m.
20
8 p.m. – 8:59 p.m.
09
9 a.m. – 9:59 a.m.
21
9 p.m. – 9:59 p.m.
10
10 a.m. – 10:59 a.m.
22
10 p.m. – 10:59 p.m.
11
11 a.m. – 11:59 a.m.
23
11 p.m. – 11:59 p.m.
99
Hour Unknown
ADMISSION TYPE – Enter the code indicating the priority of this admission. Required for
inpatient, outpatient, and LTC.
Admission Codes
Code
Description
1
Emergency
2
Urgent
3
Elective
4
Newborn
5
Trauma Center
9
Unspecified
15
ADMISSION SRC – Optional.
16
(DHR) DISCHARGE HOUR – Enter the hour during which the patient was discharged from
inpatient care. Valid values are the same as form field 13. Optional.
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17
Chapter 8
STATUS – Enter the code indicating the member discharge status as of the ending service date of the
period covered on this bill. Required for inpatient, outpatient, LTC, home health care, and
hospice.
Patient Status Codes
Code
18 – 24
Seven
maximum
allowed
Description
01
Discharged to home or self-care, routine discharge
02
Discharged or transferred to another short-term general hospital for inpatient care
03
Discharged or transferred to skilled nursing facility (SNF)
04
Discharged or transferred to an intermediate care facility (ICF)
05
Discharged or transferred to a designated cancer center or children’s hospital
06
Discharged or transferred to home under care of organized home health service organization
07
Left against medical advice or discontinued care
20
Expired
21
Discharged or transferred to court or law enforcement
30
Still a patient
43
Discharged or transferred to a federal healthcare facility
50
Discharged to hospice – Home
51
Discharged to hospice – Medical facility
61
Discharged or transferred within this institution to hospital-based Medicare swing bed
62
Discharged or transferred to another rehabilitation facility including discharge planning
units of hospital
63
Discharged or transferred to a long-term care hospital
64
Discharged or transferred to a nursing facility – Medicaid-certified but not Medicarecertified
65
Discharged or transferred to a psychiatric hospital or psychiatric unit of a hospital
66
Discharged or transferred to a critical access hospital (effective January 1, 2006)
70
Discharged or transferred to another type of healthcare institution not defined elsewhere in
the code list
71
Discharged, transferred, or referred to another institution for outpatient services when
specified by the discharge plan of care
72
Discharged, transferred, or referred within this facility for outpatient services when
specified by the discharge plan of care
CONDITION CODES – Enter the applicable code to identify conditions relating to this bill that
may affect processing. A maximum of seven codes can be entered. Required, if applicable. The
IHCP uses the following codes:
Condition Codes
Code
Description
02
Condition is employment related
03
Patient covered by insurance not reflected here
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05
Lien is filed
07
Medicare hospice by nonhospice provider
Accommodation Code
Code
40
Description
Same-day transfer
Prospective Payment Codes
Code
Description
61
Cost outlier
82
Noncovered by other insurance
Special Program Indicator Codes
Code
Description
A7
Induced abortion, danger to life
A8
Induced abortion, victim of rape or incest
25 – 28
CONDITION CODES – Not used.
29
ACDT STATE – Enter the state where the accident occurred. Optional.
30
Unlabeled Field – Not applicable.
31a – 34b
OCCURRENCE CODE and DATE – Enter the applicable code and associated date to identify
significant events relating to this bill that may affect processing. Dates are entered in an MMDDYY
format. A maximum of eight codes and associated dates can be entered. Required, if applicable. The
IHCP uses the following codes:
Occurrence Codes
Code
Description
01
Auto accident
02
No-fault insurance involved – Including auto accident or other
03
Accident or tort liability
04
Accident or employment related
05
Other accident
06
Crime victim
25
Date benefits terminated by primary payer
27
Date home health plan established or last reviewed
50
Previous hospital discharge – This code is used to bypass prior authorization (PA) editing
when certain nursing and therapy services are to be conducted during the initial period
following a hospital discharge. The discharge orders must include the requirement for such
services. Details can be found in the applicable sections of the Indiana Administrative Code
(IAC).
51
Date of discharge – This code is used to show the date of discharge from the hospital
confinement being billed, the date of discharge from a long-term care facility, or the date of
discharge from home health care and hospice, as appropriate.
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Form Field
35a–36b
Chapter 8
52
Initial examination – This code is used to show that an initial examination or initial
evaluation is being billed in a hospital setting. This code bypasses certain PA editing.
Details can be found in the applicable sections of the IAC.
61
Home health overhead – One per day
OCCURRENCE SPAN CODE, FROM/THROUGH – Enter the code and associated dates for
significant events relating to this bill. Each Occurrence Span Code must be accompanied by the span
From and Through date. The only valid home health overhead Occurrence Span Code is 61.
Optional.
Occurrence Span Code
Code
61
Description
Home health overhead amount – One per day
37
UNLABELED FIELD –For dates of service on and after January 1, 2011, the Care Select primary
medical provider (PMP) two-character alphanumeric certification code is no longer required.
For dates of service prior to January 1, 2011, enter the Care Select PMP two-character alphanumeric
certification code for dates of service rendered. Required for IHCP members enrolled in Care
Select when the service is not rendered by the member’s PMP, with the exception of outpatient
laboratory, pathology, radiology, and therapy services performed in a hospital setting for Care
Select members. The bypass of these outpatient hospital services is based on the revenue codes
being billed.
Report the PMP NPI in field 78 for claim reimbursement of these hospital services.
38
39a – 41d
VALUE CODES – Use these fields to identify Medicare Remittance Notice (MRN) or Medicare
Replacement Plan information. The following value codes must be used along with the appropriate
dollar or unit amounts for each. Required, if applicable.
42
•
Value Code A1 – Medicare deductible amount
•
Value Code A2 – Medicare coinsurance amount
•
Value Code 06 – Medicare blood deductible amount
• Value Code 80 – IHCP covered days
REV. CD. – Enter the applicable revenue code that identifies the specific accommodation, ancillary
service, or billing calculation. The appropriate three-digit, numeric revenue code must be entered to
explain each charge entered in form field 47. See the IAC for covered services, limitations, and
medical policy rules. Use the specific revenue code when available. Required.
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Form Field
43
Chapter 8
DESCRIPTION – Enter a narrative description of the related revenue code category on this bill.
Abbreviations may be used. Only one description per line. Optional.
1. Enter the National Drug Code (NDC) qualifier of N4 in the first two positions on the left side of
the field.
2. Enter the NDC 11-digit numeric code in the ‘5-4-2’ format. Do not include hyphens.
3. Enter the NDC Unit of Measurement Qualifier.
- F2 – International Unit
- GR – Gram
- ML – Milliliter
- UN – Unit
4. Enter the NDC Quantity (administered amount) with up to three decimal places, such as 1234.567.
For NDC billing for revenue codes 634, 635, and 636, required when applicable.
44
HCPCS/RATE/HIPPS CODE – Use the HCPCS code applicable to the service provided. Only one
service code per line is permitted. Required for home health, outpatient, and ASC services. This
field is also used to identify procedure code modifiers. Provide the appropriate modifier, as
applicable. Up to four modifiers are allowed for each procedure code. This is a 13-character field.
Required, if applicable.
45
SERV. DATE – Provide the date the indicated outpatient service was rendered. Required for home
health, hospice, independent laboratories, dialysis, ASC, and outpatient.
Creation Date Field 45, line 23 – Enter the date the bill is submitted. Required.
46
SERV. UNITS – Provide the number of units corresponding to the revenue code or procedure code
submitted. Six digits are allowed. Units must be billed using whole numbers. Required.
47
TOTAL CHARGES – Enter the total charges pertaining to the related revenue code for the
STATEMENT COVERS PERIOD. Enter the sum of all charges billed reflected in field 47, line 23.
The sum should be entered only on the last page of the claim. Ten digits are allowed per line, such as
99999999.99. Required.
48
NON-COVERED CHARGES – Not applicable. Information entered in this field and applied to the
bill results in an out-of-balance bill and subsequent denial. Do not enter information in this field.
49
50A–55C
FORM FIELDS 50A-55C – Medicare and a Medicare supplement (commercial insurers) are always
listed first (50A), if applicable. Other Third Party Liability (TPL) insurers are listed in the second
form field (50b), if applicable. The IHCP information is listed last (50C). EXCEPTION: Section 5-1
notes that the IHCP is primary to Children’s Special Health Care Services (CSHCS) and Victim
Assistance coverage. Required, if applicable.
FORM FIELDS 50A – 55C – Such as Medicare, Medicare supplement, and Traditional Medicaid.
A = Enter Medicare (including Medicare Replacement Plan). Required, if applicable.
B = Enter the third-party carrier’s name and additional payer names. Required, if applicable.
C = Medicaid estimated amount due – 55C
*For dates of service July 24, 2013, and after, see instructions for billing Medicare crossover claims
when the primary payer is a Medicare Replacement Plan.
50A
PAYER – Enter Medicare (including Medicare Replacement Plan). Required, if applicable.
50B
PAYER – Enter the third-party carrier’s name and additional payer names. Required, if applicable.
50C
PAYER – Enter the applicable IHCP, such as Traditional Medicaid or 590 Program. Required.
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51A–51C
HEALTH PLAN ID – The Payer C, billing IHCP provider number is entered in fields 56 and/or 57.
Provider numbers pertaining to 50A, Medicare Payer, or 50B, TPL Payer, are optional.
52A–52C
REL INFO – Not applicable.
53A–53C
ASG BEN – Mark Y for yes, benefits assigned. The IHCP Provider Agreement includes details about
accepting payment for services. Optional.
54A–54C
PRIOR PAYMENTS – Enter the amount paid by the carrier entered in form fields 50A-C.
Note: When a third-party liability (TPL) carrier makes payment on a claim, the
explanation of benefits (EOB) is not required. If the Medicare payment is
greater than zero, the MRN is not required.
55A–55B
EST. AMOUNT DUE – Not applicable.
55C
EST. AMOUNT DUE – Enter the amount billed. Calculate the estimated amount due by subtracting
the amounts in fields 54A-C from form field 47, Revenue Code 001, Total Charge Amount. This field
accommodates 10 digits, such as 99999999.99. Required.
56
NPI – Enter the 10-digit NPI for the billing provider. The billing physician’s taxonomy should be
entered in field 81CCa. Required for healthcare providers.
57A
OTHER PROVIDER ID – Primary medical provider. Optional.
57C
Other Provider ID – Atypical providers enter the LPI for the billing provider. The LPI includes nine
numeric characters and one alpha character for the service location.
58A–58C
INSURED’S NAME – Enter member’s last name, first name, and middle initial. IHCP member
information is required. Enter TPL information. Required, if applicable.
59A–59C
P. REL – Not applicable.
60A–60C
INSURED’S UNIQUE ID – Enter the member’s identification number for the respective payers
entered in form fields 50A-C. The 12-digit member identification (RID) number is required in form
field 60c. Other carrier information is required, if applicable.
61A–61C
GROUP NAME – Enter the name of the group or plan through which insurance is provided to the
member by the respective payers entered in form fields 50A-C. Required, if applicable.
62A–62C
INSURANCE GROUP NO. – Enter the identification number, control number, or code assigned by
the carrier or administrator to identify the group under which the individual is covered; see form
fields 50A-B. Enter the policy number as well. Required, if applicable.
63A–63C
TREATMENT AUTHORIZATION CODES – Enter the number that indicates the payer authorized
the treatment covered by this bill. Optional.
64A–64C
DOCUMENT CONTROL NUMBER – Not applicable.
65A–65C
EMPLOYER NAME – Enter the name of the employer that might or does provide healthcare
coverage for the insured individual identified in form field 58. Required, if applicable.
66
DX – Not applicable.
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Form Field
67
Chapter 8
PRIN. DIAG. CD – Provide the International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM) code describing the principal diagnosis, for example, the condition
established after study to be chiefly responsible for the admission of the patient for care. Required
for all inpatient (including psychiatric and rehabilitation), outpatient, LTC, hospice, ASC, and
home health.
Enter present on admission (POA) in the shaded area of field 67:
•
Y (for yes) – Present at the time of inpatient admission.
•
N (for no) – Not present at the time of inpatient admission.
•
U (for unknown) – The documentation is insufficient to determine if the condition was present at
the time of inpatient admission.
•
W (for clinically undetermined) – The provider is unable to clinically determine whether the
condition was present at the time of inpatient admission.
•
1 (one) (for unreported/not used) – Diagnosis is exempt from POA reporting.
Note: The ICD-9-CM Official Guidelines for Coding and Reporting includes a
list of diagnosis codes that are exempt from POA reporting. Use POA
indicator 1 only for codes on the list.
67A-Q
OTHER DIAGNOSIS CODES – Provide the ICD-9-CM codes corresponding to additional
conditions that coexist at the time of admission, or that develop subsequently, and that have an effect
on the treatment received or the length of stay. Required, if applicable, for inpatient, outpatient,
hospice, ASC, and home health.
Enter POA in the shaded areas of field 67A-Q:
•
Y (for yes) – Present at the time of inpatient admission.
•
N (for no) – Not present at the time of inpatient admission.
•
U (for unknown) – The documentation is insufficient to determine if the condition was present at
the time of inpatient admission.
•
W (for clinically undetermined) – The provider is unable to clinically determine whether the
condition was present at the time of inpatient admission.
•
1 (one) (for unreported/not used) – Diagnosis is exempt from POA reporting.
Note: The International Classification of Diseases, Ninth Edition, Clinical
Modifications (ICD-9-CM) Official Guidelines for Coding and Reporting
includes a list of diagnosis codes that are exempt from POA reporting. Use
POA indicator 1 only for codes on the list.
68
69
ADM. DIAG. CD – Enter the ICD-9-CM code provided at the time of admission as stated by the
physician. Required for inpatient and LTC.
70
PATIENT REASON DX – Enter the ICD-9-CM code that reflects the patient’s reason for visit at the
time of outpatient registration. Optional for outpatient.
71
PPS CODE – Not applicable.
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Form Field
Chapter 8
72
ECI (E-CODE) – If used, use the appropriate E-code provided at the time of admission as stated by
the physician. The E-code indicates the external cause of injury, poisoning, or adverse effect.
The IHCP does not require a POA indicator in the External Cause of Injury field locator 72. If a POA
indicator is entered in the External Cause of Injury field, it will be ignored and not used for AP DRG
grouping.
73
74
PRINCIPAL PROCEDURE CODE/DATE – Use the ICD-9-CM procedure code that identifies the
principal procedure performed during the period covered by this claim, and the date the principal
procedure described on the claim was performed. Required for inpatient procedures. Not allowed
for any claim type other than inpatient, inpatient crossovers, and inpatient crossover Medicare
Replacement Plans.
74a-e
OTHER PROCEDURE CODE/DATE – Use the ICD-9-CM procedure codes identifying all
significant procedures other than the principal procedure, and the dates, identified by code, the
procedures were performed. Report the codes that are most important for the encounter and
specifically any therapeutic procedures closely related to the principal diagnosis. Required, when
appropriate, for inpatient procedures. Not allowed for any claim type other than inpatient,
inpatient crossovers, and inpatient crossover Medicare Replacement Plans.
75
76
ATTENDING PHYS. ID – Enter the attending physician’s 10-digit numeric NPI. The attending
physician’s taxonomy should be entered in field 81CCb. Required for inpatient, outpatient, ASC,
and LTC.
77
OPERATING PHYS. ID – Enter the operating physician’s 10-digit numeric NPI. Required for
inpatient.
78
OTHER – Enter the other physician’s (referring/PMP physician) 10-digit numeric NPI. Required
for IHCP members enrolled in Care Select. Required for all others if the ordering, prescribing,
and referring (OPR) physician is not listed in fields 76 or 77.
79
OTHER – Not applicable.
80
REMARKS – Use this field for claim note text. Provide information, using as many as 80 characters,
which may be helpful in further describing the services rendered. Optional.
Note: The Claim Note Text field is not used systematically for claim processing at
this time, but may be used by the Claim Resolutions Unit for more
information if the claims suspend for review during processing.
81CC a, b
ADDITIONAL CODES – Enter B3 taxonomy qualifier and corresponding 10-digit alphanumeric
taxonomy code. Optional. Taxonomy may be needed to establish a one-to-one NPI/LPI match if the
provider has multiple locations.
81CC a – First box B3 qualifier, second box taxonomy code for billing provider from field 56
81CC b – First box B3 qualifier, second box taxonomy code for attending provider from field 76
8-42
Version: 13.2
Chapter 8
Figure 8.1 – UB-04 Claim Form
8-43
Version: 13.2
Chapter 8
Table 8.6 – Revenue Codes with Descriptions
Revenue
Code
Description
100
All inclusive room and board plus ancillary
101
All inclusive room and board
11X
Room and board – Private (medical or general)
110
General
111
Medical/surgical/gynecological
112
Obstetrics
113
Pediatric
114
Psychiatric
115
Hospice
116
Detoxification
117
Oncology
118
Rehabilitation
119
Other
12X
Room and board – Semiprivate (two beds) (medical or general)
120
General
121
122
Obstetrics
123
Pediatric
124
Psychiatric
125
Hospice
126
Detoxification
127
Oncology
128
Rehabilitation
129
Other
13X
Room and board – Semiprivate three to four beds
130
General
131
132
Obstetrics
133
Pediatric
134
Psychiatric
135
Hospice
136
Detoxification
137
Oncology
138
Rehabilitation
139
Other
14X
Room and board – Private (deluxe)
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Version: 13.2
Revenue
Code
Chapter 8
Description
140
General
141
142
Obstetrics
143
Pediatric
144
Psychiatric
145
Hospice
146
Detoxification
147
Oncology
148
Rehabilitation
149
Other
15X
Room and board – Ward (medical or general)
150
General
151
152
Obstetrics
153
Pediatric
154
Psychiatric
155
Hospice
156
Detoxification
157
Oncology
158
Rehabilitation
159
Other
16X
Room and board – Other
160
General
164
Sterile environment
167
Self-care
169
Other
17X
Nursery
170
General classification
171
Newborn – Level I
172
Newborn – Level II
173
Newborn – Level III
174
Newborn – Level IV
175
Neonatal intensive care
179
Other
18X
Leave of absence
180
General
181
Patient convenience – No charges billed
8-45
Version: 13.2
Revenue
Code
Chapter 8
Description
182
Patient convenience – Charges billable
183
Therapeutic leave
184
From intermediate care facility for individuals with intellectual disability
(ICF/IID, formerly ICF/MR) for any purpose
185
From nursing home for hospitalization
189
Other leave of absence
19x
Subacute care
190
General
191
Subacute care – Level I
192
Subacute care – Level II
193
Subacute care – Level III
194
Subacute care – Level IV
199
Other subacute care
20X
Intensive care
200
General
201
Surgical
202
Medical
203
Pediatric
204
Psychiatric
206
Intermediate Intensive Care Unit (ICU)
207
Burn care
208
Trauma
209
Other intensive care
21X
Coronary care
210
General
211
Myocardial infarction
212
Pulmonary care
213
Heart transplant
214
Intermediate Coronary Care Unit (CCU)
219
Other coronary care
22X
Special charges
220
General
221
Admission charge
222
Technical support charge
223
UR service charge
224
Late discharge, medically necessary
229
Other special charges
8-46
Version: 13.2
Revenue
Code
Chapter 8
Description
23X
Incremental nursing care rate
230
General
231
Nursery
232
Obstetrics
233
ICU
234
CCU
235
Hospice
239
Other
24X
All inclusive ancillary
240
General
241
Basic
242
Comprehensive
243
Specialty
249
Other all inclusive ancillary
25X
Pharmacy
250
General
251
Generic drugs
252
Nongeneric drugs
253
Take-home drugs
254
Drugs/incidental to other diagnostic services
255
Drugs/incidental to radiology
256
Experimental drugs
257
Nonprescription
258
Intravenous (IV) solutions
259
Other pharmacy
26X
IV therapy
260
General
261
Infusion pump
262
Pharmacy services
263
Drug/supply delivery
264
Supplies
269
Other IV therapy
27X
Medical/surgical supplies and devices
270
General
271
Nonsterile supply
272
Sterile supply
273
Take-home supplies
8-47
Version: 13.2
Revenue
Code
Chapter 8
Description
274
Prosthetic/orthotic devices
275
Pacemaker
276
Intraocular lens
277
Oxygen – Take home
278
Other implants
279
Other supplies/devices
28X
Oncology
280
General
289
Other oncology
29X
Durable medical equipment (DME) (other than renal)
290
General
291
Rental
292
Purchase of new DME
293
Purchase of used DME
294
Supplies/drugs for DME effectiveness (HHAs only)
299
Other equipment
30X
Laboratory
300
General
301
Chemistry
302
Immunology
303
Renal patient (home)
304
Nonroutine dialysis
305
Hematology
306
Bacteriology and microbiology
307
Urology
309
Other laboratory
31X
Laboratory pathological
310
General
311
Cytology
312
Histology
314
Biopsy
319
Other
32X
Radiology – Diagnostic
320
General
321
Angiocardiography
322
Arthrography
323
Arteriography
8-48
Version: 13.2
Revenue
Code
Chapter 8
Description
324
Chest X-ray
329
Other
33X
Radiology – Therapeutic and/or chemotherapy administration
330
General
331
Chemotherapy administration – Injected
332
Chemotherapy administration – Oral
333
Radiation therapy
335
Chemotherapy administration – IV
339
Other
34X
Nuclear medicine
340
General
341
Diagnostic
342
Therapeutic
343
Diagnostic radiopharmaceuticals
344
Therapeutic radiopharmaceuticals
349
Other
35X
CT scan (Computed Tomographic Scan)
350
General
351
Head scan
352
Body scan
359
Other CT scans
36X
Operating room services
360
General
361
Minor surgery
362
Organ transplant other than kidney
367
Kidney transplant
369
Other operating room services
37X
Anesthesia
370
General
371
Anesthesia incident to radiology
372
Anesthesia incident to other diagnostic services
374
Acupuncture
379
Other anesthesia
38X
Pints blood
380
General
381
Packed red cells
382
Whole blood
8-49
Version: 13.2
Revenue
Code
Chapter 8
Description
383
Plasma
384
Platelets
385
Leukocytes
386
Other components
387
Other derivatives (cryoprecipitates)
389
Other blood
39X
Blood and blood component administration, processing, and storage
390
General
391
Administration
392
Processing and storage
399
Other processing and storage
40X
Other imaging services
400
General
401
Diagnostic mammography
402
Ultrasound
403
Screening mammography
404
Positron Emission Tomography (PET)
409
Other
41X
Treatments – Respiratory services
410
General
412
Inhalation services
413
Hyperbaric oxygen therapy
419
Other respiratory services
42X
Treatments – Physical therapy
420
General
421
Visit charge
422
Hourly charge
423
Group rate
424
Evaluation or reevaluation
429
Other physical therapy
43X
Treatments – Occupational therapy
430
General
431
Visit charge
432
Hourly charge
433
Group rate
434
439
Other occupational therapy
8-50
Version: 13.2
Revenue
Code
Chapter 8
Description
44X
Treatments – Speech-language pathology
440
General
441
Visit charge
442
Hourly charge
443
Group rate
444
449
Other speech-language pathology
45X
Emergency room (ER)
450
General
451
Emergency medical screening service (EMTALA)
454
ER beyond EMTALA screening
456
Urgent care
459
Other ER
46X
Pulmonary function
460
General
469
Other pulmonary function
47X
Audiology
470
General
471
Diagnostic
472
Treatment
479
Other audiology
48X
Cardiology
480
General
481
Cardiac cath lab
482
Stress test
483
Echocardiology
489
Other cardiology
49X
Ambulatory surgical care
490
General
499
Other ambulatory surgical care
50X
Outpatient services
500
General
509
Other outpatient services
51X
Clinic
510
General
511
Chronic pain center
512
Dental clinic
8-51
Version: 13.2
Revenue
Code
Chapter 8
Description
513
Psychiatric clinic
514
OB/GYN clinic
515
Pediatric clinic
516
Urgent care clinic
517
Family practice clinic
519
Other clinic
52X
Freestanding clinic
520
General
521
Rural health clinic (RHC)
522
Rural health – Home
523
Family practice clinic
524
Visit by RHC/Federally Qualified Health Center (FQHC) practitioner to a
member in a covered Part A stay at SNF
525
Visit by RHC/FQHC practitioner to a member in an SNF (not covered Part A
stay)
526
Urgent care clinic
527
Visit nurse service to a member’s home in a home health shortage area
528
Visit by RHC/FQHC practitioner to other non-RHC/FQHC site
529
Other freestanding clinic
53X
Osteopathic services
530
General
531
Osteopathic therapy
539
Other osteopathic services
54X
Ambulance
540
General
541
Ambulance supplies
542
Ambulance medical transport
543
Ambulance heart mobile
544
Ambulance oxygen
545
Air ambulance
546
Neonatal ambulance services
547
Pharmacy
548
Telephone transmission electrocardiogram (EKG)
549
Other ambulance
55X
Skilled nursing
550
General
551
Visit charge
552
Hourly charge
8-52
Version: 13.2
Revenue
Code
Chapter 8
Description
559
Other skilled nursing
56X
Medical social services
560
General
561
Visit charge
562
Hourly charge
569
Other medical social services
57X
Home health aide (home health)
570
General
571
Visit charge
572
Hourly charge
579
Other home health aide
58X
Home health visits, home health only
580
General
581
Visit charge
582
Hourly charge
583
Assessment
589
Other home health
59X
Home health, units of service
590
General
599
Units of service/home health/other
60X
Rental months oxygen (home health)
600
General
601
Oxygen – Stationary equipment/supplies/contents
602
Oxygen – Stationary equipment/supplies/under 1 liter per minute (LPM)
603
Oxygen – Stationary equipment/supplies/over 4 LPM
604
Oxygen – Portable add-on
609
Oxygen – Other
61X
Magnetic Resonance Technology (MRT)
610
Magnetic resonance technology
611
Magnetic resonance imaging (MRI) – Brain/brain stem
612
MRI – Spinal cord/spine
614
MRT – Other
615
Magnetic resonance angiography (MRA) – Head and neck
616
MRA – Lower extremities
618
MRA – Other
619
MRI – Other
62X
Medical and surgical supplies
8-53
Version: 13.2
Revenue
Code
Chapter 8
Description
621
Supplies incident to radiology
622
Supplies incident to other diagnostic services
623
Surgical dressings
624
Food and Drug Administration (FDA) investigational devices
63X
Pharmacy
631
Single-source drugs
632
Multiple-source drugs
633
Restrictive prescription
634
Epoetin (EPO), less than 10,000 units
635
EPO, 10,000 or more units
636
Drugs requiring detailed coding
637
Self-administrable drugs not requiring detailed coding
64X
Home IV therapy services
640
General
641
Nonroutine nursing, central line
642
IV site care, central line
643
IV start/change, peripheral line
644
Nonroutine nursing, peripheral line
645
Training patient/caregiver, central line
646
Training, disabled patient, central line
647
Training, patient/caregiver, peripheral line
648
Training, disabled patient, peripheral line
649
Other IV therapy services
65X
Hospice service
650
General
651
Routine home care
652
Continuous home care
653
Hospice services/routine home care delivered in nursing home
654
Hospice services/continuous home care delivered in nursing home
655
Inpatient respite care
656
General inpatient care (nonrespite)
657
Physician services
658
Hospice room and board – Nursing facility
659
Other hospice
66X
Respite care
660
General
661
Hourly charge/nursing
8-54
Version: 13.2
Revenue
Code
Chapter 8
Description
662
Hourly charge/aide/homemaker/companion
663
Daily respite care
669
Other respite care
67X
Outpatient special residence charges
670
General
671
Hospital-based
672
Contracted
679
Other special residence charges
68X
Trauma response
681
Level I
682
Level II
683
Level III
684
Level IV
689
Other trauma response
70X
Cast room
700
General
71X
Recovery room
710
General
719
Other recovery room
72X
Labor room/delivery
720
General
721
Labor
722
Delivery
723
Circumcision
724
Birthing center
729
Other labor room/delivery
73X
EKG/ECG
730
General
731
Holter monitor
732
Telemetry
739
Other EKG/ECG
74X
EEG (electroencephalogram)
740
General
749
Other EEG
75X
Gastrointestinal services
750
General
759
Other gastrointestinal
8-55
Version: 13.2
Revenue
Code
Chapter 8
Description
76X
Treatment/observation room
760
General
761
Treatment room
762
Observation room
769
Other treatment/observation room
77X
Preventive care services
770
General
771
Vaccine administration
779
Other preventive care service
78X
Telemedicine
780
General
789
Other telemedicine
79X
Extracorporeal Shockwave Therapy (ESWT)
790
General
799
Other Extracorporeal Shockwave Therapy
80X
Inpatient renal dialysis
800
General
801
Inpatient hemodialysis
802
Inpatient peritoneal (Noncontinuous ambulatory peritoneal dialysis [CAPD])
803
Inpatient CAPD
804
Continuous cycling peritoneal dialysis (CCPD)
809
Other inpatient dialysis
81X
Acquisition of body components
810
General
811
Living donor
812
Cadaver donor
813
Unknown donor
814
Unsuccessful organ search – Donor bank charges
815
Heart/cadaver
816
Heart/other
817
Liver/acquisition
819
Other donor
82X
Hemodialysis – Outpatient or home
820
General
821
Hemodialysis/composite or other rate
822
Home supplies
823
Home equipment
8-56
Version: 13.2
Revenue
Code
Chapter 8
Description
824
Maintenance – 100%
825
Support services
828
Hemodialysis home/supervision
829
Other outpatient hemodialysis
83X
Peritoneal dialysis – Outpatient or home
830
General
831
Peritoneal/composite or other rate
832
Home supplies
833
Home equipment
834
835
Support services
839
Other outpatient peritoneal dialysis
84X
CAPD – Outpatient or home
840
General
841
CAPD/composite or other rate
842
Home supplies
843
Home equipment
844
Maintenance 100%
845
Support services
849
Other outpatient CAPD
85X
CCPD – Outpatient or home
850
General
851
CCPD/composite or other rate
852
Home supplies
853
Home equipment
854
855
Support services
859
Other outpatient CCPD
860
Magnetoencephalography (MEG) – General
861
Magnetoencephalography (MEG) – MEG
88X
Dialysis
880
General
881
Ultrafiltration
882
Home dialysis aid visit
889
Miscellaneous dialysis/other
89X
Other donor bank
890
Donor bank
8-57
Version: 13.2
Revenue
Code
Chapter 8
Description
891
Bone
892
Organ other than kidney
893
Skin
899
Other
90X
Behavioral health treatments/services
900
General
901
Electroshock treatment
902
Milieu treatment
903
Play therapy
904
Activity therapy
905
Intensive outpatient services – Psychiatric
906
Intensive outpatient services – Chemical dependency
907
Community behavioral health program (day treatment)
909
Psych treatment (other)
91X
Behavioral health treatments/services
910
General
911
Rehabilitation
912
Partial hospitalization – Less intensive
913
Partial hospitalization – Intensive
914
Individual therapy
915
Group therapy
916
Family therapy
917
Biofeedback
918
Testing
919
Other behavioral health treatments/services
92X
Other diagnostic services
920
General
921
Peripheral vascular lab
922
Electromyelogram
923
Pap smear
924
Allergy test
925
Pregnancy test
929
Other diagnostic services
93X
Medical rehabilitation day program
931
Half day
932
Full day
940
Other therapeutic services
8-58
Version: 13.2
Revenue
Code
Chapter 8
Description
941
Recreational therapy
942
Education/training
943
Cardiac rehabilitation
944
Drug rehabilitation
945
Alcohol rehabilitation
946
Complex medical equipment – Routine
947
Complex medical equipment – Ancillary
948
Pulmonary rehabilitation
949
95X
951
Athletic training
952
Kinesiotherapy
96X
Professional fees
960
General
961
Psychiatric
962
Ophthalmologist
963
Anesthesiologist (MD)
964
Anesthetist (CRNA)
969
Other professional fees
97X
Professional fees
970
General
971
Laboratory
972
Radiology/diagnostic
973
Therapeutic radiology
974
Radiology/nuclear medicine
975
Operating room
976
Respiratory therapy
977
Physical therapy
978
Occupational therapy
979
Speech therapy
98X
Professional fees
980
General
981
Emergency room
982
Outpatient services
983
Clinic
984
Medical social services
985
EKG
8-59
Version: 13.2
Revenue
Code
Chapter 8
Description
986
EEG
987
Hospital visit
988
Consultation
989
Private duty nurse
99X
Patient convenience items
990
General
991
Cafeteria/guest tray
992
Private linen service
993
Telephone/telegraph
994
TV/radio
995
Nonpatient room rentals
996
Late discharge charge
997
Admission kits
998
Beauty shop/barber
999
Other patient convenience items
Diagnostic and Therapeutic Codes Not Reimbursable
Under revenue codes 92x – Other Diagnostic Services and 94x – Other Therapeutic Services, the IHCP
does not reimburse revenue codes 920, 929, 940, 941, 942, 944, 945, 946, 947, or 949. Providers must
use an appropriate revenue code that is descriptive of the service or where the service was performed.
Table 8.7 shows a list of nonreimbursable revenue codes under 92x and 94x.
Table 8.7 – Diagnostic and Therapeutic Services Revenue Codes Not Reimbursable by the
IHCP
Revenue Code
Description
920
Other Diagnostic Services – General
929
Other Diagnostic Service – Other Diagnostic Service
940
Other Therapeutic Service – General
941
Other Therapeutic Service – Recreational Therapy
942
Other Therapeutic Service – Education/Training
944
Other Therapeutic Service – Drug Rehabilitation
945
Other Therapeutic Service – Alcohol Rehabilitation
946
Other Therapeutic Service – Complex Medical Equipment – Routine
947
Other Therapeutic Service – Complex Medical Equipment – Ancillary
949
Other Therapeutic Service – Additional Therapeutic Services
Therapeutic and diagnostic injections are performed within a number of treatment centers in a hospital,
including, but not limited to, an operating room (360), emergency room (450), or clinic (510). Similar
to Medicare policy, IHCP policy requires that hospitals report these injections under the revenue
8-60
Version: 13.2
Chapter 8
code for the treatment center where injections are performed. This is also consistent with rate
setting for treatment rooms, because costs for injections are considered when establishing treatment
room rates. Injections are included in the reimbursement of the treatment room when other services are
provided. However, if a patient is treated and only received the injection service, the provider will be
reimbursed the flat fee of the appropriately billed treatment room revenue code. Claims using the
revenue codes in the 92x and 94x series listed in Table 8.7 are denied with EOB code 4107 – Revenue
code is not appropriate or not covered for the type of service being provided.
Single Procedure Code with Multiple NDCs
When billing National Drug Codes (NDCs) that have one procedure code but that involves multiple
NDCs, providers no longer need to use the KP and KQ modifiers. Providers bill the claim with the
appropriate NDC for the drug they are dispensing on separate detail lines. For example, if a provider
administers 150 mg of Synagis, most likely a 50 mg vial plus a 100 mg vial would be used. These two
vials have different NDCs but one procedure code; therefore, the item would be billed with two detail
lines for the same procedure code and the corresponding NDCs. This billing requirement includes
crossover claims as well.
Compounds – Outpatient/Outpatient Crossover
When billing any compound drugs that require an NDC, providers must bill the appropriate NDC for
each procedure code. Providers receive payment for all valid NDCs included in the compound drugs.
Birthing Centers
Per Indiana Code (IC) 16-18-2-36.5, a birthing center is a freestanding entity, place, facility, or
institution where a woman is scheduled to give birth following a normal, uncomplicated (low-risk)
pregnancy. Under IC 16-21-2, this term does not include a hospital, an ambulatory surgical center, or
the residence of the woman giving birth. The IHCP created Provider Type 08 – Clinic and provider
specialty code 088 – Birthing center to identify freestanding birthing centers.
Birthing centers must be licensed by the Indiana State Department of Health (ISDH) before enrolling
in the IHCP. Birthing centers are assigned to the limited risk category and are not required to pay an
application fee during enrollment or revalidation (see the Risk Category and Application Fee Matrix
for Non-Waiver Providers on indianamedicaid.com). Providers should refer to the Provider Type and
Specialty Matrix on indianamedicaid.com for other enrollment criteria.
Facility charges are billed on a UB-04 Institutional claim form, or the Health Insurance Portability and
Accountability Act (HIPAA) 837I transaction. Birthing center claims must report taxonomy code
261QB0400X (birthing) in field locator 81CCa of the UB-04 claim form or its electronic equivalent.
Outpatient, outpatient crossover, outpatient crossover Medicare Replacement Plan, and outpatient
encounter claims are applicable claim types.
Birthing centers report all services inclusive, using revenue code 724 – Birthing center. This applies to
vaginal deliveries ONLY. When labor occurs but does not result in delivery, providers should bill
revenue code 724, along with HCPCS code S4005.
8-61
Version: 13.2
Chapter 8
Home Health Services
Coverage
Home health services are available to IHCP members medically confined to the home, when services
are ordered in writing from a physician and performed in accordance with the written plan of care. It is
important to note that there is a distinction between the Medicare home health definition of
“homebound” and Indiana Medicaid’s definition of “homebound.”
The Medicaid program serves a more expansive age range than the Medicare program. Home health
services may be provided to those who are medically confined to the home, including IHCP members
who, because of illness or injury, are unable to leave home without the assistance of another person or
an assistive device, or for whom leaving home is contrary to medical advice. Medicaid members who
require the assistance of another person or assistive device, such as a wheelchair or walker, to leave the
house to work or attend school may receive home health services. Home health services can be
provided if medically necessary to assist in these day-to-day functions.
The following sections provide specific billing procedures for home health services. Providers should
see 405 IAC 5-16-3 and 405 IAC 5-16- 3.1 for detailed information about coverage and PA
requirements.
Billing Procedures
Submit home health claims electronically, or mail to the following address for processing:
HP
Home Health Claims
P.O. Box 7271
Indianapolis, IN 46207-7271
Note: For risk-based managed care (RBMC) members, bill the appropriate
managed care entity (MCE). Contact information can be found in Chapter 1:
General Information of this manual.
Home health providers follow the general billing directions for completing the UB-04 claim form with
the exception of the service date, local codes, and the additional type of bill codes. In field 44,
HCPCS/RATES, providers must enter the HCPCS/CPT) code for the service provided, not the rate.
Table 8.8 lists revenue codes and the crosswalked HCPCS/CPT codes.
Table 8.8 – Revenue Codes/HCPCS/CPT Codes
Revenue
Code
HCPCS/
CPT Code
Revenue
Code
HCPCS/
CPT Code
Revenue
Code
HCPCS
Code
420
G0151
421
G0151
422
G0151
423
G0151
424
97001
429
G0151
430
G0152
431
G0152
432
G0152
433
G0152
434
97003
439
G0152
440
G0153
441
G0153
442
G0153
443
G0153
444
92506
449
G0153
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Code
HCPCS/
CPT Code
Revenue
Code
Chapter 8
HCPCS/
CPT Code
552
99600 TE
552
99600 TD
559
99601,
99602
572
99600
Revenue
Code
559
HCPCS
Code
S9349
Unit of Service
Each line item identifies services billed using HCPCS codes and service dates. Providers must bill each
date of service as a separate line item and bill each level of service, such as registered nurse (RN) or
licensed practical nurse (LPN), provided on the same date as a separate line item. The procedure code
description defines the unit of service. When home health providers perform the same service, such as
multiple RN visits on the same date of service, they must bill those services on the same claim form
and on one detail with the total number of units of services provided. Billing separate lines for the
same service with the same date of service causes claims to be denied as exact duplicates. The OMPP
sets the rate for each procedure code.
The billing units of home health visits for therapists, home health aides, LPNs, and RNs are as follows:
•
For therapy visits – If the therapist is in the home eight minutes or more, the provider can round the
visit up to the 15-minute unit of service. If the therapist is in the home for seven minutes or less, the
provider cannot round this up and therefore, cannot bill for it. Therapy codes are measured as one
unit equals 15 minutes.
•
For home health aides, LPN, or RN visits – If the home health aide, LPN, or RN is in the home for
fewer than 29 minutes, providers can bill for the entire first hour only if they provided a service.
For subsequent hours in the home, providers should use the partial unit procedure as outlined in the
subsection of this chapter titled Partial Units of Service. Nursing services are measured as one unit
equals one hour.
If the therapist, home health aide, LPN, or RN enters the home and the member refuses service,
providers cannot bill for any unit of service. Overheads are linked with reimbursement for services
provided. When the provider does not render a service, the IHCP does not reimburse the provider for
overhead.
Overhead Rate
Providers may report only one overhead per provider, per member, per day. Occurrence codes 62 – 66
are no longer active, and home health claims, billed with these occurrence codes are denied with the
following EOB code:
0515 – The overhead fee is not on file for the dates of service indicated or the home health occurrence
code is invalid for the date of service. Please verify and resubmit.
Providers use the UB-04 occurrence code, occurrence date, and occurrence span for fields 31-34, a–b,
on the UB-04 to indicate the appropriate overhead fee. Providers should utilize the following code to
identify the overhead rate:
•
Code 61 indicates that one encounter with the member occurred on the date shown.
•
If the dates of service billed are not consecutive, the provider should enter the occurrence code
corresponding to each date of service billed on the UB-04 in the occurrence code and occurrence
date fields 31-34 (a-b on the paper UB-04 claim form).
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If the dates of service billed are consecutive, and one encounter was provided per day, enter
occurrence code 61 and the dates of service being billed in the occurrence span code field 35 a-b.
Providers that submit more than one UB-04 claim form in a multiple-member care situation should
submit only one form with the overhead attached. As long as the overhead is attached to only one
member, it does not matter to which member it is attached.
Note: Providers should not add the dollar figures associated with the overhead
rates to the claim when calculating total charges. The Remittance Advice
(RA) or the 835 transaction automatically reflects the appropriate overhead
amounts.
Home Health Reimbursement
Home health agency rates are calculated on a rate-setting methodology that is based on 95% of the
unweighted median as the basis for rates. See 405 IAC 1-4.2-4(b).
Table 8.9 – Home Health Services
Code
Service
No Code
Overhead
99600 TD
Registered Nurse (RN)
99600 TE
Licensed Practical Nurse (LPN)
99600
Home Health Aide
G0151
Physical Therapy
G0152
Occupational Therapy
G0153
Speech Therapy
Registered Nurse Delegation to Home Health Aides
The IHCP has specific guidelines for tasks that are to be performed by RNs versus those performed by
home health aides. Providers are expected to staff per these guidelines. The IHCP provider agreement
specifies that providers follow all applicable federal and state regulations in addition to the policies and
procedures outlined in the IHCP Provider Manual, bulletins, and banner pages. Please note, the IHCP
periodically amends its policies and procedures. It is the responsibility of the provider to ensure the
most up-to-date information is being utilized. For federal and state regulations, see 42 CFR 484.36 and
410 IAC 17-14-1(g)-(n).
Multiple Visit Billing
When providers make multiple visits for the same prior-authorized service to a member during one
day, providers should bill all visits on the same claim form and on one detail with the total number of
units of service provided. If providers bill these services on separate claim forms or on separate claim
details, the IHCP denies one or more of the services as a duplicate service.
In the event additional hours of the same service are identified after a claim has been adjudicated and
paid, providers must submit a paid claim adjustment. Procedures for submitting a paid claim
adjustment are in Chapter 11: Paid Claim Adjustment Procedures of this manual.
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Home health agency providers should be aware that rotating personnel in the home merely to increase
billing is not appropriate.
Example
A home health agency sent an RN to a member’s home in the morning and an LPN to the same home
in the evening of July 15, 2012. The first nurse performed two hours of RN services in the morning,
and the second nurse performed two hours of LPN services in the evening of July 15, 2012.
Detail 1: Revenue Code 552 with HCPCS 99600 TD. The date of service is 7/15/12 and the unit of
service is 2.
Detail 2: Revenue Code 552 with HCPCS 99600 TE. The date of service is 7/15/12 and the unit of
service is 2.
Note: In this example, providers bill for only one overhead for dates of service on
and after July 1, 2012, by entering occurrence code 61 with a corresponding
date of 7/15/12 in fields 31a-34b and 35a-36b on the UB-04 claim form.
Partial Units of Service
Providers must round partial units of service to the nearest whole unit when calculating
reimbursement. Round up any partial unit of service of 30 minutes or more to the next highest unit, and
round down any partial unit of service of 29 minutes or less to the next lowest unit. Nursing services
are measured as one unit of service equals 60 minutes, while therapies are measured as one unit equals
15 minutes.
•
Example 1: 85 minutes spent on billable patient care activities is rounded down to one unit.
•
Example 2: 95 minutes spent on billable patient care activities is rounded up to two units.
Hospital Discharge
Providers can perform certain services without PA following IHCP member discharge from a hospital,
if the parameters meet those outlined in the IAC. Within the constraints in several IAC rules, the
following apply:
Note: For members enrolled in Hoosier Healthwise or Care Select, providers
should see Chapter 6: Prior Authorization of this manual for additional
information about PA.
•
Providers may perform home health services without PA when an RN, LPN, or home health aide
performs the service, if the service does not exceed 120 units within 30 calendar days following
hospital discharge.
- The physician must order services in writing prior to the patient’s hospital discharge.
- The patient must be homebound.
•
Any combination of therapy services ordered in writing by a physician cannot continue beyond 30
units in 30 calendar days without PA.
- The physician must order services in writing prior to the patient’s hospital discharge.
- The patient must be homebound.
•
Services must be within the limits specified in 405 IAC 5-16-3.
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•
Providers should use occurrence code 50 with the corresponding date of discharge in the
occurrence code and occurrence date fields 31-34, a–b on the UB-04, to bypass PA requirements
associated with the previously mentioned parameters.
•
When a provider bills for services exceeding the aforementioned parameters, and the provider has
not received PA for additional units, IndianaAIM automatically denies or cuts back units on the RA.
•
The IHCP does not require PA for an emergency visit, but providers must request a Prior
Authorization System Update from the PA Department to continue service provision.
Billing Procedures for Home Infusion and Enteral Therapy Services
Four provider types may bill for home infusion and enteral therapy services and supplies:
•
DME
•
Home medical equipment (HME)
•
HHAs
•
Pharmacies
Home infusion includes the following:
•
Enteral feeding within, or by way of, the intestine
•
Enteral tube feeding that includes the provision of nutritional requirements through a tube into the
stomach or small intestine
•
Parenteral therapy that includes any route other than the alimentary canal such as intravenous,
subcutaneous, intramuscular, or mucosal
•
Total parenteral nutrition therapy (TPN)
When providers bill for home infusion and enteral therapy, they should bill the following three
components separately:
•
DME and HME providers bill all supplies, equipment, and formulas required to administer home
infusion and enteral therapy on a CMS-1500 claim form or 837P transaction using the appropriate
HCPCS code.
•
HHAs bill only for services provided in the home by an RN or LPN on the UB-04 claim form or
837I transaction using the appropriate HCPCS codes.
•
Pharmacies bill for compound drugs or any drugs used in parenteral therapy on an Indiana Family
and Social Services Administration (FSSA) Drug Claim Form using the appropriate NDC.
Billing Procedures for Home Tocolytic Infusion Therapy Using a Home Uterine
Monitoring Device
HHAs may bill all three components using the proper billing forms and appropriate codes if the HHA
maintains multiple enrollments as an HHA, Pharmacy and DME, or HME provider.
Only those HHAs that meet the following guidelines are allowed to bill for home tocolytic infusion
therapy using a home uterine monitoring device. At a minimum, the HHA must have staff that can
perform the following:
•
Contact the patient’s physician at least weekly for updates on patient condition and compliance.
•
Provide home health care to pregnant women 24 hours a day, seven days a week.
•
Provide patient education about uterine contractions and other subtle symptoms of preterm labor.
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•
Provide pharmacological consultation about the use of tocolytics and individualized patient dosing
24 hours a day, seven days a week.
•
Provide the patient with a tocolytic infusion pump and a uterine monitoring device, including setup
and delivery; provide patient education about the use of the equipment; and be available to
troubleshoot the equipment 24 hours a day, seven days a week.
To qualify for this therapy, the member must meet the following conditions:
•
Be at least 24 to 34 weeks gestation.
•
Be in current preterm labor. Preterm labor is defined as greater than or equal to six contractions per
hour.
•
Have a cervical dilation of greater than or equal to one centimeter, or an effacement of greater than
or equal to 75%.
•
Have direct home telephone access to providers, which means having a working telephone.
•
Have experienced secondary failure to wean from infused tocolytics, or have failed oral therapy
and requires continued infusion therapy.
•
Have an obstetrician or gynecologist (OB/GYN) as the referring physician or if not, have had a
consultation with an OB/GYN.
Three codes, S9349, 99601, and 99602, are assigned to home tocolytic infusion therapy using a home
monitoring device.
Code S9349 denotes the total global package of services with home health agencies providing all the
components under home tocolytic infusion therapy.
S9349 covers the following items:
•
Home uterine monitor
•
Skilled nursing services that include the following:
- Initial nursing assessment
- Instructions given to the patient about the proper use of the monitoring equipment
- Home visits as needed to monitor signs and symptoms of preterm labor
- Twenty-four-hour telephone support for troubleshooting on the monitoring equipment, for
pharmacological support, and for patient symptoms
•
Ambulatory infusion pump
•
Tocolytic drugs
•
All other supplies necessary to maintain a patient at home on this therapy including the following:
- Conductive paste or gel
- Dressings
- Extra batteries for infusion pump
- Sharps container
- Site kits
- Syringes
- Tubing
- Other supplies
This global package also includes any costs involved in transmitting reports to the physician
electronically, such as a fax or telephone modem.
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Codes 99601 and 99602 are used if a member meets the criteria for home tocolytic infusion therapy
and the agency is providing the home uterine monitoring and skilled nursing components of the
therapy only (rather than the entire package noted in S9349). When the home health agency bills
99601 and 99602, the tocolytic drugs and other supplies must be supplied and billed separately through
another provider. The home health agency should provide only the home uterine monitor and the
skilled nursing components of the home tocolytic infusion therapy. The home health agency may bill
99601 for the first two hours of therapy and bill 99602 for each additional hour of therapy, up to 22
additional hours for each 24-hour period.
Codes 99601 and 99602 cover the following items:
•
Home uterine monitor
•
Skilled nursing services that include the following:
- Initial nursing assessment
- Instructions given to the patient about the proper use of the monitor
- Home visits to monitor signs and symptoms of preterm labor
- Twenty-four hour telephone support for troubleshooting the monitoring equipment and for
reporting patient symptoms
•
This package also includes any costs involved in transmitting reports to the physician
electronically, such as fax or telephone modem.
Or providers can write to the following address to request PA:
ADVANTAGE Health Solutions
Prior Authorization Department
P. O. Box 40789
Indianapolis, IN 46240
Note: For RBMC or Care Select members, contact the appropriate MCE to obtain
PA. The contact information can be found in Chapter 1: General Information
of this manual.
HHAs can bill for S9349, 99601, and 99602 using standard home healthcare billing guidelines. All
supplies for each therapy are bundled into a daily rate, and HHAs are not allowed to bill separately for
any supplies associated with these therapies. HHAs are also not allowed to bill an overhead charge
when daily infusion services do not include an actual encounter in the home.
Providers are allowed to bill one unit of service daily and should use revenue code 559 when billing
S9349, 99601, and 99602.
Cases of premature labor treated with oral medication only, or requests for home uterine monitoring
devices alone for the purpose of screening high-risk pregnancies, do not qualify for inclusion under the
established criteria and are not approved. Members who receive only oral medications or who require
only home uterine monitoring devices do not qualify for inclusion under the established criteria for
tocolytic infusion therapy.
Note: The OMPP closely monitors overhead billing associated with these
procedure codes and where abuse is found, initiates recoupment efforts.
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Hospice Care Coverage
IHCP members in need of hospice care must be eligible for program services, must have a prognosis of
six months or less to live, and must elect hospice services. Available hospice services include, but are
not limited to, palliative care for physical, psychological, social, and spiritual needs of the patient.
Hospice providers can provide hospice care to an IHCP member in an inpatient setting or in the
member’s home. Hospice providers must first be enrolled in the IHCP before the IHCP can reimburse
them for services rendered.
Note: Hospice providers should ensure that Hoosier Healthwise and Care Select
members disenroll from the respective program before the member elects the
hospice benefit.
Billing Procedures
Mail hospice claims to the following address for processing:
HP
Hospice Claims
P.O. Box 7271
Hospice providers follow the general directions for completing the UB-04 claim form and use the
following hospice-specific information to fill in the claim form. See the Hospice Provider Manual on
indianamedicaid.com for complete coverage information and billing instructions. Hospice providers
are paid a per diem at the hospice level of care they are providing. Hospice providers should bill only
one hospice revenue code per day. Revenue codes 183, 185, and 657 are the only revenue codes that
can be billed on the same day as another hospice revenue code.
Revenue Codes
Providers should use a code from the following applicable revenue codes for hospice care:
Revenue Code 183: Nursing Facility Bed Hold for Hospice Therapeutic Leave
Days
•
The hospice provider receives 50% of the 95% nursing facility (NF) case mix rate for the roomand-board rate associated with therapeutic leave of absence days.
•
A total of 18 therapeutic leave of absence days are allowed per patient, per calendar year.
•
One day equals one unit of service.
•
Revenue code 183 may be billed on the same day as other hospice revenue codes
Revenue Code 185: Nursing Facility Bed-Hold Policy for Hospitalization for
Services Unrelated to the Terminal Illness of the Hospice Member
•
The hospice provider receives 50% of the 95% NF case mix rate associated with each
hospitalization up to 15 days per occurrence.
•
•
Revenue code 185 may be billed on the same day as other hospice revenue codes.
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Revenue Code 651: Routine Home Care Delivered in a Private Home
•
The IHCP pays the hospice at the routine home care rate for each day the member is at home, under
the care of the hospice provider, and not receiving continuous home care.
•
The IHCP pays this rate without regard to the volume or intensity of routine home care services on
any given day.
•
Note: When an IHCP-only hospice member, residing in his or her private home, is
admitted to a NF for treatment of a nonterminal condition, the hospice
provider must continue to bill for hospice services using revenue codes 653
or 654 while the hospice member is in the facility. When the hospice patient
has resumed residence in his or her private home, the hospice provider must
bill the IHCP using hospice review codes 651 or 652 for those dates of
service following the discharge from the facility.
Revenue Code 652: Continuous Home Care Delivered in a Private Home
•
The provider gives continuous home care only during a period of crisis.
•
A period of crisis occurs when a patient requires continuous care, primarily nursing care, to achieve
palliation and management of acute medical symptoms.
•
The provider must provide a minimum of eight hours of care during a 24-hour day that begins and
ends at midnight.
•
An RN or LPN must provide care for more than half the total time. This care need not be
continuous and uninterrupted.
•
Less skilled care needed continuously to enable the member to remain at home is covered as
routine home care.
•
Divide the continuous home care per diem rate by 24 hours to calculate an hourly rate. For every
hour or part of an hour of continuous care furnished, the IHCP reimburses the hourly rate to the
hospice provider, up to 24 hours a day.
•
One hour equals one unit of service.
Revenue Code 653: Routine Home Care Delivered in a Nursing Facility
•
The IHCP pays the hospice provider at the routine home care rate for each day the member is in a
NF under the care of the hospice provider and not receiving continuous home care.
•
The IHCP pays this rate without regard to the volume or intensity of routine home care service on
any given day.
•
In addition, the IHCP pays the hospice provider 95% of the lowest NF per diem to cover room-and-board costs incurred by the contracted NF. The provider should bill only normal and customary
routine home care amounts as the billed amount; IndianaAIM calculates 95% of the lowest NF per
diem and pays accordingly.
•
Nursing facility room and board are not billable for the date of death.
•
Providers also cannot bill for NF room and board for the date the member is physically discharged
from the NF.
•
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Revenue Code 654: Continuous Home Care Delivered in a Nursing Facility
•
As in the private home setting, divide the continuous home care rate by 24 hours to calculate an
hourly rate. For every hour or part of an hour of continuous care furnished, the IHCP reimburses
the hourly rate to the hospice provider, up to 24 hours a day.
•
All limitations listed for the private home setting also apply in the NF setting.
•
In addition, the IHCP pays the hospice an additional 95% of the NF case mix rate to cover room-and-board costs incurred by the contracted NF.
•
Providers cannot bill for NF room and board for the date of death.
•
from the NF.
•
One hour equals one unit of service.
Revenue Code 655: Inpatient Respite Care
•
The IHCP pays the hospice provider at the inpatient respite care rate for each day the member is in
an approved inpatient facility and is receiving respite care.
•
Respite care is short-term inpatient care provided to the member only when necessary to relieve the
family members or other people caring for the member. Respite care may be provided only on an
occasional basis.
•
The IHCP pays for respite care for a maximum of five consecutive days at a time, including the
date of admission but not counting the day of discharge.
•
The IHCP pays for the sixth and any subsequent days at the routine home care rate.
•
This service applies only to members who normally reside in private homes.
•
The additional amount for room and board is not available for members receiving respite care.
•
•
According to 405 IAC 1-16-2(i), when a member is receiving general inpatient or inpatient respite
care, the applicable inpatient rate (general or respite) is paid for the date of admission and all
subsequent inpatient days except the day on which the patient is discharged. For the day of
discharge, the appropriate home care rate is paid unless the patient dies as an inpatient. In the case
where the member is discharged deceased, the applicable inpatient rate (general or respite) is paid
for the date of discharge.
Revenue Code 656: General Inpatient Hospice Care
•
The IHCP pays the hospice provider at the general inpatient hospice rate for each day the member
is in an approved inpatient hospice facility and is receiving general inpatient hospice care for pain
control, or acute or chronic symptom management, that cannot be managed in other settings.
•
This service applies only to members who normally reside in private homes.
•
The additional amount for room and board is not available for members receiving respite care.
•
•
According to 405 IAC 1-16-2(i), when a member is receiving general inpatient or inpatient respite
care, the applicable inpatient rate (general or respite) is paid for the date of admission and all
subsequent inpatient days except the day on which the patient is discharged. For the day of
discharge, the appropriate home care rate is paid unless the patient dies as an inpatient. In the case
where the member is discharged deceased, the applicable inpatient rate (general or respite) is paid
for the date of discharge.
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Revenue Code 657: Hospice Direct Care Physician Services
•
The IHCP reimburses on a fee-for-service (FFS) basis for physician services provided by a
physician who is an employee of the hospice provider or subcontracted by the hospice. The hospice
provider bills for these services under the hospice NPI.
•
Providers can bill this revenue code on the same day as other hospice revenue codes.
•
Revenue Code 659: Dually Eligible Nursing Facility Members Only
•
Use this revenue code for dually eligible members residing in a NF.
•
This code represents the room-and-board portion of the hospice per diem.
•
The IHCP pays the hospice provider an additional 95% of the NF case mix rate to cover room-andboard costs incurred by the contracted NF.
•
Revenue code 659 must not be billed with the following hospice-related revenue codes: 651, 652,
653, 654, 655, and 656.
•
Providers cannot bill for NF room and board for the date of death.
•
from the nursing facility.
•
Nonhospice Providers Billing Medicare for Nonterminal Conditions for a
Medicare Hospice Beneficiary
For Medicare beneficiaries, the Medicare program specifies that nonhospice providers bill Medicare
directly by using condition code 07 when the nonhospice provider delivers Medicare-covered services
to treat the nonterminal condition of a Medicare hospice beneficiary. This policy also applies to dually
eligible Medicare and IHCP hospice members because the IHCP is the payer of last resort.
The nonhospice provider must bill Medicare using condition code 07 in fields 18-24 on the UB-04
claim form. The Medicare program stipulates that nonhospice providers are subject to recovery of
overpayments and possible referral for fraud and abuse investigation if a pattern of incorrect use of
condition code 07 is determined.
Hospice or NF providers with questions about proper use of condition code 07 or a case-specific
question involving a Medicare hospice beneficiary, whether the member is Medicare only or a dually
eligible Medicare and IHCP hospice member, may contact the Medicare Part A Intermediary for
Indiana at 1-800-633-4227. Because the IHCP is the payer of last resort, hospice providers and nursing
facilities serving dually eligible Medicare and IHCP hospice members must bill Medicare first for
nonhospice services, according to the parameters established by Medicare.
Hospice Care in Group Homes
Medicaid-eligible group home members can elect the Medicaid hospice program per the CMS. The
hospice should bill Medicaid for the hospice services and the group home can bill Medicaid directly
for the group home per diem rate. Claims for group homes were previously denied by IndianaAIM with
error code 2027 – Hospice Recipient Being Billed for Non-Hospice Services. IndianaAIM has been
updated and group homes should not encounter any denials for error code 2027. Hospice and group
home providers should coordinate the overall care for the group home member. It is the responsibility
of the hospice to provide all hospice-covered services in frequency and scope to care for the terminal
illness and related conditions. Furthermore, the hospice should not delegate any hospice core services
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to group home staff. Any questions about the Medicaid hospice program should be directed to the
FSSA Division of Aging at (317) 233-1956.
Physician Services under Revenue Codes 651 through 655
Reimbursement for Physician Services
The basic payment rates for hospice care represent full reimbursement to the hospice provider for
covered services related to the treatment of the patient’s terminal illness. Covered services include the
administrative and general activities performed by physicians who are employees of, or working under
arrangements made with, the hospice provider. The physician who serves as the medical director and
the physician member of the hospice interdisciplinary group generally performs the following group
activities:
•
Establishment of governing policies
•
Participation in the establishment of plans of care
•
Periodic review and update of plans of care
•
Supervision of care and services
The costs for these services are included in the reimbursement rates for the following:
•
Continuous home care, revenue code 652 or 654
•
Inpatient respite care, revenue code 655
•
Routine home care, revenue code 651 or 653
Physician Services under Revenue Code 657
Providers should bill for a hospice-employed physician’s direct patient services (for example, not
rendered by a hospice physician volunteer) as an additional service by the hospice provider, using the
hospice NPI. The hospice may bill only direct patient care physician services. Laboratory and X-ray
services are included in the hospice daily rates.
Consulting physicians are physicians who see the hospice patient for treatment of the terminal illness
and are paid for the services out of the hospice per diem. To bill for consulting physician charges, the
hospice must do the following:
•
Ensure that hospice providers have a contract with the consulting physician that addresses
contracted service, cost for service, rate paid for service, and acknowledgement that the hospice is
the professional manager of the patient’s hospice care.
•
Bill Medicaid using hospice revenue code 657 and track the claims payment by keeping Medicaid’s
Remittance Advice for this charge, along with the consulting physician’s bill or invoice for the
service rendered.
Hospice providers must meet all standard billing rules and claim filing limits when billing for a
consulting physician. If the consulting physician has submitted a bill that is past the one-year filing
limit, that claim will deny.
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Prior-Authorized Physician Services
The IHCP reimburses a physician’s direct patient services not rendered by a hospice physician
volunteer as an additional payment, in accordance with the usual IHCP reimbursement methodology
for physician services. The hospice must not bill these services under the hospice NPI.
An attending physician may bill only the physician’s personal professional services. Do not include the
costs for services, such as laboratory or X-ray, on the attending physician’s billed charges when those
services relate to the terminal condition. Include these costs in the daily hospice care rates because they
are expressly the responsibility of the hospice provider. Providers may bill independent physician
services on the CMS-1500 claim form or 837P transaction.
Hospice Contracts with Other Entities for Hospice-related Services
State law requires the IHCP hospice program to mirror the coverage and reimbursement methodology
of the Medicare hospice program. Medicare- and Medicaid-certified hospice providers must be
certified by Medicare and licensed by the ISDH before enrollment in the IHCP. They are required to
comply with the Medicare hospice Conditions of Participation at 42 CFR 418.
The hospice provider is required to adhere to certain contractual responsibilities when entering a
contract with a nonhospice provider for a service related to the member’s terminal illness or related
conditions. The contract requires the nonhospice provider to bill the hospice for those services at the
fair market value rate noted in the contract. The nonhospice provider must not bill the IHCP for those
services separately, because this would be duplicate billing and subject the nonhospice provider to
recoupment.
Volunteer Physician Services
Volunteer physician services are excluded from reimbursement. However, a physician who provides
volunteer services to a hospice may receive reimbursement for nonvolunteer services provided to
hospice patients. In determining which services are furnished on a volunteer basis and which are not, a
physician must treat IHCP patients on the same basis as other hospice patients. For example, a
physician cannot designate all physician services rendered to non-IHCP patients as volunteer services,
and at the same time seek payment for all physician services rendered to IHCP patients.
Emergency Services
If emergency services are related to the terminal illness and the hospice member has not revoked the
hospice benefit, the hospice provider is responsible for hospital and transportation charges associated
with all emergency services provided. If the emergency services are unrelated to the terminal illness,
the IHCP may reimburse the transportation and hospital claims associated with the emergency
services.
Concurrent Hospice and Curative Care Services for Children
IHCP-enrolled children 20 years of age and under who elect the IHCP hospice benefit may also receive
curative care services for the terminal condition concurrent with hospice care. Curative services must
be medically necessary and included as part of the hospice plan of care submitted to ADVANTAGE
Health Solutions.
When the IHCP member elects concurrent hospice and curative care benefits, the palliation and
management of the terminal condition comes under the supervision of the IHCP hospice provider.
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Curative care services are covered separately from hospice services. Providers rendering curative
services under the plan of care are responsible to obtain prior authorization for their services, when
needed, and to bill for curative services. See the Hospice Provider Manual for additional information.
Billing the Programs as the Payer of Last Resort
The IHCP is always the payer of last resort. Therefore, the hospice provider must first bill other payer
sources before billing the IHCP. The following scenarios for IHCP-only hospice members and dually
eligible Medicare and Traditional Medicaid hospice members provide guidelines for hospice providers.
IHCP-Only – Hospice Member Residing in the Private Home
If the IHCP-only hospice member has private insurance and resides in a private home, the hospice
provider must first bill the private insurance for hospice services. When the private insurance company
denies or partially pays the claim, the hospice provider can bill the IHCP for the remaining balance for
hospice services.
If the private insurance company has denied payment for hospice services, in whole or in part, the
hospice provider must complete a UB-04 claim form, and send, as an attachment to the claim, a copy
of the notice from the private insurance company that outlines the denial of payment for those dates of
service. On receipt of the attachment, the IHCP processes the claim for payment.
IHCP-Only – Hospice Member Residing in a Nursing Facility
If the IHCP-only hospice member has private insurance and resides in a NF, the hospice provider must
bill the private insurance company first for the hospice services and the room-and-board services.
When the private insurance company denies or partially pays the claim, the hospice provider bills the
IHCP for the remaining balance of the hospice services and room-and-board services.
The hospice provider must attach to the UB-04 claim form a copy of the notice from the private
insurance company that outlines denial of payment for those dates of service. On receipt of the UB-04
claim form, the IHCP processes the claim for payment.
If the member has private insurance, the hospice provider must bill the private insurance company
first, and then bill Medicare for the outstanding balance, according to the guidelines established by
Medicare.
When billing for a date of service that is the same as the date of death, hospice providers must bill
occurrence code 51 in field 31 of the UB-04 claim form, along with the date of death. The IHCP only
pays for hospice services for the date of death when the services are billed with occurrence code 51
and revenue codes 653 and 654. If providers bill revenue codes 653 and 654 without occurrence code
51, the claim denies. When providers bill revenue code 659, the claim denies, even if it is billed with
occurrence code 51.
Dually Eligible Medicare and Traditional Medicaid – Hospice Member Residing
in a Private Home
For the dually eligible Medicare and Traditional Medicaid hospice member residing in a private home,
the hospice provider must bill Medicare for the hospice services and the IHCP for the outstanding
balance.
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Dually Eligible Medicare and Traditional Medicaid – Hospice Member Residing
in a Nursing Facility
If a dually eligible Medicare hospice member has private insurance and resides in a NF, Medicare and
Traditional Medicaid require that the hospice provider bill the private insurance company first for the
hospice services and room-and-board services.
If the private insurance company denies payment, in whole or in part, for the hospice services, the
hospice provider must then bill Medicare for the outstanding balance, according to the billing
guidelines established by Medicare.
If the private insurance company denies payment, in whole or in part, for the NF room-and-board
services, the hospice provider must bill the IHCP for the outstanding balance. The hospice provider
must attach to the UB-04 claim form a copy of the notice from the private insurance company that
outlines denial of payment for those dates of service.
CHOICE and Hospice Members
The Community and Home Option to Institutional Care for the Elderly and Disabled (CHOICE)
Program is a state-funded program administered by the Division of Aging (DA). Because CHOICE is
funded 100% by the state of Indiana, the DA stipulates CHOICE is the payer of last resort. Providers
must bill the IHCP and any other insurance carrier prior to submitting charges to the CHOICE
Program.
Medicare and Traditional Medicaid Eligibility Changes during the Month
An IHCP-only hospice member residing in a NF may become Medicare-eligible during a one-month
billing period. Inversely, a dually eligible Medicare and Traditional Medicaid hospice member residing
in a NF may become an IHCP-only hospice member during a one-month billing period. The change in
eligibility status changes how the hospice provider completes the UB-04 for those dates of service.
IHCP-Only – Hospice Member Who Becomes Medicare-Eligible in Nursing
Facility
The hospice provider must complete the necessary paperwork to enroll the IHCP-only hospice member
in the Medicare hospice benefit once the member has become Medicare-eligible. The hospice provider
must also submit the Change in Status of Medicaid Hospice Patient form to the appropriate MCE or
care management organization (CMO) Hospice Authorization Unit to inform the IHCP that the
member has become Medicare-eligible.
The following example provides guidelines for completing the UB-04 claim form for this scenario. For
this example, July 15 is the date the individual is considered dually eligible for Medicare and
Traditional Medicaid. The hospice provider plans to bill the IHCP for the entire month of July.
From July 1 to July 14, the hospice member was an IHCP-only member, so the hospice provider must
bill using revenue code 653 or revenue code 654 for those dates of service. Revenue codes 653 and
654 include the additional room and board per diem to cover costs incurred by the contracted NF.
From July 15 to July 31, the hospice member is considered dually eligible for Medicare and
Traditional Medicaid, and the hospice provider must bill using revenue code 659 for the additional
room and board per diem for those dates of service. The hospice provider must bill Medicare for the
hospice services.
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Dually Eligible Medicare/Traditional Medicaid – Member in a Nursing
Facility Who Becomes IHCP-Only
The hospice provider must complete the Change in Status of Medicaid Hospice Patient form to inform
the IHCP that the individual is no longer Medicare-eligible. The hospice provider must submit the
Change in Status of Medicaid Hospice Patient form to the appropriate MCE or CMO Hospice
Authorization Unit.
The following example provides guidelines for completing the UB-04 claim form for this scenario. For
this example, July 15 is the date the member is eligible for Traditional Medicaid only. The hospice
provider plans to bill the IHCP for the entire month of July.
From July 1 through July 14, the hospice member is dually eligible for Medicare and Traditional
Medicaid, so the hospice provider must bill the IHCP using revenue code 659 for the additional room
and board per diem for these dates of service. The hospice provider must bill Medicare for the hospice
services.
From July 15 through July 31, the hospice member is eligible for Traditional Medicaid only, so the
hospice provider must bill the IHCP for the hospice services and the additional room and board per
diem for these dates of service. The hospice provider must use revenue codes 653 or 654 for those
dates of service. Revenue codes 653 and 654 include the additional room and board per diem to cover
costs incurred by the contracted NF.
Billing a Continuation Claim Using the UB-04 Claim Form
The UB-04 claim form has 22 lines; therefore, providers cannot bill an entire month on one page.
The hospice provider can prepare a continuation claim, which is a claim with more than one UB-04
claim form completed as if it is one claim, to be processed for payment by the IHCP. Continuation
claims cannot contain more than 66 detail lines or be more than three pages long. The hospice provider
must complete the continuation claim as follows:
•
Mark the UB-04 claim form page numbers in the area provided on line 23.
•
Complete the first 22 lines on page one of the UB-04 claim form.
•
Do not subtotal the first page of the claim. Total only the last page of the continuation claim, or
IndianaAIM reads the claim as two claims rather than one.
•
Complete the subsequent UB-04 claims forms for the remaining dates of service of the month.
•
Provide a grand total for the continuation claim on the last page of the UB-04 claim form in the
space provided at the bottom of field locator 47.
If hospice providers prefer not to complete a continuation claim, they can complete separate UB-04
claim forms. The hospice provider completes a second UB-04 claim form for the remaining days of
service of the month, totals the daily amounts, and enters the total charges in the space provided for a
grand total on each form.
Hospice Provider Reimbursement Terms
It is not mandatory for NF providers to reserve beds; however, the OMPP continues to reimburse
hospice providers at one-half the NF case mix reimbursement rate for reserving NF beds for hospice
members, when the occupancy criteria are met as set forth in 405 IAC 5-34-12.
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It is the hospice agency’s responsibility to confirm the NF occupancy percentage on the date that the
leave of absence begins. Hospice providers can bill the IHCP for leave days only when the NF
occupancy percentage is at 90% or greater on the day the leave begins. If the NF occupancy percentage
falls below 90% following the date the leave began, the hospice provider can continue to bill the 50%
of the NF’s case mix reimbursement rate for the entire hospital or therapeutic leave.
When the NF occupancy is below 90% on the date the leave of absence begins, the hospice agency
should use revenue code 180 to bill the IHCP for leave days. Revenue code 180 is a nonpaid revenue
code used to generate an IHCP denial, and it can be used when charging a resident or legal guardian
for nonreimbursed bed-hold days.
The EOB detail for revenue code 180 lists the claim as denied, with EOB 4215 – Leave days not a
covered service for this bill type – nursing facility occupancy less than 90%.
When a member who receives hospice services and resides in a nursing facility has dual eligibility, the
hospice provider must bill claims to the IHCP using revenue code 659 – Hospice services/other/dual
eligibility NF recipients only. A member is considered dually eligible if he or she is enrolled in both
Medicare and Medicaid. The member may also have other commercial insurance. When verifying
member eligibility, members who are dually eligible will be listed as being Qualified Medicare
Beneficiaries (QMB-Also).
When a member who receives hospice services and resides in a nursing facility is not dually eligible
(not a QMB), the hospice provider must bill claims to the IHCP using revenue code 653 – Hospice
services/routine home care delivered in a nursing facility or 654 – Hospice services/continuous home
care delivered in a nursing facility. The provider must use revenue code 653 or 654 even if the
member has other commercial insurance and Medicaid.
If other insurance pays for the hospice care services in full, the hospice provider shall only receive
payment from the IHCP for room-and-board services. If other insurance and the IHCP reimbursed the
provider for hospice care services, the provider was overpaid and must refund the overpayment to the
IHCP.
To refund the overpayment, the provider must complete a Hospice Accounts Receivable Refund
Adjustment form. The form is located on the Forms page of indianamedicaid.com.
Mail the completed form and a check for the overpayment amount to:
HP Refunds
P.O. Box 2303 Dept. 130
The following example shows how to calculate the amount of an overpayment for revenue code 653 or
654.
Table 8.10 – Nursing Home Room and Board Calculation
Nursing Home Room and Board Level of Care
Letter
Represented
Description
A
Nursing Home’s Room-and-Board Rate
B
Payment Percentage of the Room-and-Board Rate
C
Medicaid Reimbursement Per Day (A*B=C)
D
Number of Days in the Month
Amount
$136.98
95%
$130.13
31
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Nursing Home Room and Board Level of Care
Letter
Represented
Description
Amount
E
Total Reimbursement Amount for the Month
(C*D=E)
$4,034.03
F
Patient Liability for the Month
$1,019.00
G
Total Medicaid Reimbursement for Room and
Board (E-F=G)
$3,015.03
Table 8.11 – Hospice Routine Healthcare Calculation
Hospice Routine Healthcare
Letter
Represented
Description
Amount
A
Routine Home Care Rate for the County of the
Provider
$126.92
B
Number of Days in the Month
C
Medicaid Hospice Reimbursement for the Month
(A*B=C)
$3,934.52
D
Amount Paid by Third-party Liability
$3,410.00
E
Total Medicaid Reimbursed for Hospice (C-D=E)
31
$524.52
In this example, the provider received the full hospice reimbursement (Table 8.11, line C) of $3,934.52
and no reimbursement for room and board (Table 8.10, line G).
The IHCP should have reimbursed the provider $3,539.55 (Total Medicaid Reimbursement for Room
and Board, $3,015.03, plus the Total Medicaid Reimbursement for Hospice, $524.52).
The provider was overpaid and must refund the IHCP $394.97 ($3,934.52 minus $3,539.55).
Note: An individual form must be completed for each claim that is being refunded.
Inpatient Hospital Services
Coverage
Inpatient services, such as acute care, mental health, and rehabilitation care, are covered when the
services are provided or prescribed by a physician, and when the services are medically necessary for
the diagnosis or treatment of the member’s condition.
Prior Authorization for Elective Hospital Inpatient Admissions
Effective January 1, 2011, for members with an admit date on or after January 1, 2011, PA is required
for all nonemergent inpatient hospital admissions, including all elective or planned inpatient hospital
admissions. This applies to medical and surgical inpatient admissions. Emergency admissions, routine
vaginal deliveries, C-section deliveries, and newborn stays do not require PA. Observation does not
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require PA. This applies to members of all ages served by Traditional Medicaid, those in the Care
Select program, and in some cases, dually eligible members.
A member who is dually eligible for Medicare and Medicaid must obtain PA for an inpatient stay that
is not covered by Medicare. If a stay is covered by Medicare, in full or in part, the member does not
require PA.
Providers are required to contact ADVANTAGE Health Solutions SM (1-800-784-3981) or MDwise (1800-356-1204) at least two business days prior to admission. MDwise provides PA for Care Select
members who are enrolled with MDwise as their care management organization. All inpatient hospital
PAs are requested via telephone. The facility must call prior to the admission and provide criteria for
medical necessity. Providers may request retroactive PA for dual members if Medicare will not cover
the inpatient stay because the member has exhausted his or her Medicare benefit or if the stay is not a
Medicare-covered service.
The IHCP follows Milliman guidelines for all nonemergent and urgent care inpatient admissions. If
IHCP criteria already exist, that criteria are used first when determining if admissions are appropriate.
If criteria are not available within Milliman or IHCP policy, the IHCP relies on medical necessity
determination of current evidence-based practice. To ensure a 48-hour turnaround, the PA request
should be made by a clinical staff person. For nonemergent and urgent care admissions that occur
outside normal business hours, including weekends and holidays, providers have 48 hours from the
time of admission to request PA.
Billing Procedures
Mail inpatient hospital claims to the following address for processing:
HP Inpatient Hospital Claims
P.O. Box 7271
Note: For RBMC members, bill the appropriate MCE.
Specified Coding Level
The IHCP adheres to the coding guidelines published in the AHA Coding Clinic® for ICD-9-CM, a
publication of the American Hospital Association, Central Office. The following clarifications may
assist providers using the UB-04 claim form:
•
Use the highest level of specificity when billing diagnostic and procedure codes.
•
Assign three-digit codes only if no four-digit codes are within that code category.
•
Assign four-digit codes only if no fifth-digit subclassification is available for that category.
•
Assign the fifth-digit subclassification code for those categories where a fifth digit exists.
•
Use the codes labeled other specified or not elsewhere classified (NEC), unspecified, or not
otherwise specified (NOS) only when the diagnostic statement or a thorough review of the medical
record does not provide adequate information to permit assignment of a more specific code.
•
Use the code assignment for other or NEC when the information at hand specifies a condition but
no separate code for that condition is provided.
•
Use unspecified or NOS when the information at hand does not permit either a more specific or
other code assignment.
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Revenue Code Itemization
Although the IHCP reimburses inpatient hospital services using a diagnosis-related group
(DRG)/Level of Care (LOC) methodology, the IHCP requires a complete itemization of services
performed using appropriate revenue codes in field 42.
The revenue code reveals crucial information about the type of service provided during the inpatient
stay. Therefore, providers need to ensure that each claim properly identifies the appropriate revenue
code. The revenue code that is used must reflect the setting in which the care was delivered. For
example, providers must use revenue code 20X to submit a claim for services provided to patients
admitted to an Intensive Care Unit.
Medical Education Reimbursement
The change in medical education reimbursement is effective for encounter claims (claims that are
forwarded to HP after being adjudicated by a managed care entity) received from the MCEs. Based
upon encounter claims data received from the MCEs, HP processes and issues the medical education
payments to the hospitals.
All medical education payment calculations are made once the MCE has posted the claim payment
information, and the encounter claim has been posted to IndianaAIM. Providers should allow 30 – 45
calendar days from the time the MCE has processed the claim for the medical education payment to be
posted to the fee-for-service Remittance Advice from HP.
Definition of Principal Diagnosis
The principal diagnosis is defined as the condition established, after study, that is chiefly responsible
for the admission of the patient to the hospital. When providers bill for inpatient services, form field 69
requires the principal diagnosis.
Note: The IHCP prohibits use of V codes as a principal diagnosis on a UB-04
claim form, except when using V codes as a principal diagnosis code for
newborns, rehabilitation, or chemotherapy.
Reporting Other Diagnoses
Providers can enter additional diagnosis codes in fields 67 A-Q to indicate all conditions that coexist at
the time of admission, that develop subsequently, or that affect the treatment received or length of stay.
Providers must exclude diagnoses that relate to an earlier episode and have no bearing on the current
hospital stay.
The IHCP defines other diagnoses as additional conditions that affect patient care in terms of requiring
the following:
•
Clinical evaluation
•
Diagnostic procedures
•
Extended length of hospital stay
•
Increased nursing care or monitoring
•
Therapeutic treatment
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Inpatient Blood Factor Claims
Indiana Medicaid reimburses providers for claims for blood factor products administered during
inpatient hospital stays at the lowest of the following:
•
Estimated Acquisition Cost (84% of the Average Wholesale Price)
•
Inpatient blood factor – State maximum allowable cost (MAC)
•
Submitted charge
Blood factor that is used during inpatient hospital stays should be billed separately from the inpatient
hospital diagnosis- related group or Level of Care claim.
Hospitals are prohibited from submitting any charges for blood factor administered during inpatient
hospital stays on their UB-04 claims. Instead, hospitals should submit their claims for blood factor
used during inpatient hospital stays on the CMS-1500 claim form and should include both the NDC
and the NDC quantity of the blood factor on the claims. Hospitals should use their facility NPIs on
their CMS-1500 claim forms.
Claims with quantities greater than 9,999.99 units must be special batched because the NDC code will
be the same for each detail and will deny for duplicates. These claims must be sent to the following
address for special handling:
HP Provider Written Correspondence
P.O. Box 7263
The place of service (POS) entered in field 24B must be 21 – Inpatient Hospital for blood factor
administered during an inpatient hospital stay.
If Medicare covers the blood factor product, the provider cannot bill it separately. If Medicare does not
cover the blood factor product, the provider needs to attach documentation, such as an MRN, to the
claim to show where the factor charges are denied or not covered under Medicare.
Present on Admission Indicators and Hospital-Acquired Conditions
The IHCP utilizes a hospital-acquired conditions (HAC) policy for Medicaid claims using its existing
version 18.0 of the All Patient Diagnosis-Related Group (AP DRG) grouper. Hospitals are required to
report whether each diagnosis on a Medicaid claim was present on admission. Claims submitted
without the required POA indicators are denied. For claims containing secondary diagnoses that are
included in the list of HACs in Table 8.12 and for which the condition was not present on admission,
the HAC secondary diagnosis is not used for AP DRG grouping. That is, the claim is paid as though
any secondary diagnoses included in Table 8.12 were not present on the claim.
Table 8.12 – HAC Categories and Corresponding CC or MCC Codes
Description
Foreign Object Retained After Surgery
Air Embolism
Applicable ICD-9 Codes
(CC – Complication or comorbidity; MCC – Major
complication or comorbidity)
998.4 (CC)
998.7 (CC)
999.1 (MCC)
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Description
Blood Incompatibility
Chapter 8
999.60 (CC)
999.61 (CC)
999.62 (CC)
999.63 (CC)
999.69 (CC)
Pressure Ulcers Stages III and IV
707.23 (MCC)
707.24 (MCC)
Falls and Trauma
Fractures
Dislocations
Intracranial Injuries
Crushing Injuries
Burns
Electric Shock
CC/MCC codes within these ranges:
800 – 829
830 – 839
850 – 854
925 – 929
940 – 949
991 – 994
Catheter-Associated Urinary Tract Infection (UTI)
996.64 (CC); also excludes the following from acting as
a CC/MCC:
112.2 (CC)
590.10 (CC)
590.11 (MCC)
590.2 (MCC)
590.3 (CC)
590.80 (CC)
590.81 (CC)
595.0 (CC)
597.0 (CC)
599.0 (CC)
Vascular Catheter-Associated Infection
999.31 (CC)
999.32 (CC)
999.33 (CC)
Manifestations of Poor Glycemic Control:
Diabetic Ketoacidosis
Nonketotic Hyperosmolar Coma
Hypoglycemic Coma
Secondary Diabetes with Ketoacidosis
Secondary Diabetes with Hyperosmolarity
MCC codes within these ranges:
250.10 – 250.13
250.20 – 250.23
249.10 – 249.11
249.20 – 249.21
251.0 (CC)
Surgical Site Infection, Mediastinitis following
Coronary Artery Bypass Graft (CABG)
519.2 (MCC) and one of the following procedure
codes: 36.10 – 36.19
Surgical Site Infection Following Certain Orthopedic
Procedures:
996.67 (CC)
998.59 (CC)
and one of the following procedure codes:
81.01 – 81.08
81.23 – 81.24
•
Spine
•
Neck
•
Shoulder
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Description
•
Elbow
Surgical Site Infection Following Bariatric Surgery for
Obesity:
•
Laparoscopic Gastric Bypass
•
Gastroenterostomy
•
Laparoscopic Gastric Restrictive Surgery
Surgical Site Infection Following Cardiac Implantable
Electronic Device (CIED) Procedures:
Chapter 8
81.31 – 81.38
81.83
81.85
Principal diagnosis 278.01
539.01 (CC)
539.81 (CC)
998.59 (CC)
44.38
44.39
44.95
996.61 or 998.59
00.50
00.51
00.52
00.53
00.54
37.80
37.81
37.82
37.83
37.85
37.86
37.87
37.94
37.96
37.98
37.74
37.75
37.76
37.77
37.79
37.89
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Description
Deep Vein Thrombosis (DVT)/Pulmonary Embolism
(PE) Following Certain Orthopedic Procedures:
•
Total Knee Replacement
•
Hip Replacement
Iatrogenic Pneumothorax with Venous Catheterization
Chapter 8
453.40 – 453.42 (MCC)
415.11 (MCC)
415.13 (MCC)
415.19 (MCC)
And one of the following procedure codes:
81.54
00.85 – 00.87
81.51 – 81.52
512.1 in combination with procedure code 38.93.
Notes: If a claim contains a HAC diagnosis with a POA indicator of “U (Unknown)” or “N”
(No), the HAC diagnosis is suppressed when the claim processes through the DRG
grouper. The IHCP does not pay the CC or MCC for HACs.
Claims containing HAC diagnoses with POA indicators of “Y” (Yes) or “W” (Clinically
undetermined) will process through the AP DRG grouper and process per normal
inpatient policy.
As of January 1, 2012, hospitals are no longer required to report the POA indicator of
“1” (1 – unreported or not used). This POA indicator is applicable only to diagnoses
exempt from POA reporting and should not be applied to any codes on the HAC list. Any
claims using the POA indicator of “1” with a nonexempt diagnosis will deny, and
providers will need to correct and resubmit the claim for reimbursement.
Present on Admission Indicator
POA is defined as a condition “present” at the time the order for inpatient admission occurs.
Conditions that develop during an outpatient encounter, including emergency department, observation,
or outpatient surgery, are considered POA. A POA indicator must be assigned to principal and
secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting).
The CMS does not require a POA indicator for an external cause of injury code unless it is being
reported as an “other diagnosis.” Therefore, the IHCP does not require a POA indicator in the External
Cause of Injury field locator 72. If a POA indicator is entered in the External Cause of Injury field, it is
ignored and not used for AP DRG grouping.
A new exemption effective July 1, 2012, for HAC/POA is Deep Vein Thrombosis (DVT)/Pulmonary
Embolism (PE) diagnoses following a total knee replacement or hip replacement for pediatric and
obstetric patients. When all these conditions are present on the claim, the HAC/POA requirement is
bypassed and none of the diagnosis codes included on the claim are suppressed.
Common POA Explanations of Benefits
The following table lists common POA EOBs.
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Table 8.13 – Common POA EOBs
EOB Code
EOB Description
4250
The Principal Diagnosis POA Indicator is Missing or Invalid – This
edit posts to the claim when the provider has omitted the POA or
submitted an invalid POA indicator.
4251-4275
The Secondary Diagnosis POA is Missing or Invalid – These EOBs
post to the claim for secondary diagnoses 1-24 if the POA is missing
or invalid. The specific diagnosis field is identified in the EOB
message. Example:
•
4251 – First Secondary Diagnosis POA Missing or Invalid
•
4252 – Second Secondary Diagnosis POA Missing or Invalid
Hospital Acquired Condition List
In conjunction with the October 1, 2011, updates to the International Classification of Diseases, Ninth
Revision (ICD-9), the IHCP has updated the list of hospital-acquired conditions (HACs) to comply
with the federally defined list. The IHCP will continue to follow CMS’ HAC determinations, including
any future additions or changes to the current list of HAC conditions, as well as diagnosis codes that
are exempt from HAC reporting. The list of exempt diagnosis codes can be found in the ICD-9-CM
Official Guidelines for Coding and Reporting. CMS released its original guidance, effective October 1,
2011, at cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf.
Provider Preventable Conditions
The CMS issued Change Request (CR) 6405 to instruct hospitals how to bill for erroneous surgeries.
Effective July 1, 2012, the IHCP adopted the CMS’ rule and does not cover surgical or other invasive
procedures to treat particular medical conditions when the practitioner performs the surgery or invasive
procedure erroneously, including:
•
Incorrect surgical or other invasive procedures
•
Surgical or other invasive procedures on the wrong body part
•
Surgical or other invasive procedures on the wrong patient
The IHCP also does not cover hospitalizations and other services related to these noncovered
procedures. All services provided in the operating room when an error occurs are considered related
and therefore not covered. All providers in the operating room when the error occurs, that could bill
individually for their services, are not eligible for payment. All related services provided during the
same hospitalization in which the error occurred are not covered.
The IHCP will deny payments to providers for inpatient, inpatient crossover, inpatient crossover
Medicare Replacement Plan, outpatient, outpatient crossover, outpatient crossover Medicare
Replacement Plan, physician, physician crossover, and physician crossover Medicare Replacement
Plan claims when provider preventable conditions (PPC) are performed on a patient. These
institutional and physician claims will deny when submitted with the following E codes:
•
E876.5 – Performance of wrong operation (procedure) on correct patient (existing code)
•
E876.6 – Performance of operation (procedure) on patient not scheduled for surgery
•
E876.7 – Performance of correct operation (procedure) on wrong side/body part
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The following PPC modifiers must be submitted on physician, physician crossover, and physician
crossover Medicare Replacement Plan claims indicating errors:
•
PA – Surgery wrong body part
•
PB – Surgery wrong patient
•
PC – Wrong surgery on patient
Medicare Exhaust Claims
Additional information regarding billing the IHCP for dually eligible members who exhaust their
inpatient hospital Medicare Benefits Medicare Exhaust Claims, can be found in Chapter 10: Claims
Processing Procedures of this manual.
Observation Billing
Providers can retain members for more than one 23-hour observation period when the member has not
met criteria for admission but the treating physician believes that allowing the member to leave the
facility would likely put the member at serious risk. This observation period can last not more than
three days or 72 hours and is billed as an outpatient claim.
For all services rendered as outpatient procedures and prior to admission, providers must bill with a
date of service corresponding to the date the procedure was performed in fields 74 and 74a-e of the
UB-04 claim form.
Transfers
Because special payment policies apply to certain transfer cases that are to be reimbursed using the
DRG payment methodology, it is important for providers to identify the transferring hospital on the
UB-04 claim form.
Indicate the following to identify the transferring hospital in field 17:
•
Patient status 02 – Discharged or transferred to another short-term general hospital for inpatient
care.
•
Patient status 03 – Discharged or transferred to skilled nursing facility (SNF).
•
Patient status 04 – Discharged or transferred to an intermediate care facility (ICF).
•
Patient status 05 – Discharged or transferred to a designated cancer center or children’s hospital.
•
Patient status 06 – Discharged or transferred to home under care of organized home health service
organization.
•
Patient status 08 – Discharged or transferred to home under care of a home intravenous provider.
•
Patient status 43 – Discharged or transferred to a federal healthcare facility.
•
Patient status 61 – Discharged or transferred within this institution to hospital-based Medicare
swing bed.
•
Patient status 62 – Discharged or transferred to another rehabilitation facility including discharge
planning units of hospital.
•
Patient status 63 – Discharged or transferred to a long-term care hospital.
•
Patient status 64 – Discharged or transferred to a nursing facility – Medicaid-certified but not
Medicare-certified.
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•
Patient status 65 – Discharged or transferred to a psychiatric hospital or psychiatric distinct part
unit of a hospital.
•
Patient status 66 – Discharged or transferred to a critical access hospital.
•
Patient status 70 – Discharged or transferred to another type of healthcare institution not defined
elsewhere in code list.
•
Patient status 71 – Discharged, transferred, or referred to another institution for outpatient services
when specified by the discharge plan of care.
•
Patient status 72 – Discharged, transferred, or referred within this facility for outpatient services
when specified by the discharge plan of care.
Providers are not to bill separately for two DRG-reimbursed inpatient stays when a member is
transferred from one unit of the hospital to another unit within the same inpatient facility. Inpatient
transfer claims from one inpatient unit of the hospital to another inpatient unit should be billed on one
claim form, as they are considered part of the same episode of care. Exclusions to this policy are
claims priced according to the LOC reimbursement methodology.
Providers must combine the original admission and subsequent return stay on one claim for billing
purposes. Transfer claims continue to be subject to retrospective review to ensure appropriate billing
and payment.
Also, claims for patients that are transferred within 24 hours of admission are to be billed as outpatient
claims. Claims grouping to DRG 639 – Neonate, transferred < 5 days old, born here, and DRG 640 –
Neonate, transferred < 5 days old, not born here, are exempt from this policy.
Special payment policies apply to transfer cases paid using the DRG methodology. The receiving
hospital, or transferee hospital, is reimbursed according to the DRG or LOC methodology, whichever
is applicable. Transferring hospitals are reimbursed a DRG-prorated daily rate for each day, not to
exceed the full DRG amount. The IHCP calculates the DRG daily rate by dividing the DRG rate by the
average length of stay. The full payment to the transferring hospital is the sum of the DRG daily rate,
the capital per diem rate (up to the DRG average length of stay), and the medical education per diem
rate (up to the DRG average length of stay). Transferring hospitals are eligible for outlier payments.
To ensure accurate reimbursement for transfer cases, the appropriate discharge status code of 02, 05,
62, 63, 65, 66, and 70 must be placed in form locator 17 of the UB-04 claim form.
For detailed reimbursement information about transfers and readmissions, see Chapter 7:
Reimbursement Methodologies of this manual.
Inpatient Claims for Spend-down Members Spanning Multiple Months
When a spend-down member has an inpatient stay that spans multiple months, and the date of the
discharge is the first day of a month, the claims are denied for EOB 3005 – The claim covers multiple
months and spend-down has not been met for all months billed on the claim. Submit these claims to the
Written Correspondence Unit for processing along with an attached cover letter referencing this
process. Submit claims that span multiple months with a date of discharge that is not the first of the
month to the normal claims address. Inpatient claims with dates of services that span more than one
month are prorated on a daily basis, not counting the discharge date. Spend-down is credited in each
month based on the number of days of service reported on the claim for each month minus the day of
discharge. The reimbursement is based on the total claim allowed minus the sum of the spend-down
credits.
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Inpatient Mental Health
405 IAC 5-20-1(d) states that PA is required for all inpatient psychiatric admissions, including
admissions for substance abuse. The IHCP reimburses providers for inpatient psychiatric services
provided to an eligible individual between 22 and 65 years old only in a certified psychiatric hospital
of 16 beds or less. If the member is 22 years old and began receiving inpatient psychiatric services
immediately before his or her 22nd birthday, inpatient psychiatric services are available.
According to 405 IAC 5-20-3, a psychiatric hospital must meet the following conditions to be
reimbursed for inpatient mental health services:
•
The facility must be enrolled in the IHCP.
•
The facility must maintain special medical records for psychiatric hospitals as required by
42 CFR 482.61.
•
The facility must provide services under the direction of a licensed physician.
•
The facility must meet federal certification standards for psychiatric hospitals.
•
The facility must meet utilization review requirements.
The IHCP also reimburses providers for reserving beds in a psychiatric hospital but not in a general
acute care hospital for hospitalization of Traditional Medicaid members, as well as for reserving beds
for a therapeutic leave of absence. In both instances, the IHCP reimburses the facility at one-half the
regular per diem rate. 405 IAC 5-20-2 provides specific criteria about the reservation of beds in an
inpatient psychiatric facility.
The IHCP reimburses for inpatient psychiatric services provided by facilities that are freestanding or
distinct parts at an all-inclusive, statewide per diem rate that includes routine, ancillary, and capital
costs. The IHCP bases reimbursement for substance abuse and chemical dependency admissions on
DRG payment methodology. Direct care services of physicians, including psychiatric evaluations, are
excluded from the per diem rate and are billable separately by the rendering provider on the CMS-1500
claim form or 837P transaction. The per diem rate includes all other supplies and services provided to
patients in inpatient psychiatric facilities, including services of health service providers in psychology
(HSPP), clinical psychologists, and clinical social workers, regardless of whether they are salaried,
contracted, or independent providers. Providers cannot bill these supplies and services separately.
All mental health service admissions, including admissions for substance abuse and chemical
dependency regardless of the setting, require a Certification of Need, Form 1261A. For nonemergency
admissions, the IHCP must receive the 1261A form within 10 working days of the admission. For
emergency admissions, the IHCP must receive the 1261A form within 14 working days of the
admission. The 1261A form must include detailed information to document the admission. If the
1261A form does not meet the requirements, any claim associated with the admission is denied.
Chapter 6: Prior Authorization provides specific information about obtaining PA for inpatient
psychiatric admissions.
Providers must submit inpatient psychiatric claims using the revenue code that has been authorized for
the admission. Inpatient mental health services, including substance abuse treatment, provided to
RBMC network members in acute care facilities are the responsibility of the MCE in which the
member is enrolled. The State requires MCEs to manage behavioral healthcare to promote
comprehensive and coordinated medical and behavioral services for Hoosier Healthwise members.
This policy change excludes psychiatric residential treatment facility (PRTF) services and Medicaid
Rehabilitation Option (MRO) services which continue to be carved out or excluded from the RBMC
network and paid on a FFS basis, as well as long-term inpatient services in state-operated facilities.
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Package C
The IHCP covers inpatient mental health and substance abuse services when the services are medically
necessary for the diagnosis or treatment of the member’s condition, except when provided in a mental
health institution with more than 16 beds.
Coding Claims for Newborns
Coding claims for newborns requires birth weight for the proper DRG assignment. The fifth digit of
diagnosis codes 764 and 765 indicates birth weight. Use the following fifth-digit subclassification with
categories 764.X and 765.X to denote birth weight. Table 8.14 lists birth weight codes.
Table 8.14 – Birth Weight Codes
Code
Birth Weight
0
Unspecified weight
1
Less than 500 grams
2
500 grams – 749 grams
3
750 grams – 999 grams
4
1,000 grams – 1,249 grams
5
6
7
8
9
2,500 grams and over
Do not use these codes as principal diagnosis codes.
When a newborn transfers to another hospital for observation, not for treatment for a specific illness,
the receiving provider must enter the diagnosis code V71.8 – Observation for other suspected
conditions as the principal diagnosis.
Unit and Age Limitations on Inpatient Neonatal and Pediatric
Critical Care Services
Unit and age limitations on inpatient neonatal and pediatric critical care services include the following:
•
CPT code 99478 –Subsequent intensive care, per day, for the evaluation and management of the
recovering very low birth weight infant (present body weight less than 1,500 grams).This CPT code
is limited to one unit per day.
•
CPT code 99480 – Subsequent intensive care, per day, for the evaluation and management of the
recovering infant (present body weight less than 2,501−5,000 grams). This CPT code is limited to
one unit per day.
•
CPT code 99469 – Subsequent inpatient neonatal critical care, per day, for the evaluation and
management of a critically ill neonate, 28 days of age or younger. This code has an age limit of
0−28 days of age. This CPT code is limited to one unit per day.
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•
CPT code 99471 – Initial inpatient pediatric critical care, per day, for the evaluation and
management of a critically ill infant or young child, 29 days through 24 months of age. This code
has an age limit of 0−2 years of age. This CPT code is limited to one unit per day.
•
CPT code 99472 – Subsequent inpatient pediatric critical care, per day, for the evaluation and
management of a critically ill infant or young child, 29 days through 24 months of age. This code
has an age limit of 0−2 years of age. This CPT code is limited to one unit per day.
Providers rendering services under the RBMC program should also follow IHCP policy and CPT
coding guidelines when billing these procedure codes.
Stereotactic Radiosurgery
The IHCP currently covers several types of stereotactic radiosurgery (SRS) as represented by HCPCS
codes G0173, G0251, G0339, G0340, and 77301U5. In addition, the IHCP covers preoperative
planning under HCPCS code 77301 U5. Reimbursement for physician services is bundled into the
preoperative planning service.
Ventricular Assist Devices
The IHCP has instituted changes to the medical necessity criteria for ventricular assist devices (VADs)
and considers them medically necessary under the following conditions:
•
The IHCP covers treatment of postcardiotomy cardiogenic shock when ventricular dysfunction
continues after maximum medical therapy or as a means of myocardial recovery support for
individuals who are unable to be weaned from cardiopulmonary bypass with maximal inotropic
support and use of an intra-aortic balloon pump.
•
The IHCP covers bridge-to-transplant for members who meet the following criteria:
- The member must be at risk of imminent death from nonreversible left ventricular failure (New
York Heart Association [NYHA] Class III or IV).
- The member has received prior authorization for a heart transplant (excluding dually eligible
members).
- The member is listed as a candidate for heart transplantation by a Medicare and Medicaidapproved heart transplant center.
- If the VAD is implanted at a different site than the Medicare and Medicaid-approved transplant
center, the implanting site must receive written permission from the Medicare and Medicaidapproved center where the patient is listed for transplant prior to implantation of the VAD.
•
The IHCP covers destination therapy for members who meet the following criteria:
- The member must not be a candidate for a heart transplant.
- The member must have chronic end-stage heart failure (NYHA Class IV) for at least 90 days,
and have a life expectancy of fewer than two years.
- The member’s Class IV heart failure symptoms must have failed to respond to optimal medical
therapy for at least 60 of the last 90 days. Medical therapy must include salt restriction, diuretics,
digitalis, beta-blockers, and angiotensin receptor blockers (ARBs) or angiotensin-converting
enzyme (ACE) inhibitors (if tolerated).
- Left Ventricular Ejection Fraction (LVEF) must be less than 25%.
- The member has demonstrated functional limitation with a peak oxygen consumption of less
than 12ml/kg/min or continued need for IV inotropic therapy due to symptomatic hypotension,
decreasing renal function, or worsening pulmonary congestion.
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- The member has the appropriate body size (greater than or equal to 1.5m2) to support the Left
Ventricular Assist Device (LVAD) implantation.
- VAD implantation must occur at a Medicare and Medicaid-approved heart transplant center.
A VAD is a covered service for postcardiotomy cardiogenic shock or bridge-to-transplant only if it has
received approval from the FDA for the intended purpose, and only if it is used according to the FDAapproved labeling instructions for that intended purpose. A VAD is a covered service for destination
therapy only if it has received approval from the FDA for destination therapy or as a bridge-totransplant, or has been implanted as part of an FDA investigational device exemption trial for one of
these two indications.
Noncovered Services
•
VADs are noncovered for all conditions not listed previously.
•
Use of a non-FDA-approved VAD is considered investigational and is a noncovered service.
•
The artificial heart (for example, AbioCor, CardioWest) as a replacement for a diseased heart is
noncovered by the IHCP.
Prior Authorization
VADs and their surgical implantation do not require PA. However, members who receive bridge-totransplant or destination therapy, and who can continue therapy on an outpatient basis, require
accessory equipment for use with the VAD. The patient supplies and replacement equipment for the
VAD require PA.
Coding and Billing Instructions
Tables 8.15 and 8.16 list the appropriate codes for billing implantation and removal of VADs. The
tables include the following:
•
Table 8.15 lists the applicable ICD-9-CM procedure codes for implantation, repair, and removal of
a VAD. The ICD-9-CM code must be billed on the UB-04 claim form and is incorporated into the
DRG payment.
•
Table 8.16 lists the applicable CPT codes for the physician component of the implantation and
removal of a VAD. The CPT code should be billed on a CMS-1500 claim form or 837P electronic
transaction.
The DRG for hospital inpatients using the VAD system includes the following codes and equipment,
which are not separately reimbursable:
•
ICD-9-CM diagnoses (primary, secondary, tertiary, as appropriate)
•
ICD-9-CM procedures
•
VAD (included in the ICD-9-CM procedure code)
•
Stationary power base and display module (capital purchase by the hospital)
•
Rechargeable batteries and harness (for untethered systems)
•
Miscellaneous supplies
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Table 8.15 – ICD-9 Procedure Codes
Code
Description
37.63
Repair of heart assist system
Replacement of parts of an existing VAD
37.64
Removal of heart assist system
37.65
Implant of external heart assist system
Device (outside the body but connected to heart) with external circulation and pump
Includes open chest procedure for cannula attachments
Insertion of implantable heart assist system
37.66
Device directly connected to the heart and implanted in the upper left quadrant of peritoneal cavity
Includes the following:
•
Axial flow heart assist system
•
Diagonal pump heart assist system
•
LVAD
•
Pulsatile heart assist system
•
Right ventricular assist device (RVAD)
•
Rotary pump heart assist system
•
Transportable, implantable heart assist system
•
VAD, not otherwise specified
Table 8.16 – CPT Procedure Codes
Code
Description
33975
Insertion of ventricular assist device; extracorporeal, single ventricle
33976
Insertion of ventricular assist device; extracorporeal, biventricular
33977
Removal of ventricular assist device; extracorporeal, single ventricle
33978
Removal of ventricular assist device; extracorporeal, biventricular
33979
Insertion of ventricular assist device, implantable, intracorporeal, single ventricle
33980
Removal of ventricular assist device, implantable intracorporeal, single ventricle
33990
Insertion of ventricular assist device percutaneous including radiological supervision and
interpretation; arterial access only
33991
Insertion of ventricular assist device, percutaneous including radiological supervision and
interpretation; both arterial and venous access, with transeptal puncture
33992
Removal of percutaneous ventricular assist device at separate and distinct session from insertion
33993
Reposition of percutaneous ventricular assist device with imaging guidance at separate and distinct
session from insertion
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Long-Term Acute Care Facility Services
Long-Term Acute Care Facilities
Long-term acute care (LTAC) facilities must submit charges on a UB-04 claim form. The billing
provider must use the revenue code 101 – All-inclusive room and board for the PA process and include
it on the UB-04 claim form.
The discharging hospital must enter the patient status code 63 in field 17 on the UB-04 claim form.
This indicates the status of the patient as of the ending service date when the patient was discharged or
transferred to a long-term care facility.
Package C
LTC facility services are not covered for Package C members.
Nursing Facility Services
Coverage
Inpatient LTC services are available to IHCP members who meet the threshold of nursing care needs
required for admission to, or continued stay in, an IHCP-certified nursing facility. Additional
information about LTC coverage and billing procedures is located in Chapter 14: Long Term Care of
this manual.
Billing Procedures
Instructions for billing LTC facility services are separated into two subsections, based on the type of
facility rendering the service.
This section outlines billing instructions for NFs and ICFs/IID. For detailed information about
reimbursement for LTC facilities, see Chapter 7: Reimbursement Methodologies of this manual.
Providers should mail LTC paper claims to the following address for processing:
HP Nursing Home Claims
P.O. Box 7271
NFs and ICFs/IID may bill using the UB-04 claim form, electronic 837I transaction, or Web
interChange claim formats. If submitting paper claims, NFs must follow the general instructions for
completing the UB-04 claim form, as well as the specific instructions that follow.
NFs bill for room-and-board charges using the applicable room-and-board revenue code. Acceptable
room and board revenue codes include 110, 120, and 130. Revenue codes 180, 183, and 185 for leaveof-absence days are no longer reimbursable. The OMPP uses a case mix reimbursement methodology
based on the Resource Utilization Group (RUG)-III Classification of that member. The facility must
maintain documentation in the medical record that substantiates the physical or behavior needs of the
member as identified on the minimum data set (MDS). The RUG-III Classification is based on the
MDS. All long-term care providers must have a State-approved Form 450B or OMPP Form 450B
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SA/DE on file in IndianaAIM for the appropriate provider number before billing services provided to a
member.
Nursing facilities cannot bill separately for medical and nonmedical supply items, personal care items,
or therapies. Providers can bill parenteral or enteral services and therapies received by Medicare- and
Traditional Medicaid-eligible members to Medicare and, subsequently, the IHCP as crossover claims
on the appropriate claim form for these services. Inpatient care crossover services must be billed on the
UB-04 claim form, 837 electronic transaction, or Web interChange institutional claim format. Any
inappropriate billing and reimbursement is subject to recoupment by the IHCP Program Integrity
Department.
Providers can bill short-term stays of less than 30 days upon discharge of the patient. Providers can bill
long-term stays of 30 days or more monthly, or more frequently if desired.
Member Liability
Member liability is the term applied to the monetary amount that a Traditional Medicaid resident must
contribute toward monthly care in the NF. The term personal resource contribution also indicates
member liability.
The calculating and assigning of the member liability amount is a function of the local county office of
the Division of Family Resources (DFR). Member information, including member liability or personal
resource contribution reflected in IndianaAIM, is updated daily from the information relayed by the
Indiana Client Eligibility System (ICES) at the county offices.
Providers must apply current income to current needs. As an example, a Social Security benefit check
received in October must be applied to October charges. The only exception is the direct deposit
benefit check that is sometimes recorded by the bank at the end of one month instead of early in the
next month when it would normally be received. Because most resources are available on a calendar
month basis, all accounts that involve resource deductions must be billed on a calendar month basis,
for example, June 1 through June 30, or July 1 through July 31.
Note: Deduct patient resources from the payment in the month that the resources
are received.
The IHCP automatically deducts the member’s liability amount from the total reimbursement of the
claim. The provider must not indicate the resource contribution anywhere on the claim form. When a
member transfers between facilities during a billing period, the member liability is deducted from the
first claim received and processed by IndianaAIM. Therefore, the facilities involved in the transfer
must coordinate any liability deductions.
Leave Days
The IHCP does not reimburse for bed-hold days in a nursing facility as a member benefit unless the
member is under the care of hospice. All IHCP members residing in a NF are directed to talk with their
individual provider regarding any type of “bed hold” or leave day policy that may exist in that facility.
Providers must make members aware of their policies and that members cannot be charged for services
they do not request. There is no requirement that nursing facilities hold beds.
The facility must inform a resident in writing prior to a hospital transfer or departure for therapeutic
leave that Medicaid does not pay for bed holds; the facility must also communicate its policies
regarding bed-hold periods. A nursing facility is required to follow a written policy under which a
resident, whose hospital or therapeutic leave exceeds Medicaid coverage limitations, is readmitted to
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the facility upon the first availability of a bed in a semiprivate room, if the resident requires NF level
services and is eligible for Medicaid NF services. (See 42 CFR 483.12(b)(3) and 410 IAC 16.2-3.112(a)(27).) Regardless of the length of leave, if the individual remains eligible for nursing facility level
of care and Medicaid, he or she must be readmitted to the facility to the first available bed.
Because Medicaid does not pay to hold beds in nursing facilities under any circumstances, all bed
holds for days of absence are considered noncovered services for which the resident may elect to pay.
If the facility offers this option, the facility must include this information in its written policy, as well
as on the written information provided to the resident prior to hospital transfer or departure for
therapeutic leave.
Facilities cannot establish a minimum bed-hold charge, such as a certain number of days, because this
could overlap with covered services if the resident returns before the minimum period lapses. The
facility must also follow the requirements for billing members for noncovered services set forth in
Chapter 4: Provider Enrollment, Eligibility, and Responsibilities, Section 5 of this manual. Further, it
is the resident’s choice to elect to pay for this service. Facilities can charge residents only for items and
services requested by the resident. See 42 CFR 483.10(c)(8).
Nursing facilities are also obligated to inform residents upon admission of services for which the
resident may be charged and the amounts of those charges. Residents must also be informed of any
changes to available services and any charges. See 42 CFR 483.10(b)(5) – (6). Facilities must provide
30 days’ advance written notice to residents of any changes in rates or services the rates cover. See 410
IAC 16.2-3.1-4(i).
It is not necessary to submit claims for bed-hold days under any circumstances, even for revenue code
180 – Bed-hold days not eligible for payment.
Code any leave day on the claim using one of the codes listed in Table 8.17.
Table 8.17 – Bed-Hold Revenue Codes
Revenue Code
Description
180
Bed-hold days not eligible for payment
183
Therapeutic bed-hold days eligible for payment
185
Hospital bed-hold days eligible for payment
The types of are as follows:
•
Hospitalization – Must be ordered by the physician for treatment of an acute condition that cannot
be treated in the NF. The total length of time allowed for payment of a reserved bed for a single
hospital stay is 15 consecutive days. Providers must use revenue code 185 to denote a leave of
absence for hospitalization. The IHCP reimburses leave days at one-half the case mix room and
board rate. To determine the leave day rate, divide the case mix per diem rate in half.
•
Therapeutic Leave of Absence – Must be for therapeutic reasons, as prescribed by the attending
physician and as indicated in the member’s plan of care. The maximum total length of time allotted
for therapeutic leave in a calendar year is 30 days for any NF resident. Providers must use revenue
code 183 to denote a therapeutic leave of absence.
Autoclosure Billing
To ensure that IHCP members receive all benefits to which they are entitled, it is the responsibility of
each LTC provider to properly document the discharge of residents in a timely manner. IndianaAIM
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uses the patient status code from the UB-04 claim form (locator box 22, STAT) to close the member’s
LOC segment. This eliminates the need for submitting written discharge information to the OMPP.
If the LOC is not updated, it prevents members from receiving services, such as supplies and pharmacy
prescription fulfillment, upon discharge from LTC facilities. Providers should be aware that
overpayments to facilities are subject to recoupment.
The following discharge status codes are the only valid codes for members who are discharged from
LTC facilities:
•
01 – Discharged to home or self-care, routine discharge
•
02 – Discharged or transferred to another short-term general hospital for inpatient care
•
05 – Discharged or transferred to a designated cancer center or children’s hospital
•
07 – Left against medical advice or discontinued care
•
08 – Discharged or transferred to home under care of a home intravenous provider
•
20 – Expired
LTC providers do not receive reimbursement for the date of discharge. Therefore, it is imperative that
LTC providers carefully complete the UB-04 claim form to ensure that the “Through Date of Service”
(TDOS) in field locator 6 on the claim form accurately reflects the actual date of discharge for the
member.
Medicare Crossover Payment Policy
The IHCP makes a payment only when the Medicare payment amount is less than the IHCP rate on file
at the time HP processes the crossover claim. This change in payment policy for Medicare crossover
claims is addressed in 405 IAC 1-18-2. A paid claim can have an amount of $0. See Chapter 14: Long
Term Care of this manual for additional information.
When a nursing facility resident elects Medicare benefits for room and board at the beginning of the
month, the nursing facility collects liability at the beginning of the month, as if the resident was not
using Medicare days. If the resident uses Medicare room-and-board benefits for the entire month, the
nursing facility places the liability collected at the beginning of the month in the resident’s personal
needs allowance account. If the resident uses Medicare benefits for room and board for several months,
this may exhaust the resident’s personal resources. In this case, the nursing facility must notify the
county caseworker, who redetermines the financial eligibility of the resident and may end-date the
resident’s IHCP eligibility until personal resources are again exhausted. The resident may then reapply
for Medicaid and must complete a new Form 450B. If the resident uses only a portion of the month for
Medicare room-and-board benefits, the liability collected by the nursing facility is only for the days
that Medicaid paid the nursing facility room and board. The nursing facility places the remaining
liability in the resident’s personal needs allowance account. If the dollar amount in the personal needs
account exceeds the limit allowed, the nursing facility must notify the county caseworker.
Nursing Facilities Not Medicare-Certified
IHCP-enrolled nursing facilities that are not Medicare-certified must comply with the following:
•
The nursing facility must use the Certification Statement available on indianamedicaid.com to
certify to the OMPP that it will not request payment from the IHCP for services rendered to dually
eligible IHCP members who are eligible to receive Medicare Part A nursing facility benefits. For as
long as a nursing facility elects not to become Medicare-certified, the NF must submit this
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certification annually to the OMPP’s rate-setting contractor, Myers and Stauffer, LC. NFs must
send the Certification Statement with the facility’s regularly scheduled cost report submission.
•
The nursing facility must maintain clinical, payment, and benefit records in sufficient detail to
substantiate to the OMPP that a member for whom IHCP payment was requested is not also
entitled to or eligible for Medicare Part A nursing facility benefits. The facility must contact the
Medicare fiscal intermediary to determine the availability of Medicare.
Intermediate Care Facility for Individuals with Intellectual
Disability Services
ICFs/IID are divided into three distinct categories:
•
Small ICFs/IID – Four to eight beds and are commonly referred to as community residential
facilities for the developmentally disabled (CRF/DD):
- Basic developmental
- Child rearing
- Child-rearing residences with specialized programs
- Developmental training
- Extensive support needs residences for adults
- Intensive training
- Sheltered living
- Small behavioral management residences for children
- Small extensive needs medical residences for adults
•
Large, private ICFs/IID – More than eight beds
•
State-operated facilities – More than eight beds
ICFs/IID bill for room-and-board charges using the applicable room-and-board revenue code.
Acceptable room-and-board revenue codes include 100, 110, 120, and 130.
The ICF/IID reimbursement rate is an inclusive rate. Therefore, ICFs/IID cannot bill separately for
medical and nonmedical supply items, personal care items, or therapies. The small ICFs/IID
reimbursement rate also includes day services as part of the inclusive rate. However, ICFs/IID can bill
separately when billing crossover claims. Any inappropriate billing or reimbursement is subject to
recoupment by the IHCP Program Integrity Department.
Type of Bill
Providers must use type of bill 66X in form field 4 of the UB-04 claim form to denote a large or Stateowned ICF/IID.
Type of bill 67X denotes a group home or small ICF/IID.
Leave Days
Reimbursement is available for reserving beds for members in a private or State-operated ICF/IID,
provided that the criteria set out in 405 IAC 5-13-6 is met.
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Providers must use the appropriate room-and-board revenue code for the days the member was a
patient in the ICF/IID and use the applicable leave of absence revenue code for the days the member
was out of the ICF/IID.
The two types of reimbursed leave days are as follows:
•
Hospitalization – Must be ordered by the physician for treatment of an acute condition that cannot
be treated in the facility. The total time allowed for payment of a reserved bed for a single hospital
stay is 15 consecutive days. If the member requires hospitalization longer than 15 consecutive days,
the member must be discharged from the ICF/IID. If the member is discharged from the ICF/IID
following a hospitalization in excess of 15 consecutive days, the ICF/IID is still responsible for
appropriate discharge planning. Discharge planning is required if the ICF/IID does not intend to
provide ongoing services following the hospitalization for those members who continue to require
ICF/IID Level of Care services. The facility must maintain a physician’s order for hospitalization in
the member’s file at the facility. Providers must use revenue code 185 to denote a leave of absence
for hospitalization.
•
Therapeutic Leave of Absence – Must be for therapeutic reasons, as prescribed by the attending
physician and as indicated in the member’s habilitation plan. The maximum total length of time
allotted for therapeutic leaves in any calendar year is 60 days per member residing in an ICF/IID.
The leave days need not be consecutive. If the member is absent for more than 60 days per year, no
further reimbursement is available to reserve a bed for that member in that year. The facility must
maintain a physician’s order for the therapeutic leave in the member’s file at the facility. Providers
must use revenue code 183 to denote a therapeutic leave of absence.
Use revenue code 180 when the hold days are not eligible for payment.
Outpatient Services
Coverage
Outpatient services are services provided to members who are not registered as inpatients in an acute
care or psychiatric hospital. Outpatient services include surgery, therapy, laboratory, radiology,
chemotherapy, renal dialysis, clinic, treatment room, and emergency department care. The IHCP
covers outpatient services when such services are provided or prescribed by a physician, and when the
services are medically necessary for the diagnosis or treatment of the member’s condition. The
member’s medical condition, as described and documented in the medical record by the primary or
attending physician, must justify the intensity of service provided.
The four categories of service within the defined outpatient hospital prospective payment system are as
follows:
•
Outpatient surgeries
•
Treatment room visits
•
Stand-alone services
•
Add-on services
Medicare and Medicaid
The IHCP developed the coverage policies, reimbursement policies, and billing requirements of the
Outpatient Prospective Payment System. The IHCP does not intend for these policies and requirements
to mirror the policies and procedures of the Medicare program.
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Billing Procedures
Mail outpatient claims to the following address for processing:
HP
Outpatient Claims
P.O. Box 7271
Note: RBMC members must bill the appropriate MCE.
The following clarifications may assist providers using the UB-04 claim form. Detailed information
about reimbursement for outpatient services is in Chapter 7: Reimbursement Methodologies of this
manual.
Package B Billing
Services for Hoosier Healthwise Package B must comply with the following restrictions:
•
The IHCP does not reimburse for any services other than pregnancy-related services.
•
The IHCP pays for drugs prescribed for indications directly related to the pregnancy in accordance
with IAC restrictions.
In addition to drug coverage, transportation, family planning, routine prenatal care, delivery, and
postpartum care, the IHCP reimburses providers for a condition that may complicate the pregnancy.
The IHCP defines a condition that may complicate the pregnancy as any condition manifesting itself
by symptoms of sufficient severity that the absence of medical attention could reasonably be expected
to result in a deterioration of the patient’s condition or a need for a higher level of care.
The IHCP does not dictate to physicians conditions that may or may not complicate a pregnancy.
Therefore, if the physician determines that the illness or injury could complicate the pregnancy or have
an adverse effect on the outcome of the pregnancy, the IHCP covers the care provided for that illness
or injury. Providers should list a pregnancy diagnosis code as the primary diagnosis code and identify
the illness or injury being treated as the secondary diagnosis code if the condition is considered a risk
of complication of the pregnancy.
When billing for emergency services, providers must appropriately code claims as emergency. The
primary diagnosis code must be pregnancy-related, or the IHCP denies the claim. Providers must
indicate the pregnancy-related diagnosis code in primary diagnosis field 67 on the UB-04 claim form.
If the pregnancy diagnosis does not adequately address the specific reason for the visit or care,
providers must also include the visit or care diagnosis as a secondary or tertiary diagnosis on the claim
form.
If a Package B member receives a sterilization procedure following delivery, the primary diagnosis
code must be pregnancy with voluntary sterilization as a secondary diagnosis. The member must
complete consent forms, and the provider must send them with the claim. Consent forms are available
at indianamedicaid.com under the Forms quick link. Instructions for completion can be found in the
Informed Consent Claim Attachment Instructions section of this chapter.
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Notification of Pregnancy Billing
Early prenatal care can address potential health risks that contribute to poor birth outcomes. In
addition, earlier enrollment of pregnant women in Medicaid case management programs is associated
with better birth outcomes. The OMPP data shows that some low-income pregnant women do not seek
prenatal services in the earliest stages of pregnancy, which often leads to untreated health risks. The
OMPP Neonatal Quality Committee, made up of Indiana health professionals, has identified early
prenatal care and the identification of health-risk factors of expectant mothers as an area of focus..
The OMPP is using the Notification of Pregnancy (NOP) form to improve the identification of healthrisk factors of expectant mothers as early as the first trimester of pregnancy. Providers are reimbursed
for submitting an NOP by completing the following instructions:
1. The NOP must be submitted via Web interChange no more than five calendar days from the date the
risk assessment was completed. The NOP cannot be a duplicate of a previously submitted NOP, and
the member’s gestation must be 29 weeks or less.
2. NOP claim forms from hospitals must be coded with the following:
- Revenue code 960
Note: The revenue code, CPT code, and modifier must be billed together to be
reimbursed the NOP fee when billed on the UB-04 claim form.
Duplicate NOPs will not be reimbursed.
Hospitals can submit claims for completing the NOP using the UB-04 claim form. Hospitals should
submit the claim form to the appropriate managed care entity following the previously stated
guidelines for reimbursement. Instructions for submitting the NOP can be found in the Process for
Completion of the Notification of Pregnancy section.
Outpatient Surgeries
The IHCP reimburses an all-inclusive flat fee that includes all related procedures for outpatient
surgeries provided in either a hospital or an ambulatory surgical center (ASC). The IHCP reimburses
for outpatient surgeries provided in a number of settings including an operating room, treatment room,
emergency department, or clinic.
Surgical Revenue Codes
Surgical revenue codes are generally defined as 36X and 49X. The revenue codes for treatment rooms,
such as 45X, 51X, 52X, 70X, 72X, and 76X, are defined as surgical revenue codes when accompanied
by a surgical CPT or HCPCS code. The IHCP reimburses these revenue codes at the appropriate ASC
rate. If the provider performs no surgical procedure, the provider must submit the revenue code
without a CPT or HCPCS code. The IHCP reimburses these services at the treatment room rate.
Providers combine all charges and services associated with the surgical procedure as an all-inclusive
charge on one line item. Component billing of any related services is not appropriate and is denied.
Note: The IHCP does not allow add-on or stand-alone services with any surgical
revenue codes.
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Reimbursement is based on the assignment of the CPT code to one of 16 ASC groups. Reimbursement
rates have been established for each ASC group that reflects the average cost for procedures within the
group. Please note that the assignment of CPT codes to ASC groups may not be the same as the
assignment formally used by the Medicare program. Table 8.18 identifies the ASC groups.
Table 8.18 – ASC Groups
ASC Group
Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
Group 7
Group 8
A – Extensive
B – Complicated
C – Intermediate
D – Simple
E – Moderate
F – Minimal
G – Drug Eluting Stents
H–
M–
T – Telemedicine
The IHCP reimburses a maximum of two units of service regardless of the number of incisions. The
IHCP reimburses the procedure with the highest ASC rate at 100% of that rate, and it reimburses the
procedure with the second-highest ASC rate or bilateral procedure at 50% of the respective ASC rate.
All other procedures are denied. To denote multiple surgeries, the provider must list the appropriate
revenue code and CPT code as two separate detail line items on the claim form.
Providers must bill outpatient surgeries provided in a hospital or an ASC on a UB-04 claim form.
Combine all charges and services associated with the surgical procedure as an all-inclusive charge on
each line item. The appropriate CPT surgical procedure code (10000 through 69999) must accompany
one of the revenue codes listed in Table 8.19:
Table 8.19 – Revenue Codes
Revenue Code
Description
36X
Operating room services
45X
Emergency department
49X
Ambulatory surgical care
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Table 8.19 – Revenue Codes
Revenue Code
Description
51X
Clinic
52X
Freestanding clinic
70X
Cast room
72X
Labor/delivery room
76X
Providers must include all outpatient services provided on the day of the surgery on a single claim.
Include the charges for any other services provided on the day of the surgery with the charge for the
surgery, as described previously. Add-on or stand-alone services are not separately reimbursable.
Implantable DME
The cost of certain implantable durable medical equipment is separately reimbursable for outpatient
claims. Some of these items require prior authorization (see Chapter 6: Prior Authorization of this
manual for more information about PA). Providers should submit claims for these items on the CMS1500 claim form or 837P transaction. Submit only these items on the CMS-1500 claim form or 837P
transaction. The IHCP permits only these items to have separate reimbursement. Table 8.20 lists the
implantable durable medical equipment.
Table 8.20 – Implantable Medical Equipment
Category
Type
Notes
Cardiac Pacemakers
Single-chamber
C1786, C2620
Cardiac Pacemakers
Dual-chamber
C1785, C2619
Cardiac Pacemakers
Other than singleor dual-chamber
C2621
Implantable Cardioverter
Defibrillators
N/A
See Implantable Cardioverter
Defibrillators
Implantable Loop Recorders
N/A
See Patient-Activated Event Recorder—
Implantable Loop Recorder.
N/A
See Phrenic Nerve Stimulator (Breathing
Pacemaker).
Spinal Cord Stimulators
N/A
See Spinal Cord Stimulators
New Technology Intraocular
Lenses
N/A
Phrenic Nerve Stimulators
Vagal Nerve Stimulators
N/A
Implantable Infusion Pumps
Nonprogrammable
Implantable Infusion Pumps
Programmable
See Intraocular Lenses.
See NeuroCybernetic Prosthesis System –
Vagus Nerve Stimulator.
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Corneal Tissue
The cost associated with corneal tissue acquisition, HCPCS code V2785 – Processing, preserving, and
transporting corneal tissue, is separately reimbursable from the ASC rate for outpatient corneal
transplant procedures. Submit claims for this item on the CMS-1500 claim form or through the 837P
transaction. Make sure to attach a copy of the invoice from the eye bank or organ procurement
organization showing the actual cost of acquiring the tissue. Providers must follow current policy for
submitting paper attachments with the 837P transaction. HCPCS code V2785 is reimbursed 100% of
the cost invoice.
Pacemakers
When the implantation is performed in an outpatient surgical setting, the IHCP reimburses the cost of
single- and dual-chamber pacemakers identified in Table 8.20 in addition to the ASC rate. The facility
purchasing the pacemaker must submit, as an attachment to the CMS-1500 or 837P electronic
transaction, a manufacturer’s cost invoice showing the purchase price for the pacemaker. The IHCP
reimburses the provider at 100% of the cost invoice for this device.
Implantable Cardioverter Defibrillators
Effective March 1, 2012, the IHCP reimburses the cost of implantable cardioverter defibrillator
devices separately from reimbursement for the implantation procedure, when the implantation is
performed in an outpatient surgical setting. Coverage is retroactive to dates of service on or after
January 1, 2009.
Prior authorization
Prior authorization is required for all implantable cardioverter defibrillators, per 405 IAC 5-3-13.
Covered indications
Implantable cardioverter defibrillators are indicated for members who are receiving ongoing optimal
medical therapy, have a reasonable expectation of survival with good functional status for more than
one year, and meet the following criteria:
•
Survivors of cardiac arrest due to ventricular fibrillation or hemodynamically unstable, sustained
ventricular tachycardia (VT) (after evaluation to define the cause of the event and to exclude any
completely reversible causes). In addition:
- Members must be able to give informed consent.
- Ejection fractions must be measured by angiography, radionuclide scanning, or
echocardiography.
- Myocardial infarctions (MIs) must be documented and defined according to the criteria in Table
8.21.
•
Left ventricular (LV) dysfunction with prior MI (ischemic cardiomyopathy) and one of the
following:
- LVEF less than or equal to 35%, due to prior MI; at least 40 days post-MI; and a NYHA
functional Class II or III classification (see Table 8.22)
- LV dysfunction due to prior MI; at least 40 days post-myocardial infarction; an LVEF less than
or equal to 30%; and an NYHA functional Class I classification (see Table 8.22)
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- Nonsustained VT due to prior MI; LVEF less than or equal to 40%; and inducible ventricular
fibrillation or sustained VT at electrophysiological study
The following must also be met:
- Members must be able to give informed consent.
 Ejection fractions must be measured by angiography, radionuclide scanning, or
echocardiography.
 MIs must be documented and defined, according to the criteria in Table 8.21.
•
Nonischemic, dilated cardiomyopathy with an LVEF less than or equal to 35%; and an NYHA
functional Class II or III classification (see Table 8.22).
•
Sustained VT, either spontaneous or induced by an electrophysiology (EP) study; not associated
with an acute MI; and not due to a transient or reversible cause
•
Syncope of undetermined origin with one of the following:
- Clinically relevant, hemodynamically significant sustained VT
- Ventricular fibrillation induced at electrophysiological study
- Unexplained syncope, significant LV dysfunction, and nonischemic dilated cardiomyopathy
•
One or more of the following familial or inherited conditions with a high risk of life-threatening
VT:
- Hypertrophic cardiomyopathy with one or more of the following major risk factors for sudden
cardiac death (SCD):
 Prior cardiac arrest
 Spontaneous sustained VT
 Spontaneous nonsustained VT
 Family history of SCD
 Syncope
 LV thickness greater than or equal to 30 mm
 Abnormal blood-pressure response to exercise
- For the prevention of SCD in members with arrhythmogenic right ventricular
dysplasia/cardiomyopathy (ARVD/C) with one or more risk factors for SCD:
 Induction of VT during electrophysiological testing
 Detection of nonsustained VT on noninvasive testing
 Male gender
 Severe right-ventricular dilation
 Extensive right-ventricular involvement
 Young age at presentation (less than 5 years old)
 LV involvement
 Prior cardiac arrest
 Unexplained syncope
 Deleterious genetic mutations associated with ARVD/C
- The reduction of SCD in members with Long QT Syndrome who are experiencing syncope or
VT while receiving beta blockers
- Brugada syndrome and one of the following:
 Previous syncope
 Documented VT that has not resulted in cardiac arrest
 Catecholaminergic polymorphic VT with syncope or documented, sustained VT while
receiving beta blockers
 Nonhospitalized members awaiting heart transplants
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 Cardiac sarcoidosis
 Giant cell myocarditis
 Chagas disease
Implantable Cardioverter Defibrillators for Pediatric Members and Members
with Congenital Heart Disease
Implantable cardioverter defibrillators are indicated for pediatric members and members with
congenital heart disease who meet the following criteria:
•
Survival of cardiac arrest (after evaluation to define the cause of the event and to exclude any
reversible causes)
- Symptomatic, sustained VT in association with congenital heart disease in members who have
undergone hemodynamic and electrophysiological evaluation
 Catheter ablation or surgical repair may offer possible alternatives in carefully selected
patients.
- Congenital heart disease with recurrent syncope of undetermined origin in the presence of
ventricular dysfunction or inducible ventricular arrhythmias at electrophysiological study
- Recurrent syncope associated with complex, congenital heart disease and advanced, systemic,
ventricular dysfunction when thorough invasive and noninvasive investigations have failed to
define a cause
Noncovered Indications
Implantable cardioverter defibrillators are not covered when members meet the following criteria:
•
Irreversible brain damage, or disease or dysfunction that precludes the ability to give informed
consent
•
Significant psychiatric illnesses that may be aggravated by device implantation or that may
preclude systematic follow-up
•
Any disease, other than cardiac disease (for example, cancer, uremia, liver failure, advanced
cerebrovascular disease) associated with less than one year’s survival
•
Ventricular tachyarrhythmias due to a completely reversible disorder in the absence of structural
heart disease (for example, electrolyte imbalance, drugs, or trauma)
•
Asymptomatic VT or symptomatic VT/ventricular fibrillation (VF):
- Associated with acute MI within two days
- Due to a remediable cause
- Controlled by appropriate drug therapy
- Manageable through the use of other therapies (for example, ablation procedures, surgery)
•
Incessant VT or VF
•
Syncope of undetermined cause without inducible ventricular tachyarrhythmias and without
structural heart disease
•
Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
•
CABG or percutaneous transluminal coronary angiography within the past three months
•
Acute MI within the past 40 days
•
Clinical symptoms or findings that make the member a candidate for coronary revascularization
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•
NYHA Class IV symptoms and drug-refractory congestive heart failure but no possibility of
cardiac transplantation or implantation of a cardiac resynchronization therapy (CRT) device that
incorporates both pacing and defibrillation capabilities
•
VF or VT that is amenable to surgical or catheter ablation (for example, atrial arrhythmias
associated with Wolff-Parkinson-White syndrome, right ventricular or LV outflow tract VT,
idiopathic VT, or fascicular VT in the absence of structural heart disease)
•
Recipient of an implantable cardioverter defibrillator that has not received market approval from
the FDA
Table 8.21 – Diagnosis Criteria for an MI
Diagnosis Criteria for an Acute, Evolving or Recent MI
Either one of the following criteria satisfies the diagnosis for an acute, evolving or recent MI:
•
Typical rise and gradual fall (Troponin) or more rapid rise and fall (CK-MB) of biochemical
markers of myocardial necrosis with at least one of the following:
- Ischemic symptoms
- Development of pathologic Q waves on the ECG
- ECG changes indicative of ischemia (ST segment elevation or depression)
- Coronary artery intervention (for example, coronary angioplasty)
•
Pathologic findings of an acute MI
Diagnosis Criteria for Established MI
Either of the following criteria satisfies the diagnosis for an established MI:
•
Development of new pathologic Q waves on serial ECGs
- Member may or may not remember previous symptoms.
- Biochemical markers of myocardial necrosis may have normalized, depending on the length of
time that has passed since the infarct developed.
•
Pathologic findings of a healed or healing MI
Table 8.22 – New York Heart Association Functional Classification
NYHA Class
Symptoms
I
No symptoms and no limitation in ordinary physical activity, such as
shortness of breath when walking, climbing stairs
II
Mild symptoms (mild shortness of breath and/or angina) and slight limitation
during ordinary activity
III
Marked limitation in activity due to symptoms, even during less-thanordinary activity, such as walking short distances (20–100 m); comfortable
only at rest
Reimbursement
The IHCP will reimburse for the surgical implantation and the implantable cardioverter defibrillator
devices when they are billed appropriately. Providers must bill using the procedure codes listed in
Table 8.23 − Implantable Cardioverter Defibrillator Surgical CPT Codes and Table 8.24 − Implantable
Cardioverter Defibrillator Device HCPCS Codes.
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Table 8.23 – Implantable Cardioverter Defibrillator Surgical CPT Codes
CPT Code
Description
33212
Insertion of pacemaker pulse generator only; with existing single lead
33216
Insertion of a single transvenous electrode, permanent pacemaker, or cardioverter-defibrillator
33217
Insertion of 2 transvenous electrodes, permanent pacemaker, or cardioverter-defibrillator
33240
Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead
33249
Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous
lead(s), single or dual chamber
The IHCP will provide reimbursement for the implantable cardioverter defibrillator device when billed
on a CMS-1500 claim form or 837P transaction. The IHCP permits only certain implantable items to
have separate reimbursement. Providers must bill utilizing the procedure codes listed in Table 8.24.
Table 8.24 – Implantable Cardioverter Defibrillator Device HCPCS Codes
HCPCS
Code
Description
C1721
Cardioverter-defibrillator, dual chamber (implantable)
C1722
Cardioverter-defibrillator, single chamber (implantable)
C1777
Lead, cardioverter-defibrillator, endocardial single coil (implantable)
C1779
Lead, pacemaker, transvenous VDD single pass
C1882
Cardioverter-defibrillator, other than single or dual chamber (implantable)
C1895
Lead, cardioverter-defibrillator, endocardial dual coil (implantable)
C1896
Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable)
C1898
Lead, pacemaker, other than transvenous VDD single pass
C1899
Lead, pacemaker/cardioverter-defibrillator combination (implantable)
C1900
Lead, left ventricular coronary venous system
Billing instructions
Submission of these attachments can be either via paper claim with the attachments behind the claim
or via Web interChange using the paper attachment process.
For dates of service January 1, 2009, through June 30, 2011, providers must submit a retail invoice or a
manufacturer’s cost invoice with their claim, along with a copy of the front page of bulletin BT201203.
For dates of service July 1, 2011, through February 29, 2012, providers must submit a cost invoice and
documentation of the manufacturer’s suggested retail price (MSRP) with their claim, along with a copy
of the front page of BT201203.
For dates of service on or after March 1, 2012, providers must submit a cost invoice and
documentation of MSRP with their claim.
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Phrenic Nerve Stimulator (Breathing Pacemaker)
The phrenic nerve stimulator (breathing pacemaker) is an electrophrenic pacemaker for pacing the
diaphragm. The device consists of an external radio frequency transmitter, an antenna, a subcutaneous
radio receiver, and a bipolar platinum nerve electrode. Diaphragmatic pacing (intermittent electrical
stimulation of the phrenic nerves) offers freedom from mechanical ventilation for patients who need
long-term ventilation, and have a functionally intact phrenic nerve and chest-wall stability. The IHCP
now covers the phrenic nerve stimulator subject to specific coverage criteria.
Prior Authorization
Prior authorization (PA) is required for this device and its implantation, whether the device is
implanted on an inpatient or an outpatient basis. One or more of the following ICD-9-CM diagnosis
codes must be used when submitting requests for PA. Members with these diagnoses who are
ventilator dependent and have a tracheostomy due to partial or complete respiratory insufficiency are
considered candidates for this device, subject to review.
•
344.0-344.9 – Includes quadriplegia and quadraparesis of all types
•
780.51 and 780.53 – Nonobstructive sleep apnea
•
786.09 – Congenital respiratory abnormalities, other
Coding and Billing Instructions
For inpatient billing of the implantation of the device, the appropriate DRG is used. The claim for the
device must be submitted as a DME item on a CMS-1500 claim form. When the device is implanted as
an outpatient procedure, revenue code 360 with CPT code 33282 should be used on the UB-04 claim
form and the device billed as a DME item on a CMS-1500 claim form. The decision for either
outpatient or inpatient status is made by the physician and determined by the assessment of
complicating factors and their severity at the time the procedure is planned.
Table 8.25 provides the CPT codes and description information to use when submitting claims as an
inpatient or outpatient.
Table 8.25  CPT Codes for Phrenic Nerve Stimulator Services on
Inpatient and Outpatient Claims
CPT Code
Description
64585
Revision or removal of peripheral
neurostimulator electrode array
95970
Electronic analysis of implanted
neurostimulator pulse generator system (eg,
rate, pulse amplitude, pulse duration,
configuration of wave form, battery status,
electrode selectability, output modulation,
cycling, impedance and patient compliance
measurements); simple or complex brain,
spinal cord, or peripheral (ie, cranial nerve,
peripheral nerve, sacral nerve, neuromuscular)
neurostimulator pulse generator/transmitter,
without reprogramming
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CPT Code
95974
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Description
Electronic analysis of implanted
neurostimulator pulse generator system (eg,
rate, pulse amplitude, pulse duration,
configuration of wave form, battery status,
electrode selectability, output modulation,
cycling, impedance and patient compliance
measurements); complex cranial nerve
neurostimulator pulse generator/transmitter,
with intraoperative or subsequent
programming, with or without nerve interface
testing, first hour
Coverage Issues
Patient Selection
The primary objective of implanting the phrenic nerve stimulator is to allow the member to return to a
home environment from a skilled nursing facility and be more independent. Therefore, the following
criteria are mandatory for prospective candidates requesting this device:
•
Functional lungs and diaphragm muscle
•
Absence of infection
•
A clear and adequate upper airway (including nasopharynx, pharynx, larynx)
•
Family support that includes an unpaid, physical caregiver of adequate quality and the availability
of nursing and medical care
Medical Review Documentation
Prior authorization for medical necessity is required for this device and its implantation. The
equipment is costly and requires preoperative testing of the components, and thorough education of the
member and his or her caregivers concerning its use.
Medical Policy Criteria
1. Members who qualify for this device demonstrate life-threatening oxygen depletion when respiration
is unassisted.
2. For stable, nonacute quadriplegics and other members with spinal-cord or brain-stem injuries [ICD9-CM 344(00-09) diagnosis codes], all the following criteria must be met:
- Patient is oriented to name, date, and place.
- Patient’s mobility will be improved. Patient will be able to be out of bed and be mobile per
wheelchair, which may allow for employment or school attendance. Increased mobility will
enable the patient to function without interference of large equipment.
- Patient’s skin integrity will be better maintained because of increased mobility.
- Patient has the capacity to be productive. He or she will more easily perform cognitive tasks
within physical limitations.
- Patient will be better able to eat and swallow.
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3. For nonobstructive (or central) sleep apnea (ICD-9-CM 780.51, 780.53 diagnosis codes) only when
other treatments have failed. The following criteria must be met:
- The requesting physician will present sleep studies demonstrating life-threatening respiratory
cycles when the patient is asleep.
- The member must have a diagnosis of central sleep apnea and have failed to maintain an
appropriate PO2 level (oxygen partial pressure) with continuous positive air pressure (CPAP)
and bilevel continuous positive airway pressure (BiPAP) treatments.
- Documentation by a specialist in otolaryngology or pulmonology of treatment attempts will
accompany the prior authorization request.
- The breathing pacemaker should never be recommended for treatment of obstructive sleep
apnea.
4. Documentation indicating medical necessity for the appropriate diagnosis will be submitted prior to
surgical implantation of the stimulator wires.
Device Monitoring
Medical device tracking regulations of the U.S. Food and Drug Administration require that the
manufacturer of the device be notified when the following occurs:
•
Diaphragm pacing system is implanted
•
Diaphragm pacing receiver or electrode is explanted (date, name, mailing address, and telephone
number of the explanting physician are to be included)
•
Diaphragm pacing patient dies
•
Diaphragm pacing device is returned
•
Diaphragm pacing device is permanently retired from use or otherwise permanently discarded
Spinal Cord Stimulators
This section covers coverage criteria for the IHCP billing requirements and PA criteria for spinal cord
stimulation (SCS). SCS is used to treat chronic pain syndromes intractable to other treatment
modalities. SCS is frequently used to treat failed back surgery, complex regional pain syndromes,
peripheral neuropathies, angina, peripheral vascular disease, post-herpetic neuralgia, occipital
neuralgia, and chronic pelvic pain. This treatment is considered a last resort for individuals who have
failed other treatment options for the management of intractable, chronic pain. SCS is a covered
service for all IHCP programs.
Spinal Cord Stimulation Prior Authorization Criteria
SCS treatment must be evaluated in a three- or seven-day trial stimulation period prior to permanent
implantation. Providers must request PA for both the trial and permanent phases of this service. The
IHCP will only cover SCS services with the appropriate ICD-9-CM diagnosis codes listed in Table
8.26, the CPT codes listed in Table 8.27, and the HCPCS codes listed in Table 8.28. All other
diagnoses of chronic, nonmalignant, neuropathic pain will be considered for approval on a case-bycase basis by a pain management consultant if all other PA criteria are met.
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Three- to Seven-Day Trial Stimulation Period
The first phase of SCS must be evaluated prior to a permanent SCS implantation. Members must meet
the following criteria for the three- to seven-day trial stimulation period:
1. The implantation of the stimulator is used only as a treatment of last resort for members with chronic
intractable, nonmalignant pain.
2. There is documented pathology, such as an objective basis for the pain complaint.
3. There must be documentation of failure of at least six months of conservative treatment, including at
least three of the following therapies: pharmacological, surgical, physical, and psychological.
4. The member must not be a candidate for further surgical interventions.
5. An evaluation must be performed by a physician experienced in treating chronic pain, which
includes documentation of a psychological evaluation, as well as a consultation from another pain
specialist, that indicates the member would benefit from SCS.
The psychological evaluation should reveal no evidence of an inadequately controlled mental health
problem (for example, alcohol or drug dependence, depression, psychosis) that would negatively
impact the success of a SCS or contraindicate its placement.
6. The member must not have any existing, untreated drug addictions.
Permanent SCS Implantation
Following the trial stimulation period, PA will be approved for permanent implantation after the
following criteria have been met. These criteria meet medical necessity for permanent implantation:
•
All six criteria for a three- to seven-day trial implantation period must be met.
•
Once the trial implantation has been performed, providers must submit documentation of successful
treatment showing a 50% reduction in pain for at least two days to receive approval for permanent
implantation. Providers must submit documentation of successful treatment.
•
IHCP providers are directed to use the Multidimensional Affect and Pain Scale, the Brief Pain
Inventory, and/or the Faces Pain Scale to measure pain levels. Providers are responsible for
deciding which pain measurement scale is appropriate for each member.
Table 8.26 – Recommended ICD-9-CM Diagnosis Codes for SCS
Diagnosis Code
Description
036.0
Meningococcal meningitis
250.60
Diabetes with neurological manifestations, type II or
unspecified type, not stated as uncontrolled
250.61
Diabetes with neurological manifestations, type I (juvenile
type), not stated as uncontrolled
250.62
Diabetes with neurological manifestations; type II or
unspecified type, uncontrolled
250.63
Diabetes with neurological manifestations; type I [juvenile
type], uncontrolled
322.0
Nonpyogenic meningitis
322.1
Eosinophilic meningitis
322.2
Chronic meningitis
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Diagnosis Code
Description
322.9
Meningitis, unspecified
337.20
Reflex sympathetic dystrophy, unspecified
337.21
Reflex sympathetic dystrophy of the upper limb
337.22
Reflex sympathetic dystrophy of the lower limb
337.29
Reflex sympathetic dystrophy of other specified site
353.0
Brachial plexus lesions
353.1
Lumbosacral plexus lesions
353.6
Phantom limb (syndrome)
353.8
Other nerve root and plexus disorders
353.9
Unspecified nerve root and plexus disorder
354.4
Causalgia of upper limb
354.8
Other mononeuritis of upper limb
354.9
Mononeuritis of upper limb, unspecified
355.71
Causalgia of lower limb
355.79
Other mononeurits of lower limb
355.8
Mononeuritis of lower limb, unspecified
413.9
Other and unspecified angina pectoris
440.22
Atherosclerosis of the extremities with rest pain
443.9
Peripheral vascular disease, unspecified
722.81
Postlaminectomy syndrome, cervical region
722.82
Postlaminectomy syndrome, thoracic region
722.83
Postlaminectomy syndrome, lumbar region
723.4
Brachial neuritis or radiculitis NOS
724.3
Sciatica
724.4
Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.9
Other unspecified back disorders
952.xx
Spinal cord injury without evidence of spinal bone injury
953.x
Injury to nerve roots and spinal plexus
Table 8.27 – CPT codes for SCS
CPT Code
Description
PA
63650
Percutaneous implantation of neurostimulator electrode
array, epidural
Yes
63655
Laminectomy for implantation of neurostimulator
electrodes, plate/paddle, epidural
No
63661
Removal of spinal neurostimulator electrode percutaneous
array(s), including fluoroscopy, when performed
No
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Description
PA
63662
Removal of spinal neurostimulator electrode plate/paddle(s)
placed via laminotomy or laminectomy, including
fluoroscopy, when performed
No
63663
Revision including replacement, when performed, of spinal
neurostimulator electrode percutaneous array(s), including
fluoroscopy, when performed
No
63664
Revision or removal including replacement, when
performed, of spinal neurostimulator electrode
percutaneous array(s) or plate/paddle(s) placed via
laminotomy or laminectomy, including fluoroscopy, when
performed
No
63685
Insertion or replacement of spinal neurostimulator pulse
generator or receiver, direct or inductive coupling
Yes
63688
Revision or removal of implanted spinal neurostimulator
pulse generator or receiver
No
95970
Electronic analysis of implanted neurostimulator pulse
generator system (eg, rate, pulse amplitude and pulse
duration, configuration of wave form, battery status,
electrode selectability, output modulation, cycling,
impedance and patient compliance measurements); simple
or complex brain, spinal cord, or peripheral (ie, cranial
nerve, peripheral nerve, sacral nerve, neuromuscular)
neurostimulator pulse generator/transmitter, without
reprogramming
No
95971
impedance and patient compliance measurements); simple
spinal cord, or peripheral (ie, peripheral nerve, sacral nerve,
neuromuscular) neurostimulator pulse
generator/transmitter, with intraoperative or subsequent
programming
No
95972
impedance and patient compliance measurements);
complex spinal cord, or peripheral (ie, peripheral nerve,
sacral nerve, neuromuscular) (except cranial nerve)
neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, first hour
No
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CPT Code
95973
Chapter 8
Description
generator system (eg, rate, pulse amplitude, pulse duration,
configuration of wave form, battery status, electrode
selectability, output modulation, cycling, impedance and
patient compliance measurements); complex spinal cord, or
peripheral (ie, peripheral nerve, sacral nerve,
neuromuscular) (except cranial nerve) neurostimulator
pulse generator/transmitter, with intraoperative or
subsequent programming, each additional 30 minutes after
first hour (List separately in addition to code for primary
procedure)
PA
No
Table 8.28 – HCPCS Codes for Spinal Cord Stimulation Equipment
HCPCS
Code
Description
PA
L8680
Implantable neurostimulator electrode, each
Yes
L8681
Patient programmer (external) for use with implantable
programmable neurostimulator pulse generator,
replacement only
Yes
L8682
Implantable neurostimulator radiofrequency receiver
Yes
L8683
Radiofrequency transmitter (external) for use with
implantable neurostimulator radiofrequency receiver
Yes
L8685
Implantable neurostimulator pulse generator, single
array, non-rechargeable, includes extension
Yes
L8686
Implantable neurostimulator pulse generator, single
array, non-rechargeable, includes extension
Yes
L8687
Implantable neurostimulator pulse generator, dual array,
rechargeable, includes extension
Yes
L8688
Implantable neurostimulator pulse generator, dual array,
non-rechargeable, includes extension
Yes
L8689
External recharging system for battery (internal) for use
with implantable neurostimulator, replacement only
Yes
L8695
External recharging system for battery (external) for use
with implantable neurostimulator; replacement only.
No
Intractable Angina
The IHCP also covers SCS for the treatment of intractable angina for members who are not surgical
candidates and whose pain is unresponsive to standard therapy. This treatment also requires PA.
Providers are instructed to use the appropriate ICD-9-CM diagnosis codes in Table 8.26 and the CPT
and HCPCS codes in Tables 8.27 and 8.28. The following criteria must be met for the treatment of
intractable angina:
1. Angiography documents significant coronary artery disease and the patient is not a candidate for
percutaneous transluminal coronary angiography (PTCA) or CABG.
2. The angina pectoris is New York Heart Association Functional Class III or IV.
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3. Reversible ischemia is documented by symptom-limited treadmill exercise tests.
4. The member has had optimal pharmacotherapy for at least one month. Optimal pharmacotherapy
includes the maximum tolerated doses of at least two of the following medications: long-acting
nitrates, beta-adrenergic blockers, or calcium channel blockers.
5. There is documentation of successful trial spinal cord stimulator implantation showing a 50%
reduction in pain for at least two days.
Table 8.29 – New York Heart Association Functional Class
Class
Class I (Mild)
Symptoms
No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or dyspnea.
Class III
(Moderate)
Class IV
(Severe)
Marked limitation of physical activity. Comfortable at rest, but less than ordinary
activity causes fatigue, palpitation, or dyspnea
Unable to carry out any physical activity without discomfort. Symptoms of cardiac
insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Billing Requirements
Following PA approval, providers must bill using the appropriate ICD-9-CM, CPT, and HCPCS codes
for SCS services. Separate outpatient reimbursement for the SCS implantable device is covered.
Please see Table 8.28 for spinal cord stimulation equipment. Providers are reminded that separate
outpatient reimbursement is also subject to medical necessity and PA guidelines.
Patient-Activated Event Recorder – Implantable Loop Recorder
The IHCP reimburses for the insertion and programming of the patient-activated event recorder –
implantable loop recorder (ILR). Claims should be billed with the ICD-9 diagnosis code that supports
medical necessity, 780.2 – Syncope and collapse. This section provides details about coverage and
billing of the patient-activated event recorder – ILR, also referred to as the implantable loop recorder.
Coverage
The IHCP covers the patient-activated event recorder – ILR for use after a syncopal event. The device
may be implanted at any of three places of service including inpatient, outpatient, or physician’s office.
The device may not be implanted in the same member more often than every two years or 24 months.
The recorder activator is furnished with the system and is not separately reimbursed.
Prior Authorization
Neither the implantation of the device nor the patient-activated event recorder – ILR requires PA, but
is subject to retrospective review according to IHCP criteria. If a replacement recorder activator is
needed, PA is required.
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Reimbursement and Billing Instructions
The procedure code for the implantation of the patient-activated event recorder – ILR is CPT code
33282. The code for the removal of this device is 33284. These procedure codes have a 90-day global
postoperative care designation for which care related to the surgical procedure is not separately
reimbursable unless such care is nonroutine, such as treatment of complications.
If the procedure is performed when the patient is an inpatient for a related problem, submit a UB-04
using the ICD-9-CM code 780.2 – Syncope and collapse as one of the diagnosis codes on the claim
form. If the procedure is performed as an outpatient, submit a UB-04 using revenue code 360 and the
CPT code 33282 for implantation. The device itself should be billed on a CMS-1500 using codes
E0616 and 780.2 – Syncope and collapse as the primary diagnosis code. Use CPT code 33284 with
revenue code 360 to bill for removal of the device. Physician’s charges for the surgery should be billed
on a CMS-1500.
If the procedure is performed in a physician’s office, the physician should bill CPT code 33282 for
implantation and E0616 for the device. Both codes are billed on the CMS-1500. Table 8.30 illustrates
coding for each place of service:
Table 8.30  Place of Service Codes
Inpatient
Physician’s Office
Outpatient
UB-04
UB-04 (and CMS-1500 if
billing for device)
CMS-1500
ICD-9-CM Diagnosis
Code
780.2 – Syncope and
Collapse
780.2 – Syncope and
Collapse
780.2 – Syncope and Collapse
Revenue and CPT Codes
Revenue code – 360
CPT code not
necessary
Revenue code – 360
CPT code – 33282 for
insertion
CPT code – 33284 for
removal
Revenue code not needed
CPT code – 33282 for insertion
CPT code – 33284 for removal
Not needed
On CMS-1500 – E0616
E0616
Type of Claim
HCPCS Code
Table 8.31 illustrates the codes for implantation and the device. Providers must bill their usual and
customary charges on the claim form. Insertion of the device carries a 90-day global surgery
designation with no assistant surgeon required.
Table 8.31  Loop Recorder System Implantation Codes
Code
Description
33282
Implantation of patient-activated cardiac event recorder
33284
Removal of an implantable, patient-activated cardiac
event recorder
93285
Programming device evaluation (in person) with iterative
adjustment of the implantable device to test the function
of the device and select optimal permanent programmed
values with analysis, review and report by a physician or
other qualified health care professional; implantable loop
recorder system.
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Description
E0616
Implantable cardiac event recorder with memory,
activator, and programmer. (The programmer is furnished
by the manufacturer, to the physician, for use in the office
for reading saved information in the recorder.)
E1399
Recorder activator (replacement)
Device Monitoring
The CPT code for analysis of information collected by the recorder is 93285 and should be billed only
subsequent to the date of insertion. Initial analysis and monitoring is included in the fee for insertion;
therefore, code 93285 may not be billed on the date of insertion. The programmer used to program the
patient-activated event recorder – ILR – to retrieve, display, and print stored data is furnished to the
physician, but remains the property of the manufacturer.
Coverage Criteria
Coverage criteria include the following:
•
A patient-activated event recorder – ILR is covered only if a definitive diagnosis has not been made
after meeting all the following conditions:
- Complete history and physical examination
- Electrocardiogram (ECG)
- Two negative or nondiagnostic 30-day presymptom memory loop patient demand recordings
(may be single- or multiple-event recordings, with or without 24-hour attended monitoring)
- Negative or nondiagnostic tilt-table testing
- Negative or nondiagnostic electophysiological testing
•
The patient must be capable of activating the hand-held telemetry unit.
•
The patient-activated event recorder – ILR is not covered for the following:
- Patients with presyncopal episodes
- Patients failing to fulfill the indications for coverage in this policy
- Patients for whom compliance or lifestyle make use of the external monitoring systems
inappropriate
•
Removal of a patient-activated event recorder – ILR on the same day as the insertion of a cardiac
pacemaker is considered part of the pacemaker insertion procedure and is not reimbursed
separately.
•
Only one patient-activated event recorder – ILR is covered for a given patient in any two-year time
period.
•
ECG analyses obtained during device insertion for signal quality and amplification purposes are
considered part of the implant procedure and are not reimbursed separately.
Intraocular Lenses
New technology intraocular lenses (NTIOL) are intraocular lenses (IOLs) that the CMS has identified
as being superior to other IOLs of the same category because of a demonstrated decrease in
postoperative complications. Providers should use the appropriate HCPCS V-code.
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Any facility reimbursed at an ASC rate should submit claims for surgical insertions of IOLs using the
Physician’s CPT code 66983, 66984, 66985, or 66986 and the appropriate revenue code on a UB-04
claim form. The NTIOL claim must be submitted on a separate CMS-1500 claim form using the
facility’s DME NPI.
NeuroCybernetic Prosthesis System – Vagus Nerve Stimulator
The IHCP reimburses for the NeuroCybernetic Prosthesis (NCP) System, a vagus nerve stimulator that
works as a pacemaker for the brain. The NCP System is indicated for use as an adjunctive therapy in
reducing the frequency of seizures in adults and adolescents older than 12 years old with partial-onset
seizures that are refractory to anti-epileptic medications, and for whom surgery has failed or is not
recommended.
Coverage Criteria for the NCP System
The IHCP has approved the following criteria:
•
Reimbursement for implantation, revision, programming and reprogramming, and removal of the
vagus nerve stimulator device is available under the IHCP for members older than 12 years old
with medically intractable partial-onset seizures. These members are not otherwise surgical
candidates. Providers are required to perform this procedure on an outpatient basis whenever
medically possible. Implantation procedures and equipment require prior authorization with
documentation of medical necessity. In situations where complicating factors require this procedure
to be performed on an inpatient basis, medical history and records should support the need for the
inpatient admission. Prior authorization is not required by the hospital for the inpatient admission
or the device (included in the DRG reimbursement). The device cannot be billed separately for
inpatients. Prior authorization must be obtained by the physician for the implantation procedures
regardless of setting. The prior authorization request must be submitted with the following
information:
•
Documentation that an evaluation has been made by a neurologist
•
Documentation of the member’s type of epilepsy
•
Documentation that the member’s seizures are medically intractable ([member continues with an
unacceptable number of seizures with adequate treatment with two or more anti-epileptic drugs
[AEDs] for a period of at least 12 months)]
•
Documentation that the member is not an intracranial surgical candidate or that surgery has been
unsuccessful (for example, the member is not a surgical candidate due to multiple epileptic foci)
Members with diagnoses of ominous prognosis or other limiting factors would not be considered
appropriate candidates for the implantation of the vagus nerve stimulator (for example, members with
an absent left vagus nerve, severe intellectual disability, cerebral palsy, stroke, progressive fatal
neurologic disease, or progressive fatal medical disease).
Diagnosis and Procedure Codes
Use the following diagnosis and procedure codes when billing for the implantation, revision,
programming and reprogramming, and removal of the vagus nerve stimulator device.
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Table 8.32 – ICD-9-CM Diagnosis Codes for Vagus Nerve Stimulator Device
Code
Description
345.41
Partial epilepsy with impairment of consciousness
345.51
Partial epilepsy without impairment of consciousness
Table 8.33 – ICD-9 Procedure Codes for Vagus Nerve Stimulator Device
Code
Description
04.92
Implantation or replacement of peripheral neurostimulator
04.93
Removal of peripheral neurostimulator
Table 8.34 – Surgeon CPT Procedure Codes for Vagus Nerve Stimulator Device
Code
Description
61885
Insertion or replacement of cranial neurostimulator pulse generator or receiver,
direct or inductive coupling, with connection to a single electrode array
61888
Revision or removal of cranial neurostimulator pulse generator or receiver
64553
Percutaneous implantation of neurostimulator electrode array; cranial nerve
64568
Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator
electrode array and pulse generator
64585
Revision or removal of peripheral neurostimulator electrode array
Table 8.35 – Neurologist CPT Procedure Codes for Vagus Nerve Stimulator Device
Code
Description
95970
Electronic analysis of implanted neurostimulator pulse generator system (eg, rate,
pulse amplitude, pulse duration, configuration of wave form, battery status, electrode
selectability, output modulation, cycling, impedance and patient compliance
measurements); simple or complex brain, spinal cord, or peripheral (ie, cranial
nerve, peripheral nerve, sacral nerve, neuromuscular) neurostimulator pulse
generator/transmitter, without reprogramming
95974
measurements); complex cranial nerve neurostimulator pulse generator/transmitter,
with intraoperative or subsequent programming, with or without nerve interface
testing, first hour
95975
measurements); complex cranial nerve neurostimulator pulse generator/transmitter,
with intraoperative or subsequent programming, each additional 30 minutes after
first hour (List separately in addition to code for primary procedure)
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Hospital Outpatient and Freestanding Ambulatory Surgical Center Billing
Instructions
•
For claims from hospital outpatient and ambulatory surgical centers, revenue codes 360 or 490
should be used on the UB-04 claim form.
•
Table 8.36 indicates the procedure codes to use when billing for the incision, implantation,
revision, or removal of the vagus stimulator. The CPT code must be billed in conjunction with the
appropriate revenue code on the UB-04 claim form.
The surgical procedure involves two separate incisions. Therefore, 64568 and 61885 or 64553 and
61885 CPT codes should be used. Reimbursement is based on 100% of the highest ASC group and
50% for the second-highest ASC group (no additional reimbursement is available for three or more
procedures).
Additional reimbursement, separate from the ASC rate for the implantation procedure performed in an
outpatient setting, is allowed for the cost of the device. Providers are to bill their usual and customary
charge for this device and will be reimbursed the lesser of the submitted charges for the device or the
maximum fee amount. The device must be billed on a CMS-1500 claim form and prior authorization
must be obtained.
Note: Providers may not separately bill for individual components when
implanting the complete system.
In situations where a complicating factor is present and the patient requires
admission to the hospital for the procedure, the procedure and device are
reimbursed according to the appropriate DRG payment. Prior authorization
is required for the admission as of January 1, 2011. The device does not
require separate PA, because it is included in the DRG reimbursement. The
physician for the surgical procedure must obtain prior authorization. The
hospital stay must be billed on the UB-04 claim form and must include a
secondary diagnosis indicating a complicating factor that necessitated
inpatient admission. Hospitals cannot receive additional reimbursement
outside the DRG payment for the cost of the device. DRG payments for
inpatient procedures with complicating factors include reimbursement for
the device.
Physician Billing Instructions
Physicians should bill professional services on the CMS-1500 claim form, using the appropriate
procedure codes in the following tables.
Table 8.37 – Procedure Codes for Vagus Nerve Stimulator Device
Category
Implanting
CPT
Code
Description
PA
Required?
64568
Incision for implantation of cranial nerve (eg, vagus
nerve) neurostimulator electrode array and pulse
generator
No
64553
Percutaneous implantation of neurostimulator
electrode array; cranial nerve
Yes
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Category
Revision/Removal
CPT
Code
Chapter 8
Description
PA
Required?
61885
Insertion or replacement of cranial neurostimulator
pulse generator or receiver, direct or inductive
coupling with connection to a single electrode array
Yes
64585
Revision or removal of peripheral neurostimulator
electrode array
No
61888
Revision or removal of cranial neurostimulator pulse
generator or receiver
No
Note: Surgeons use the previous codes. Anesthesia practitioners use the previous
codes using the appropriate modifiers.
The codes in Table 8.38 should be used by the neurologist for interrogation and programming services
performed on patients with implants.
Table 8.38 – Interrogation and Programming Services Codes for Implant Patients
Code
Description
PA
Required?
95970
Electronic analysis of implanted neurostimulator pulse generator system (eg,
rate, pulse amplitude, pulse duration, configuration of wave form, battery
status, electrode selectability, output modulation, cycling, impedance and
patient compliance measurements); simple or complex brain, spinal cord, or
peripheral (ie, cranial nerve, peripheral nerve, sacral nerve, neuromuscular)
neurostimulator pulse generator/transmitter, without reprogramming
No
95974
patient compliance measurements); complex cranial nerve neurostimulator
pulse generator/transmitter, with intraoperative or subsequent programming,
with or without nerve interface testing, first hour
No
95975
patient compliance measurements); complex cranial nerve neurostimulator
pulse generator/transmitter, with intraoperative or subsequent programming,
each additional 30 minutes after first hour (List separately in addition to
code for primary procedure)
No
Bariatric Age Restriction
Members must be between the ages of 18 and 65 to receive bariatric surgery. Members must also be
physically mature, as shown by sexual maturity and the closure of growth plates. Members younger
than 21 years of age must have documentation in the medical record by two physicians who have
determined bariatric surgery is necessary to save the life of the member or restore the member’s ability
to maintain a major life activity defined as self-care, receptive and expressive language, learning,
mobility, and self-direction, capacity for independent living or economic self-sufficiency.
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Treatment Room Visits
For purposes of the IHCP’s outpatient prospective payment system, treatment rooms include
emergency departments, clinics, cast rooms, labor and delivery rooms, and observation rooms.
The IHCP reimburses emergency department services for the treatment of ill and injured persons that
require immediate unscheduled medical or surgical care. The IHCP reimburses clinic services for
diagnostic, preventative, curative, and rehabilitative services provided to ambulatory patients.
Reimbursable observation services are furnished by a hospital on the hospital’s premises, including the
use of a bed and periodic monitoring by a hospital’s nursing staff, and are reasonable and necessary to
evaluate the patient’s condition or determine the need for possible admission to the hospital as an
inpatient.
When surgeries are performed in a treatment room, the appropriate CPT code should accompany the
revenue code, and reimbursement is based on the ASC methodology. Facilities should otherwise not
use a surgical CPT code in addition to the treatment room revenue code.
Treatment room services are reimbursed at a flat rate that includes most drugs and supplies. The IHCP
allows multiple treatment room visits on the same day. Overutilization will be subject to postpayment
review. Services must be billed on the UB-04 claim form using the appropriate revenue code. The
treatment room revenue codes are listed in Table 8.39.
Table 8.39 – Treatment Room Services
Revenue Code
Description
45X
Emergency department
51X
Clinic
52X
Freestanding clinic
70X
Cast room
72X
Labor/delivery room
76X
Providers may bill stand-alone services in conjunction with treatment room services. Stand-alone
services include therapies, dialysis, radiology, and laboratory services.
The IHCP allows certain add-on services, described in the Add-on Services section, if they are billed in
conjunction with a treatment room. These services are 255 (Drugs Incident to Radiology), 258 (IV
Solutions), 29X (DME), ,38X (Blood), 39X (Blood Storage and Processing), and 62X (Diagnostic
Supplies). All other add-on services are denied if billed in conjunction with a treatment room service.
Emergency Services
The IHCP does not reimburse hospitals for nonemergency services rendered in emergency room
settings. Hospitals are reimbursed for screenings that are necessary to determine if the member has an
emergency condition. Revenue code 451 – EMTALA – Emergency Medical Screening Service is
reimbursed for the nonemergent screening, system modifications were implemented to deny all
ancillary charges submitted with revenue code 451with EOB code 4180 – Ancillary services are not
payable when a 451 revenue code is billed on an outpatient, outpatient crossover, or outpatient
Medicare Replacement Plan claim.
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The IHCP continues to cover services for a member presenting to an emergency room with an
emergency medical condition, as determined by the screening physician. Per 42 U.S.C. § 1395dd(e)(1),
an emergency medical condition is a medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of immediate medical
attention to result in the following:
•
Placing the health of the individual (or with respect to a pregnant woman, the health of the woman
or her unborn child) in serious jeopardy
•
Serious impairment to bodily functions
•
Serious dysfunction of any bodily organ or part
When the screening does not meet the definition of an emergency visit under the layperson review
criteria utilizing this definition, the provider should bill only for the screening service (revenue code
451).
Note
For members enrolled in an MCE, providers must contact the member’s
MCE for more specific guidelines.
Add-on Services
The IHCP reimburses add-on services at a flat statewide rate when billed with a stand-alone procedure.
Table 8.40 lists add-on services.
Note: Add-on services are not allowed with any surgical revenue codes.
Table 8.40 – Add-on Services
Revenue
Code
Description
250
Pharmacy – General
251
Generic drugs
252
Brand drugs
253
Take-home drugs
254
Drugs incident to other diagnostic procedures
255
Drugs incident to radiology
256
Drugs experimental
257
Nonprescription drugs
258
IV solutions
259
Other pharmacy
270
Med/surg supply – General
271
Nonsterile supply
272
Sterile supply
273
Take-home supplies
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Revenue
Code
Chapter 8
Description
274
Prosthetic/orthotic devices
275
Pacemaker
276
Intraocular lens
277
Oxygen – Take home
278
Other implants
279
Other supplies/devices
290
DME – General classification
291
DME – Rental
292
DME – New
293
Purchase of used DME
299
Other med equipment
370
Anesthesia – General
371
Anesthesia – Incident to radiology
372
Anesthesia – Incident to other diagnostic services
374
Anesthesia – Acupuncture
379
Anesthesia – Other
380
Blood pints blood
381
Packed red cells
382
Blood – Whole
383
Blood – Plasma
384
Blood – Platelets
385
Blood – Leucocytes
386
Blood – Other components
387
Blood – Other derivatives
389
Blood – Other
390
Blood storage and process – General
391
Blood administration
399
Other blood processing
621
Supplies incident to radiology
622
Supplies incident to other diagnostic
623
Surgical dressings
624
FDA investigational devices
Add-on services are separately reimbursable in conjunction with a stand-alone procedure. Certain addon services are also separately reimbursable if billed in conjunction with a treatment room. These
services are 255 (Drugs Incident to Radiology), 258 (IV Solutions), 29X (DME), 370 (Anesthesia),
38X (Blood), 39X (Blood Storage and Processing), and 62X (Diagnostic Supplies). All other add-on
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services are denied if billed in conjunction with a treatment room service. Add-on services are not
separately reimbursable if provided on the same day as an outpatient surgery.
Stand-alone Services
Stand-alone services include therapies, diagnostic testing, dialysis, laboratory, and radiology
procedures performed in an outpatient setting. Providers can bill stand-alone services separately or in
conjunction with treatment room services. Stand-alone services are not separately reimbursable with
outpatient surgeries if provided on the same day as the surgery.
The IHCP reimburses stand-alone services at an established flat statewide rate and reimburses
laboratory and radiology services at the lower of the submitted charge or the fee schedule amount. The
IHCP allows a maximum of one unit of service, per revenue code, for each date of service, except for
lab and radiology. Providers must bill services on the UB-04 claim form. Table 8.41 lists the revenue
codes for stand-alone services.
Table 8.41 – Stand-alone Services
Revenue Code
Description
260
IV therapy – General
261
IV therapy – Infusion pump
269
IV therapy – Other
28X
Oncology
30X
Laboratory
31X
Laboratory pathological
32X
Radiology – Diagnostic
33X
Radiology – Therapeutic
34X
Nuclear medicine
35X
CT scan
40X
Other imaging service
410
Respiratory services – General
412
Inhalation services
413
Hyperbaric oxygen therapy
419
Other respiratory
42X
Physical therapy
43X
44X
Speech-language pathology
460
Pulmonary function – General
469
Other pulmonary function
47X
Audiology
480
Cardiology
481
Cardiac catheter laboratory
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Revenue Code
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Description
482
Stress test
483
Echocardiology
489
Other cardiology
61X
MRT
634
EPO, less than 10,000 units
635
EPO, 10,000 units or more
636
Drugs requiring detailed coding
730
Electrocardiogram (EKG/ECG)
731
EKG/ECG – Holter monitor
732
EKG/ECG – Telemetry
739
Other EKG/ECG
740
Electroencephalogram (EEG)
749
EEG – Other
75X
Gastrointestinal services
780
Telemedicine
79X
Extracoporeal shockwave therapy
820
Hemodialysis OP/home – General
821
Hemodialysis OP/home – Composite
823
Hemodialysis – Home equipment
825
Hemodialysis – Support services
829
Other OP hemodialysis
830
Peritoneal dialysis – General
831
Peritoneal dialysis – Composite
832
Peritoneal – Home supplies
833
Peritoneal – Home equipment
841
CAPD OP/home – Composite
851
CCPD OP/home – Composite
860
Magnetoencephalography (MEG) General
861
Magnetoencephalography (MEG) MEG
890
Donor bank – General
921
Peripheral vascular lab
922
Electromyelogram
923
Pap smear
924
Allergy test
925
Pregnancy test
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Revenue Code
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Description
94X
Therapeutic services – Other
943
Cardiac rehabilitation
Stand-alone Laboratory Services
A physician or other practitioner authorized to do so under state law must order laboratory services in
writing. Laboratories performing the services must bill the IHCP directly unless otherwise approved.
Providers may submit only one claim when providing multiple laboratory services. Hospitals must bill
laboratory services using the most appropriate HCPCS code. Revenue codes billed without the
appropriate HCPCS procedure code are denied.
Providers must bill the professional component of a laboratory service performed in an outpatient
hospital setting on the CMS-1500 claim form or an 837P transaction with the appropriate HCPCS code
and 26 modifier.
See the CMS-1500 and 837P Transaction Billing Instructions section of this chapter for specific CMS1500 billing instructions.
Billing and Coverage Policies Low Osmolar Contrast Materials
The IHCP has determined that separate reimbursement under revenue code 636 is appropriate for the
low osmolar contrast material (LOCM) procedure codes listed in the following table. Effective July 15,
2012, for dates of service on or after July 1, 2012, the following procedure codes may be billed with
revenue code 636 for IHCP reimbursement consideration.
Table 8.42 – LOCM Procedure Codes That May Be Billed with Revenue Code 636 for Dates
of Service on or after July 1, 2012
Code
Description
Revenue Code
Q9965
Low osmolar contrast material, 100-199
mg/ml iodine concentration, per ml
636
Q9966
636
Q9967
636
Additionally, effective July 15, 2012, for dates of service on or after July 1, 2012, the LOCM
procedure codes listed in the following table are noncovered.
Table 8.43 – LOCM Procedure Codes That Are Noncovered for Dates of Service on or after
July 1, 2012
Code
Description
Q9951
Low osmolar contrast material, 400 or greater mg/ml iodine
concentration, per ml
Q9953
Injection, iron-based magnetic resonance contrast agent, per ml
Q9955
Injection, perflexane lipid microspheres, per ml
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Coverage and reimbursement for all other LOCM procedure codes remain unchanged.
Code Auditing Methodologies for Hospitals
Code auditing rules have been implemented in the Medicaid claims processing to represent correct
coding methodologies and other coding methods based upon general guidance from the CMS, the
American Medical Association (AMA), specialty society guidance, industry standard coding, and
prevailing clinical practice. As part of this enhanced code auditing, effective for date of service (DOS)
on or after July 15, 2011, the following rules apply:
•
Code auditing on UB-04 outpatient claims that are billed with multiple units of the same laboratory
code on the same date of service
•
Bilateral services billed with a unit of service quantity greater than one
UB-04 claims billed with lines containing multiple units of the same laboratory procedure code billed
without modifier 59 (distinct procedural service) or modifier 91 (repeat clinical diagnostic laboratory
tests), when submitted by either the same or a different provider for the same member and for the same
date of service, will be denied with EOB 4189 - Multiple units of the same laboratory procedure billed
for the same date of service.
Effective March 31,, 2011, outpatient claims are subjected to component rebundling. The edit will post
and deny when multiple component codes are billed, and a single comprehensive code should have
been billed.
Stand-alone Radiology Services
A physician or other practitioner authorized to do so under state law must order radiology services in
writing. Facilities must bill the IHCP directly. Hospitals billing under the provider type of “01” should
bill only the technical component (TC) for radiology services provided in an outpatient hospital setting
on the UB-04 claim form. No TC modifier is necessary for provider type 01. Providers must bill
radiology revenue codes in conjunction with the appropriate HCPCS procedure code. Revenue codes
billed without the appropriate HCPCS procedure code are denied. Do not fragment radiology
procedures and bill them separately.
Providers must bill the professional component of a radiology service performed in an outpatient
hospital setting with the appropriate HCPCS code and 26 modifier on the CMS-1500 claim form or
837P transaction.
Freestanding radiology facilities must bill the technical and/or professional components of a radiology
service on the CMS-1500 claim form or 837P transaction with the appropriate HCPCS code. If the
freestanding radiology facility performed both components of the service, a modifier is not necessary.
If the radiology facility performed only one component, the applicable 26 or TC modifier is necessary.
See the CMS-1500 and 837P Transaction Billing Instructions section of this chapter for specific CMS1500 billing instructions.
Stand-alone Chemotherapy and Radiation Services
Bill all outpatient hospital chemotherapy and radiation treatment services on the UB-04 claim form or
837I transaction.
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Chemotherapy services consist of four components:
•
Administration of chemotherapy agent
•
Chemotherapy agent
•
Intravenous (IV) solution and equipment
•
Treatment room services
Each of the four components is separately reimbursable when chemotherapy is administered using the
following code combinations:
•
Administration of chemotherapy agent – Bill using revenue codes 331, 332, or 335. The
appropriate CPT chemotherapy codes are 96401 through 96549.
•
Chemotherapy agent – Bill using revenue code 636 – Drugs requiring detailed coding, along with
the appropriate HCPCS code.
•
IV solution and equipment – Bill using revenue code 258 for the IV solution and revenue code 261
for IV equipment.
•
Treatment room services – Bill using revenue codes 45X, 483, 51X, 52X, or 76X.
Radiation treatment services consist of two components:
•
Administration of radiation treatment
•
Treatment room services
Both components are separately reimbursable, using the following code combinations:
•
Administration of radiation treatment – Bill using revenue codes 330, 333, or 339, along with the
appropriate CPT radiation treatment code, 77261 through 77799.
•
Treatment room services – Bill using revenue codes 45X, 483, 51X, 52X, or 76X.
Note: When chemotherapy and radiation treatment services are rendered on the
same day, bill all applicable components to the IHCP.
Stand-alone Renal Dialysis Services
This section addresses billing requirements for hemodialysis and peritoneal dialysis services rendered
in a hospital outpatient setting in independent renal dialysis facilities called end-stage renal disease
(ESRD) dialysis facilities; or in a patient’s home.
Composite Rate for Method I Dialysis
Patients who have ESRD, a chronic condition with kidney impairment considered irreversible and
permanent, require a regular course of dialysis or a kidney transplant to maintain life. The IHCP
reimburses for routine dialysis. The cost of dialysis treatments includes overhead costs, personnel
services, administrative services (includes nursing staff members, social worker, and dietician),
equipment and supplies, ESRD-related laboratory tests, certain injectable drugs, and biologicals.
The composite rate for dialysis is the charge for the actual treatment or dialysis session. Routine
laboratory charges are included in the fee for hemodialysis or peritoneal dialysis and, as such, are not
billed separately. However, the IHCP covers nonroutine lab services when billed separately if medical
justification is indicated. The composite rate also includes all durable and disposable items and
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medical supplies necessary for the effective performance of a patient’s dialysis. Supplies include, but
are not limited to, the following:
•
Forceps
•
Syringes
•
Alcohol wipes
•
Needles
•
Topical anesthetics
•
Rubber gloves
•
Dialysate heaters
•
Dialysate
•
Connecting tubes
The composite rate covers certain parenteral items used in the dialysis procedure; therefore, these
items cannot be billed separately. The following drugs are included under the composite rate:
•
Heparin
•
Protamine
•
Mannitol
•
Saline
•
Pressor drugs
•
Glucose
•
Dextrose
•
Antihistamines
•
Antiarrhythmics
•
Antihypertensives
Billing Guidelines
The following billing guidelines are for hemodialysis and peritoneal dialysis, and are used in the
following settings:
•
Hospital outpatient
•
Independent renal dialysis facilities (ESRD dialysis facilities)
•
Patient’s home (some are Method II)
Providers of dialysis services must use the UB-04 claim form to submit claims to the IHCP. The IHCP
allows providers to bill for the drugs associated with renal dialysis services on the CMS-1500 claim
form. Providers must bill all services provided by the ESRD facility on the UB-04 claim form. For
IHCP-only claims, providers must bill each date-specific service separately on the UB-04 claim form.
For example, if the patient receives 15 dialysis treatments in the month, enter 15 detail lines of revenue
code 821 on the UB-04 claim form with the specific service date in field 45. This is true for all other
services provided during the month.
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Type of Bill Codes
Providers must use the following Type of Bill codes when submitting claims for renal dialysis:
•
Freestanding renal dialysis facilities (ESRDs) should use Type of Bill code 721.
•
Outpatient hospital renal dialysis facilities should use Type of Bill code 131.
•
Inpatient renal dialysis services should be billed with Type of Bill code 111.
Diagnosis Codes
•
584.X – Acute kidney failure
•
585.X – Chronic kidney disease (CKD)
•
586 – Renal failure unspecified
Revenue Codes
•
Dialysis Sessions – Hemodialysis sessions are reimbursable at an established flat statewide rate.
These services represent the number of hemodialysis sessions. “Outpatient or home” and “units of
service” reflect the number of actual sessions rendered (one per day). Use Revenue Codes 82X,
83X, 84X, and 85X.
- Revenue category 82X: 821 – Hemodialysis/composite or other rate. This revenue code
represents the number of hemodialysis sessions, provided in an outpatient setting or at home,
rendered per day. Providers should indicate a “1” in field 46, Service Units, on the UB-04 claim
form. The IHCP allows only one unit per date of service. For ESRD providers, Revenue Code
category 82X cannot be billed on the same claim with 83X, 84X, and 85X.
- Revenue category 83X: 831 – Peritoneal dialysis/composite or other rate. This revenue code
represents the number of peritoneal dialysis sessions performed in the outpatient or home setting.
Providers should indicate a “1” in field 46, Service Units, on the UB-04 claim form. The IHCP
allows only one unit per date of service.
- Revenue category 84X: 841 – CAPD/composite or other rate. This revenue code represents the
charges for continuous ambulatory peritoneal dialysis, using the patient’s peritoneal membrane
as a dialyzer, which is performed in the home or outpatient setting. Providers should indicate a
“1” in field 46, Service Units on the UB-04 claim form. The IHCP allows only one unit per date
of service. For ESRD providers, Revenue Code category 82X cannot be billed on the same claim
with 83X, 84X, and 85X.
- Revenue category 85X: 851 – CCPD/composite or other rate. This revenue code represents the
charges for continuous cycling peritoneal dialysis performed in an outpatient or home setting.
Providers should indicate a “1” in field 46, Service Units on the UB-04 claim form. The IHCP
allows only one unit per date of service.
- Revenue code 881 – Ultrafiltration. This revenue code is reimbursable only for dates of service
on which no other dialysis services were provided. As a stand-alone service, a maximum of one
unit of service for each date of service is allowed.
Note: Providers can submit claims for revenue codes 820, 821, 830, 831, 840, 841,
849, 850, and 851with more than one unit of service on a detail line. When
multiple units span multiple days, providers must indicate the date range in
the Statement Covers Period field. If providers do not include the date range
in this field, the claim may be denied.
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• Administration of Epoetin – Providers must use the following revenue codes with the appropriate
HCPCS J code when billing for the administration of Epoetin in a hospital outpatient or ESRD
setting. The IHCP currently allows payment for HCPCS codes J0885, J0886, or Q4081 for patients
with a hematocrit range of less than 20 to 40 and above.
- 634 Epoetin, less than 10,000 units
- 635 Epoetin, 10,000 or more units
•
Drugs Requiring Detailed Coding – Revenue code 636 is used with the appropriate HCPCS code to
report charges for drugs and biological products requiring specific identification. Submit Revenue
Code 636 in field 42 on the UB-04 claim form. Providers must submit the appropriate HCPCS
code, including J codes, identifying the specific drug injected, in field 44. In field 46 on the UB-04
claim form, submit the number of units administered.
•
Laboratory Services – The composite rate for hemodialysis or peritoneal dialysis includes routine
laboratory charges; therefore, providers cannot bill separately for them. However, the IHCP covers
nonroutine lab services when billed separately, if medical justification is indicated. Use Revenue
Code category 30X with the appropriate HCPCS code. Laboratory tests included in the composite
rate and their anticipated frequency include the following:
- Per Treatment – All hematocrit, hemoglobin, and clotting times furnished incident to dialysis
treatments
- Weekly – Prothrombin time for patients on anticoagulant therapy, serum creatinine, and blood
urea nitrogen (BUN)
- Monthly – Serum calcium, serum bicarbonate, alkaline phosphatase, serum potassium, serum
phosphorous, aspartate aminotransferase (AST, formerly SGOT), serum chloride, total protein,
lactate dehydrogenase (LDH), complete blood count (CBC), and serum albumin
- Nonroutine lab services – The IHCP covers nonroutine lab services when billed separately, if
medical justification is indicated. Use revenue code category 30X with the appropriate HCPCS
code.
Note: The facility performing the dialysis treatment must bill all laboratory
services performed. An independent lab cannot bill labs for dialysis patients
separately. These independent labs should be contracted with the dialysis
facility to perform the actual tests and cannot bill the IHCP separately for
their services.
•
Supplies – The composite rate includes all durable and disposable items and medical supplies
necessary for the effective performance of a patient’s dialysis. However, providers can use revenue
code 270 to bill supplies outside the list of those included in the composite rate. Supplies are not
paid if billed in conjunction with treatment room revenue codes. Supply revenue codes are denied if
billed without an HCPCS surgical procedure code or if billed in conjunction with treatment room
revenue codes 45X, 51X, 52X, 70X, 71X, 72X, and 76X, which are also billed without an HCPCS
surgical procedure code. Providers can bill revenue code 270 with multiple units only when the
member has any of the following renal diagnoses – 584.x, 585.x, or 586 – and when the service is
directly related to the dialysis service. This is subject to postpayment review and recoupment.
Transportation Services
Providers may not bill transportation services on the UB-04 claim form. Providers must obtain a
separate provider number to bill transportation services. These services must be billed on the CMS1500 claim form or 837P transaction.
Specific billing information for transportation services is provided in the Transportation Services
section in this chapter.
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Outpatient Mental Health
As required by the House Enrolled Act (HEA) 1396, the Covered Services Rule, 405 IAC 5-20,
providers cannot use revenue codes 500, 510, 90X, 91X, and 96X to bill covered outpatient mental
health hospital services. Hospitals can bill for the facility use associated with these services by billing
the appropriate clinic or treatment room revenue code.
Effective January 1, 2012, the IHCP changed fee-for-service (FFS) billing requirements for therapy
services rendered in an outpatient facility and billed on the UB-04 claim form. For outpatient claims
with dates of service on or after January 1, 2012, providers no longer bill individual, group, or family
therapy with revenue code 510 – Clinic. Providers that continue to bill revenue code 510 for outpatient
individual, group, or family therapy are subject to postpayment review by the IHCP Program Integrity
Department.
Providers are required to bill for individual, group, or family counseling procedure codes listed in
Table 8.44, using revenue code 513 – Clinic/Psychiatric.
If the claim detail is billed with revenue code 513 and the corresponding procedure code is not listed in
the table, the detail will be denied for edit 520 – Invalid revenue code/procedure code combination. If
the claim detail is billed with revenue code 513 and no corresponding procedure code is present on the
claim, the detail will be denied for edit 389 – Revenue code requires a corresponding HCPCS/CPT 4
code. As a general reminder, modifiers should be used on outpatient claims as appropriate; however,
modifiers are used not to affect pricing, but to identify the level of service rendered.
For family and group therapy codes, the IHCP will reimburse the lesser of the billed amount or a
statewide flat fee of $20.40, per member, per session. The 5% reduction now in effect for provider type
01 – Outpatient providers with respect to these services will be applied to this rate at reimbursement.
Individual therapy codes will be reimbursed the lesser of the billed amount or a statewide flat fee of
$40.80, per member, per session.
Note: Providers should bill one unit per encounter/session/date of service.
This change does not apply to claims for members who are dually eligible. Providers must continue to
bill Medicare for dually eligible members following Medicare claim submission policy, which may
include revenue code 510. However, if using revenue code 513 when billing Medicare, providers must
identify the service rendered to ensure that the claim detail will not be denied for one of the previously
mentioned edits, and that the allowed amount is calculated appropriately.
Table 8.44 – Procedure Codes That Must Be Billed with Revenue Code 513
Procedure Code
Description
90785
Interactive complexity (List separately in addition to the code for primary procedure
90791
Psychiatric diagnostic evaluation
90792
Psychiatric diagnostic evaluation with medical services
90832
Psychotherapy, 30 minutes with patient and/or family member
90833
Psychotherapy, 30 minutes with patient and/or family member when performed with an
evaluation and management service (List separately in addition to the code for primary
procedure)
90834
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Procedure Code
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Description
90836
procedure)
90837
90838
procedure)
90839
Psychotherapy for crisis; first 60 minutes
90840
Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code
for primary service)
90845
Psychoanalysis
90846
Family medical psychotherapy (without the patient present)
90847
Family medical psychotherapy (conjoint psychotherapy) (with patient present)
90849
Multi-family group psychotherapy
90853
Group medical psychotherapy (other than of a multiple-family group)
90853Family medical psychotherapy (conjoint psychotherapy) (with patient present)Providers must
bill all professional services associated with outpatient mental health services on the CMS-1500 claim
form or 837P transaction.
Inpatient mental health services, including substance abuse treatment, provided to RBMC network
members in acute care facilities are the responsibility of the MCE in which the member is enrolled.
The State now requires MCEs to manage behavioral healthcare to promote comprehensive and
coordinated medical and behavioral services for Hoosier Healthwise members. This policy excludes
PRTF and MRO services, which are carved out of the RBMC delivery system and paid on a FFS basis.
Partial Units of Service
Providers must round partial units of service to the nearest whole unit when calculating
reimbursement. For example, if a unit of service equals 15 minutes, a minimum of eight minutes must
be provided to bill for one unit.
Filing UB-04 Crossover Claims
Processing Crossover Claims
This section provides clarification of the billing procedures providers must follow when submitting
paper UB-04 crossover claims to HP.
The IHCP requires direct submission of crossover claims when a claim does not cross over
automatically from Medicare. A claim may not cross over for the following reasons:
•
The Medicare carrier or intermediary is not National Government Services (previously known as
AdminaStar Federal of Indiana) or is not a carrier that has a partnership agreement with HP.
•
Medicare does not reimburse the claim. Medicare denies payment because the service is not
covered or does not meet the Medicare medical necessity criteria.
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•
The IHCP provider file does not reflect the Medicare provider number. Chapter 4: Provider
Enrollment, Eligibility, and Responsibilities of this manual provides additional information.
•
The provider has no record of a claim crossing over automatically within 60 days after the claim is
reimbursed by the Medicare intermediary.
•
The provider is not a Medicare provider and does not accept assignment to bill the IHCP for dual
eligible members.
•
Some ASCs must bill services to Medicare on a CMS-1500 claim form or 837P transaction with the
SG modifier. If the services fail to cross over, the provider must submit the claim on a paper UB-04
claim form with a copy of the MRN.
Attachments for UB-04 Paper Claims or 837I Transaction Submissions
Mail paper crossover claims to the following address for processing:
HP
Institutional Crossover Claims
P.O. Box 7271
The following guidelines are required to ensure appropriate processing of Medicare and IHCP-related
claims:
•
Providers must not submit Medicare-denied services on the claim form or electronic transaction
with Medicare paid services. Providers must split the claim and group all denied line items on one
claim or electronic transaction, and all paid line items on another. It is critical that providers attach
a copy of the MRN to the paper claim or send it as an attachment for the 837I transaction
containing the Medicare denied services.
•
Applicable documentation for third-party liability or spend-down information should be submitted
with the paper claim or sent as an attachment for the electronic 837I transaction.
Note: EOB codes 0512 and 0545 state that a claim submitted after the one-year
filing limit without acceptable documentation does not apply to a crossover
claim when Medicare made a payment. Specifically, EOBs 0512 and 0545
are bypassed for cases in which Traditional Medicaid is paying the
coinsurance and deductible amounts. If Medicare denies a claim, EOB codes
0512 and 0545 apply to the Traditional Medicaid claim.
UB-04 Crossover and Medicare Replacement Billing Procedures
Providers should follow the general directions for filling out the UB-04 claim form when filing
crossover claims. Providers can also submit crossover claims electronically using the electronic 837I
transaction or through Web interChange. For claims received on or after September 1, 2013,
replacement plans are billed as crossover claims. The following billing instructions help ensure
accurate processing of all UB-04 Medicare or Medicare Replacement Plan crossover claims for dates
of service prior to August 99, 2012.
•
Use fields 39-41 to indicate a value code of A1 to reflect the Medicare or Medicare Replacement
Plan deductible amount, a value code of A2 to reflect the Medicare or Medicare Replacement Plan
coinsurance amount, and a value code of 06 to reflect the blood deductible amount. Use a value
code of 80 to reflect covered days.
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•
Chapter 8
Use fields 50a–54a to reflect Medicare information only. Use form field 54a to indicate the
Medicare or Medicare Replacement Plan paid amount. Do not include the Medicare or Medicare
Replacement Plan allowed amount or contract adjustment amount in field 54.
Note: If the Medicare paid amount is greater than the billed amount, indicate the
correct dollar values in the fields. Then reflect the estimated amount due as
$0 in form field 55c. This amount does not have a negative impact on the
payment of a crossover claim.
•
Fields 50b–54b are reserved for commercial insurance carrier information. Use form field 54b to
denote any commercial insurance carrier or third-party liability payment information.
• Use field 55c to reflect the amount calculated in the following equation:
- Total claim amount – Medicare or Medicare Replacement Plan paid (54a) – Medicare
supplement or third-party liability (54b) = Est. Amount Due (55c)
- Automated spend-down outpatient hospital claims that span more than one month are credited to
spend-down based on individual dates of services, as reported on the detail lines of the claim.
Note: Leave fields 55a and 55b blank. The amount in form field 55c is not
necessarily equal to the coinsurance and deductible amounts present on the
Medicare MRN, but is calculated using the correct data for each of the
fields.
•
Field 67, Principal Diagnosis Code, and field 69, Admitting Diagnosis Code, are required for all
inpatient claims, including LTC and hospice. Complete these fields to avoid claim denial.
•
Field 45, Service Date, is required for all outpatient, hospice, renal dialysis, and home health
claims. The date in field 45 populates the statement From and Through dates for the
aforementioned claim types. EOB code 264 – Date-of-service is missing posts with a denial on all
claims submitted without this required information.
For additional details regarding Medicare and Medicare Replacement Plan claim billing, see Chapter
10: Claim Processing Procedures of this manual.
Billing Medicare Denied Services
If Medicare does not pay a detail, the IHCP does not consider the detail a crossover claim. Providers
must bill this detail separately using a UB-04 claim form or the 837I transaction.
Providers must attach copies of the MRN and any applicable third-party EOBs when submitting these
types of claims.
Note: Providers cannot submit paid and denied charges on the same claim form or
electronic transaction. Providers must submit the paid portion of the
Medicare charges as a crossover claim, and they must submit denied
Medicare charges as a separate claim or transaction. Line items submitted
on incorrect claim forms are denied.
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837I Electronic Transaction
Providers must use the standard 837I format to submit electronic institutional claims. These standards
are published in the 837I Implementation Guides (IGs). An addendum to most IGs has been published
and must be used to properly implement each transaction. The IGs are available for download through
the Washington Publishing Company website at wpc-edi.com.
Companion Guides
implementation process. Information contained in the IHCP Companion Guides is intended only to
supplement the adopted IGs and provide guidance and clarification as the guides apply to the IHCP.
IHCP Companion Guides are never intended to modify, contradict, or reinterpret the rules established
by the IGs. The Companion Guides are located on indianamedicaid.com in the EDI Solutions section.
Some data elements that providers submit may not be used in processing the 837I transaction;
however, they may be returned in other transactions, such as the 277 Claim Status Request and
Response or the 835 Remittance Advice transactions. These data elements are necessary for processing,
and failure to append these data elements may result in claim suspension or denial.
Providers may submit as many as 48 occurrence (span) codes and dates. IndianaAIM accepts as many
as 24 occurrence codes and 24 occurrence span dates.
Diagnosis Codes
Providers may submit as many as 27 ICD-9-CM five-digit diagnosis codes on the 837I. IndianaAIM
accepts admit, primary, E-code, and 24 secondary diagnosis codes. The provider uses these codes to
describe the medical condition of the patient, and the IHCP uses them to process the transaction. The
IHCP processes the first 11 diagnosis codes including the principal, admission, and additional
diagnosis codes submitted. This rule applies to paper claims and 837I transaction submissions.
Additional UB-04 and 837I Admission and Duration Changes
The following requirements apply to the UB-04 claim form and the 837I transaction:
•
Always include an admitting code for inpatient claims.
•
Always enter accommodation rates in full units.
•
A day begins at midnight and ends 24 hours later. For LTC, a part of a day, including day of
admission, counts as a full day if the member is not readmitted to the hospital by midnight on the
same day. The day of death is the day of discharge and is not counted for inpatient or LTC services.
Hospice services can include the day of death as a billable date for the hospice portion of the claim
when the member resides in a nursing facility. The date of discharge or death is not payable for the
room-and-board portion of the hospice claim when the member resides in a nursing facility.
•
Always include an admitting code for inpatient claims.
•
Always include principal, admitting, and E-codes for all claims except religious, nonmedical claims
and hospital, and other.
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Section 3: Telemedicine
Overview
This section discusses applicable coverage parameters and billing guidelines for telemedicine services.
Telemedicine services refer to a specific method of delivery of certain services, including medical
exams and consultations, which are already reimbursed by Medicaid. Telemedicine uses
videoconferencing equipment allowing a medical provider to render an exam or other service to a
patient at distant location. Telemedicine services are covered by the Indiana Health Coverage
Programs (IHCP) within the parameters specified in 405 IAC 5-38.
In any telemedicine encounter, there will be the following: (1) a hub site, (2) a spoke site, (3) an
attendant to connect the patient to the specialist at the hub site, and (4) a computer or television
monitor to allow the patient to have real-time, interactive; and face-to-face communication with the
hub specialist/consultant via interactive television (IATV) technology. Services may be rendered in an
inpatient, outpatient, or office setting.
Definitions
•
Hub Site – Location of the physician or provider rendering consultation services.
•
Spoke Site – Location where the patient is physically located when services are provided.
•
IATV – Videoconferencing equipment at the hub and spoke sites that allows real-time, interactive,
and face-to-face consultation.
•
Store and Forward – Electronic transmission of medical information for subsequent review by
another healthcare provider.
Only IATV is separately reimbursed by the IHCP. Store-and-forward technology to facilitate other
reimbursable services is allowed; however, separate reimbursement of the spoke-site payment is not
provided for this technology because of restrictions in 405 IAC 5-38-2(4).
Note: Telemedicine is not the use of the following:
(1)
Telephone transmitter for transtelephonic monitoring
(2)
Telephone or any other means of communication for consultation from one
provider to another
Provider or Service Requirements
The following service or provider types cannot be reimbursed for telemedicine per 405 IAC 5-38-4(5):
•
Ambulatory surgical centers
•
Outpatient surgical services
•
Home health agencies or services
•
Radiological services
•
Laboratory services
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•
Long-term care facilities, including nursing facilities, intermediate care facilities, or community
residential facilities for the developmentally disabled
•
Anesthesia services or nurse anesthetist services
•
Audiological services
•
Chiropractic services
•
Care coordination services
•
Durable medical equipment (DME), medical supplies, hearing aids, or oxygen
•
Optical or optometric services
•
Podiatric services
•
Services billed by school corporations
•
Physical or speech therapy services
•
Transportation services
•
Services provided under a Medicaid waiver
Conditions of Payment
1. The IHCP reimburses for telemedicine services only when the hub and spoke sites are greater than
20 miles apart.
2. The member must be present and able to participate in the visit.
3. For a medical professional to receive reimbursement for professional services in addition to payment
for spoke services, medical necessity must be documented. If it is medically necessary for a medical
professional to be with the member at the spoke site, the spoke site is permitted to bill an evaluation
and management code in addition to the fee for spoke services. Adequate documentation must be
maintained in the patient’s medical record to support the need for the provider’s presence at the
spoke site during the visit. Documentation is subject to postpayment review.
4. The audio and visual quality of the transmission must meet the needs of the physician located at the
hub site. The IATV technology must meet generally accepted standards to allow the physician at the
hub site to render medical decisions.
Hub Site Services and Billing Requirements
The following Current Procedural Terminology (CPT ®) codes are reimbursable for providers that
render services via telemedicine at the hub site. Modifier GT – Via interactive audio and video
telecommunications system must be used to denote telemedicine services. The payment amount is
equal to the current fee schedule amount for the following services:
•
Consultations – 99241 – 99245 and 99251 – 99255
•
Office or other outpatient visit – 99201 – 99205 and 99211 – 99215
•
Individual psychotherapy – 90832 – 90840
•
Psychiatric diagnostic interview – 90791 and 90792
•
End-stage renal disease (ESRD) services – 90951 – 90970
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Spoke Site Services and Billing Requirements
The following Healthcare Common Procedure Coding System (HCPCS) code and revenue code are
reimbursable for providers that render services via telemedicine at the spoke site. Modifier GT – Via
interactive audio and video telecommunications system must be used to denote telemedicine services.
The payment amount is equal to the current fee schedule amount for HCPCS code Q3014 Telehealth
originating site facility fee.
1. Spoke services are reimbursed using HCPCS code Q3014 – Telehealth originating site facility fee.
The GT modifier must be used to denote telemedicine services.
2. Revenue code 780 represents telemedicine services. If a different, separately reimbursable treatment
room revenue code is provided on the same day as the telemedicine consultation, the appropriate
treatment room revenue code should also be included on the claim. Documentation must be
maintained in the patient’s record to indicate that services were provided separate from the
telemedicine visit.
3. If spoke site services are provided in a physician’s office and other services are provided on the
same date as the spoke service, the medical professional should bill Q3014 as a separate line item
from other professional services.
Documentation Standards
1. Documentation must be maintained at the hub and spoke locations to substantiate the services
provided. Documentation must indicate the services were rendered via telemedicine.
2. Documentation must clearly indicate the location of the hub and spoke sites.
3. All other IHCP documentation guidelines apply for services rendered via telemedicine, such as chart
notes, and start and stop times. Documentation must be available for postpayment review.
4. Providers must have written protocols for circumstances when the member must have a hands-on
visit with the consulting provider. The member should always be given the choice between a
traditional clinical encounter versus a telemedicine visit. Appropriate consent from the member must
be obtained by the spoke site and maintained at the hub and spoke sites.
Special Considerations
1. When ongoing services are provided, the member should be seen by a physician for a traditional
clinical evaluation at least once a year, unless otherwise stated in policy. In addition, the hub
physician should coordinate with the patient’s primary care physician.
2. The existing service limitations for office visits are applicable. All telemedicine consultations billed
using the codes listed in the Hub Site Services and Billing Requirements section are counted against
the office visit limit. Third-party liability (TPL), spend-down, managed care, and all other
considerations apply.
3. Reimbursement for ESRD-related services under HCPCS codes 90951 – 90970 is permitted in the
telemedicine setting. The IHCP requires at least one monthly visit for ESRD-related services to be a
traditional clinical encounter to examine the vascular access site.
4. Federally Qualified Health Centers (FQHCs) or rural health clinics (RHCs) are reimbursed only for
hands-on services and are therefore not permitted to bill for telemedicine services.
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Managed Care Considerations
Refer questions to the appropriate managed care entity (MCE) for risk-based managed care
considerations.
FQHCs and RHCs may submit claims to an MCE as fee-for-service and receive reconciliation review
through Myers & Stauffer, which, in coordination with the Office of Medicaid Policy and Planning
(OMPP), determines billable and nonbillable services.
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Section 4: CMS-1500 and 837P Transaction Billing
Instructions
Introduction
This document refers to the CMS-1500 Health Insurance Claim Form as CMS-1500 claim form, and it
refers to the 837P Health Care Claim: Professional Health Insurance Portability and Accountability
Act (HIPAA) transaction as 837P or 837P transaction. Providers should refer to the Indiana Health
Coverage Programs (IHCP) Companion Guides page on indianamedicaid.com for specific information
about electronic billing.
The paper claim form billing instructions align the paper claim process with the electronic claim
requirements mandated by the HIPAA Administrative Simplification requirements. Providers should
refer to the appropriate transaction implementation guide and IHCP companion guide for information
about the 837P transaction.
Providers Using the CMS-1500 Claim Form or the 837P
Transaction
The following is a list of provider types and services covered that are billed using the CMS-1500 claim
form or 837P transaction:
•
Advanced practice nurses – Midwife services, nurse practitioner services, nurse anesthetist
services, and clinical nurse specialists
•
Audiologists – Audiology services
•
Case managers – Care coordination services
•
Certified registered nurse anesthetists (CRNAs)
•
Chiropractors – Chiropractic services
•
Clinics – Family planning services, Federally Qualified Health Center (FQHC) services, medical
services, nurse practitioner services, rural health center (RHC) services, therapy services, and
surgical services
•
Comprehensive outpatient rehabilitation facility
•
Dentists – Oral surgery
•
Diabetes self-management services
•
Durable medical equipment (DME), home medical equipment (HME), and supply dealers – DME,
medical supplies, and oxygen
•
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service providers
•
Freestanding radiology facilities – Radiological services, professional component or global
•
Hearing aid dealers – Hearing aids
•
Independent diagnostic testing facility
•
Laboratories – Lab services, professional component
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•
Mental health providers – Medicaid Rehabilitation Option (MRO) services, outpatient mental
health services
•
Mid-level practitioners – Anesthesiology assistant services, physician assistant services,
independent practice school psychologists, and advanced practice nurses under
Indiana Code (IC) 25-23-1-1(b)(3), credentialed in psychiatric or mental health nursing by the
American Nurses Credentialing Center
- Billing under the supervising physician rendering National Provider Identifier (NPI)
•
Opticians – Optical services
•
Optometrists – Optometric services
•
Pharmacies – Supplies
•
Physicians, medical doctors, and doctors of osteopathy – Anesthesiology services, lab services,
professional component, medical services, mental health services, radiology services, renal dialysis
services, surgical services
•
Podiatrists – Podiatric services
•
Public health agencies – Medical services
•
School corporations – Therapy services: physical, occupational, speech, mental health
•
Therapists – Therapy services: physical, occupational, speech, audiology
•
Transportation provider – Transportation services, including hospital-based ambulance services
•
Waiver providers – Waiver services
General Information
The IHCP uses the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD9-CM) and Healthcare Common Procedure Coding System (HCPCS) Level I and II coding systems.
Each coding system is described as follows:
•
ICD-9-CM codes Volume 1 are numeric diagnosis codes, Volume 2 is an alphabetic index, and
Volume 3 is a tabular list of codes and an alphabetic index for procedures.
•
HCPCS Level I codes are Current Procedural Terminology (CPT ®) numeric codes and modifiers
created by the American Medical Association (AMA).
•
HCPCS Level II codes are A through V alphanumeric codes and modifiers created by the Centers
for Medicare & Medicaid Services (CMS) and are found in the HCPCS manual. These codes
identify products, supplies, materials, and services that are not included in the CPT code book.
Except where otherwise noted, the IHCP uses coding practices created and published by these entities.
Coding exceptions and clarifications are noted throughout the remainder of this chapter. Additional
exceptions related to the Medicare resource-based relative value (RBRVS) reimbursement system are
noted in Chapter 7: Reimbursement Methodologies of this manual.
Providers should always monitor all bulletins, banner page articles, and newsletter articles for future
coding information and clarification of billing practices.
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Claims Submission Addresses
Mail all claims, including those that have passed the filing limit, to one of the following addresses:
HP CMS-1500 Claims
P.O. Box 7269
HP Medical Crossover Claims
P.O. Box 7267
Note: For risk-based managed care (RBMC) members, providers should send
claims to the appropriate managed care entity (MCE) unless otherwise
indicated.
National Correct Coding Initiative
The IHCP applies National Correct Coding Initiative (NCCI) editing to medical services billed on the
CMS-1500 claim form. NCCI editing occurs on claims billed with the same date of service, same
member, and same billing provider NPI. NCCI editing is applied to CMS-1500 professional claims
with a date of service of October 1, 2010 and after.
Claims Processing and Mass Adjustments
Effective for dates of service on or after October 1, 2010, NCCI editing is applicable to CMS-1500
professional claims. This includes NCCI Column I and Column II, Mutually Exclusive (ME) edits, and
Medical Unlikely Edits (MUEs) for professional claims.
Code Auditing Methodologies for Physicians
Code auditing rules that are being implemented in the Medicaid claims processing system represent
correct coding methodologies and other coding methods based upon general guidance from the CMS,
the AMA, specialty society guidance, industry standard coding, and prevailing clinical practice.
Coding methodologies are as follows:
•
CMS-1500 claims that are billed with multiple units of the same laboratory code on the same date
of service
•
CPT add-on codes reported without reporting a corresponding primary procedure/service
•
Reporting multiple units of a primary service when add-on codes should be used
•
Nonanesthesia services submitted by an anesthesia provider specialty where the service billed is not
normally performed by an anesthesia provider specialty
•
Nonanesthesia services submitted by an anesthesia provider specialty where there is a more
appropriate anesthesia code that should be used for billing
•
Evaluation and Management codes billed on the same date of services as a procedure with a global
period
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•
Evaluation and Management codes billed within the pre- and post-operative period
•
Component rebundling to deny claims when component codes are billed and a single
comprehensive code should be billed
NCCI/Code Auditing Explanation of Benefits Codes
The IHCP developed explanation of benefits (EOB) codes that specifically identify when a claim detail
has encountered an NCCI/Code Auditing edit or a claim that could not process through NCCI/Code
Auditing editing for an unexpected event.
Table 8.45 – EOB Codes Related to NCCI/Code Auditing
New EOB
EOB Description
Purpose of EOB
4181
Service denied due to an NCCI edit. Go
to the Medicaid website at medicaid.gov
for information regarding NCCI coding
policies.
This EOB identifies when a detail
on a professional (CMS-1500) or
institutional outpatient ASC (UB04) claim has denied for Column
I/II and/or ME edit.
4182
Service denied due to an NCCI edit. Go
to the Medicaid website for information
regarding NCCI coding policies.
This EOB identifies when a detail
on an institutional claim
(outpatient) has denied for Column
I/II and/or ME edit.
4183
Units of service on the claim exceed the
MUE allowed per date of service. Go to
the Medicaid website for information
regarding maximum number of units of
service allowed for the service billed.
This EOB identifies when the units
of service allowed on a claim detail
exceed the MUE unit limit as
defined by CMS.
4184
NCCI editing occurred during recycle
process.
This EOB identifies when the
interface connection between the
IndianaAIM claims processing
system and McKesson ClaimsXten
is not successful.
4185
The claim did not process through NCCI
editing. The claim will be reprocessed or
adjusted at a later date. Please monitor
future Remittance Advice statements for
processing activity related to this claim.
This EOB identifies when a claim
could not go through NCCI editing
due to an unexpected event. The
claim is allowed to continue
through normal processing and will
be subject to a mass adjustment at a
later date.
4186
Component rebundling.
This EOB identifies when multiple
procedure codes are unbundled and
a single comprehensive code
should have been billed.
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New EOB
EOB Description
Purpose of EOB
4189
Multiple units of same lab not payable
without modifiers on same date of
service.
detail is paid containing the same
laboratory procedure code and is
billed for the same member, same
date of service by the same or a
different provider without medical
necessity or override modifiers 59
or 91 appended to procedure code.
4190
Add-on codes not payable when base
code not billed.
This EOB identifies when an addon code is billed without the
primary service/procedure for the
same member, same date of service
by the same provider on the same
claim or across claims in history.
4191
Base code limited to one unit per date of
service.
This EOB identifies when a
primary service or procedure code
is billed with multiple units for the
same member, same date of service
by the same provider on the same
claim or across claims in history.
4192
Nonanesthesia services are not
reimbursable for the anesthesiology
provider specialty billed.
detail contains procedure code that
cannot be billed by provider
specialties 311-Anesthesiologist or
094-Certified Registered Nurse
Anesthetist (CRNA) because the
procedure code cannot be
crosswalked for one of the
following reasons: it is not a
primary procedure code, anesthesia
care is not normally required, it is a
radiology service related to a
diagnostic or therapeutic service, or
the CPT book states this procedure
is performed without anesthesia.
4193
Service billed not reimbursable by
anesthesiologist.
detail contains a procedure code
that cannot be billed by provider
specialties 311-Anesthesiologist or
094-Certified Registered Nurse
Anesthetist (CRNA). The provider
must resubmit with the appropriate
anesthesia code to report anesthesia
services.
4194
Evaluation and management codes are not
reimbursable on the same day of surgery
that has a global period.
detail contains evaluation and
management procedure code billed
on the same date of service as
surgery that has a global period of
0, 10, or 90 days.
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New EOB
EOB Description
Purpose of EOB
4195
Multiple units of service cannot be billed
with modifier 50.
has a procedure code with modifier
50 and has more than one unit of
service billed.
4196
Evaluation and management codes are not
reimbursable during pre-op period.
detail contains an evaluation and
management procedure code billed
within the pre-operative period,
which is one day before a surgery
that has a 90 global period. Codes
with 0 or 10-day global surgery
periods are considered minor
surgical procedures and are not
subject to this rule.
4197
Physician claim type, effective September
26, 2012. Evaluation and management
codes are not reimbursable during post-op
period.
This EOB denies claim details
when an E&M procedure code is
billed within the post-operative
period. See
medicaid.gov/Medicare/Physician
Fee Schedule to determine the
global period for a procedure code.
Codes with a global surgery that
does not equal “000, 010, or 090”
are not considered codes with a
global period.
9092
The claim was subjected to NCCI editing
methodologies.
has gone through NCCI editing and
did not encounter any Column I/II,
ME, or MUE edits.
9094
Reimbursement based on bilateral
service.
This EOB identifies when the same
provider bills more than one
surgical procedure on the same date
of service for the same member.
NCCI Column I/Column II Edits
When the NCCI was first established, the “Column I/Column II Correct Coding Edit Table” was
termed the “Comprehensive/Component Edit Table.” Although the Column II code is often a
component of a more comprehensive Column I code, this relationship is not true for many edits. In the
latter type of edit, the code pair edit simply represents two codes that should not be reported together.
Mutually Exclusive (ME) Edits
Many procedure codes cannot be reported together because they are mutually exclusive of each other.
Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same
patient encounter.
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Medical Unlikely Edits (MUE)
An MUE for a HCPCS/CPT code is the maximum number of units of service under most
circumstances allowable by the same provider for the same beneficiary on the same date of service.
MUE editing is based on the units of service allowed on the claim, not the units of service billed.
Ordering, Prescribing, and Referring Providers
For dates of service on and after October 1, 2012, when providers are providing services that were
ordered, prescribed, or referred by another provider, the submitting providers will be required to
include the National Provider Identifier (NPI) of the provider that ordered, prescribed, or referred the
services or supplies.
The IHCP’s claims processing will monitor whether the ordering, prescribing, or referring (OPR)
provider is enrolled in the IHCP. Claims will deny if the OPR provider is not enrolled. To supplement
the existing Provider Search function, a directory of OPR providers is available at
indianamedicaid.com under the OPR Provider Search option.
The OPR information must appear on provider claims in the field detailed in the following table.
Table 8.46 – Entering OPR Information on Claim Form
Claim Form
Field Locator
CMS-1500
17b (Referring NPI)
837P Professional EDI Batch Transaction
Loop 2310A Referring Provider
NM101 = P3 or DN NM109 = NPI
Web interChange – Medical Claims
Referring NPI field
CMS-1500 Paper Claim Form Requirements
This section provides a brief overview for completing the CMS-1500 claim form version 08-05.
Note: Providers are encouraged to submit claims on the standard red-ink form to
expedite claim processing and improve the accuracy of data entry.
Billing and Rendering Provider Numbers
The following are the four provider classifications:
1. Billing – A practitioner or facility operating under a unique taxpayer identification number (TIN).
The TIN may be the practitioner’s Social Security number (SSN) or a Federal Employer
Identification Number (FEIN), but a sole proprietor’s TIN may not be shared or used by any other
practitioner, group, or facility.
2. Group – Any practice with one or more practitioners (rendering providers) sharing a common TIN.
A group may be a corporation or partnership, or any other legally defined business entity. The group
must have members linked to the business, and these members are identified as rendering (the
person performing the service) providers.
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3. Rendering – The provider that performs the services. Reimbursement for these services is paid to the
group and reported on the group’s TIN.
4. Dual – A provider that is a billing and rendering provider. The provider is enrolled as a billing
provider at one or more locations, and is also a member of a group or groups at one or more
locations.
It is imperative that providers enter only the NPI in field 33a on the CMS-1500. Placement of
more than one NPI in this field could result in reimbursement of the claim to the wrong provider. For
more instructions about NPI requirements, see the National Provider Identifier and One-to-One Match
section in Section 1 of this chapter.
Note: Atypical providers (nonmedical service providers) will continue to bill using
the Legacy Provider Identifier (LPI) in field 33b with the 1D or G2 qualifier.
When the rendering provider’s NPI appears in form field 33a on the CMS-1500, and the IHCP makes a
payment to the rendering provider, the rendering provider must refund the incorrect payment. Mail
refunds to the following IHCP address:
HP Refunds
P.O. Box 1937, Dept. 104
Description of Fields on the CMS-1500 Claim Form
This section explains the CMS-1500 claim form and the 837P transaction. Some information is
required on the form and other information is optional.
The field chart in Table 8.47 indicates if a field is Required or Required, if applicable. Optional and
Not applicable information is displayed in normal type. Specific instructions applicable to a particular
provider type are included. The table describes each form locator by referring to the number found in
the left corner of each box on the CMS-1500 claim form. These boxes contain the data elements.
IndianaAIM processes a maximum of six service lines per paper CMS-1500 claim form and 50 service
lines on the 837P.
Effective April 1, 2014, the Indiana Health Coverage Programs (IHCP) will accept only the revised
version of the CMS-1500 (02/12) paper claim form. Paper claims submitted on the current version of
the CMS-1500 (08/05) after March 31, 2014, will not be processed and will be returned to the provider.
The claim form and completion instructions for CMS-1500 Version 02/12 have been inserted below.
All form fields with changes are noted with an asterisk (*).
Figure 8.2 shows a sample copy of the CMS-1500, Version 02-12 claim form.
Table 8.47  CMS-1500, Version 02-12 Claim Form Locator Descriptions
Form Locator
1
INSURANCE CARRIER SELECTION – Enter X for Traditional Medicaid. Required.
1a
INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1) – Enter the IHCP member identification
number (RID). Must be 12 digits. Required.
2
PATIENT’S NAME (Last Name, First Name, Middle Initial) – Provide the member’s last name, first
name, and middle initial obtained from the Automated Voice Response (AVR) system, electronic
claim submission (ECS), Omni, or Web interChange verification. Required.
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Form Locator
3
PATIENT’S BIRTH DATE – Enter the member’s birth date in MMDDYY format. Optional.
SEX – Enter X in the appropriate box. Optional.
4
INSURED’S NAME (Last Name, First Name, Middle Initial) – Not applicable.
5
PATIENT’S ADDRESS (No., Street), city, state, ZIP Code, telephone (include area code) – Enter the
member’s complete address information. Optional.
6
PATIENT RELATIONSHIP TO INSURED – Not applicable.
7
INSURED’S ADDRESS (No., Street), city, state, ZIP Code, telephone (include area code) – Not
applicable.
8*
RESERVED FOR NUCC Use – Not applicable.
9
OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) – If other insurance is
available, and the policyholder is other than the member shown in fields 1a and 2, enter the
policyholder’s name. Required, if applicable.
9a
OTHER INSURED’S POLICY OR GROUP NUMBER – If other insurance is available, and the
policyholder is other than the member noted in fields 1a and 2, enter the policyholder’s policy and
group number. Required, if applicable.
9b*
RESERVED FOR NUCC USE – Not applicable.
9c*
9d
INSURANCE PLAN NAME OR PROGRAM NAME – If other insurance is available, and the
policyholder is other than the member shown in field 1a and 2, enter the policyholder’s insurance plan
name or program name information. Required, if applicable.
10
IS PATIENT’S CONDITION RELATED TO – Enter X in the appropriate box in each of the three
categories. This information is needed for follow-up third-party recovery actions. Required, if
applicable.
10a
EMPLOYMENT (CURRENT OR PREVIOUS) – Enter X in the appropriate box. Required, if
applicable.
10b
AUTO ACCIDENT – Enter X in the appropriate box. Required, if applicable.
PLACE (State) – Enter the two-character state code. Required, if applicable.
10c
OTHER ACCIDENT – Enter X in the appropriate box. Required, if applicable.
10d*
CLAIM CODES (Designated by NUCC) – Not applicable.
Fields 11 and 11a through 11d are used to enter member insurance information.
11
INSURED’S POLICY GROUP OR FECA NUMBER – Enter the member’s policy and group
number of the other insurance. Required, if applicable.
11a
INSURED’S DATE OF BIRTH – Enter the member’s birth date in MMDDYY format. Required, if
applicable.
SEX – Enter an X in the appropriate sex box. Required, if applicable.
11b*
OTHER CLAIM ID (Designated by NUCC) – Not applicable.
11c
INSURANCE PLAN NAME OR PROGRAM NAME – Enter the member’s insurance plan name
or program name. Required, if applicable.
11d*
IS THERE ANOTHER HEALTH BENEFIT PLAN? – Enter X in the appropriate box. If the
response is Yes, complete fields 9, 9a, and 9d. Required, if applicable.
12
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE – Not applicable.
13
INSURED’S OR AUTHORIZED PERSON’S SIGNATURE – Not applicable.
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Form Locator
14*
DATE OF CURRENT ILLNESS (First symptom date) OR INJURY (Accident date) OR
PREGNANCY (LMP date) – Enter the date of the last menstrual period (LMP) for pregnancy-related
services in MMDDYY format. Required if applicable
Note: Qualifier code is not applicable..
15*
OTHER DATE – Enter date in MMDDYY format. Optional.
Note: Qualifier code is not applicable.
16
DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION – If field 10a is Yes,
enter the applicable FROM and TO dates in a MMDDYY format. Required, if applicable.
17*
NAME OF REFERRING PROVIDER OR OTHER SOURCE – Enter the name of the referring
physician. Required, if applicable. For waiver-related services, enter the provider or case manager
name. Optional.
Note: Qualifier code is not applicable. The term referring provider includes
physicians primarily responsible for the authorization of treatment for lockin or Right Choices Program members.
17a
ID NUMBER OF REFERRING PROVIDER, ORDERING PROVIDER OR OTHER SOURCE
– Enter the qualifier in the first shaded box of 17a, indicating what the number reported in the second
shaded box of 17a represents. Atypical providers should report the IHCP LPI provider number in the
second box of 17a. Healthcare providers should report the taxonomy code in the second box of 17a.
The qualifier is required when entering the IHCP LPI provider number or taxonomy.
Qualifiers to report to IHCP:
1D and G2 are the qualifiers that apply to the IHCP provider number, also called the LPI for the
atypical nonhealthcare provider. The LPI includes nine numeric characters and one alpha character for
the service location.
ZZ and PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code
includes 10 alphanumeric characters. Taxonomy may be needed to establish a one-to-one NPI/LPI
match if the provider has multiple locations.
Required when applicable and for any waiver-related services.
Required if applicable.
17b
NPI – Enter the 10-digit numeric NPI of the referring provider, ordering provider, or other source.
18
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES – Enter the requested
FROM and TO dates in MMDDYY format. Required, if applicable.
19*
ADDITIONAL CLAIM INFORMATION. (Designated by NUCC) – Not applicable.
20
OUTSIDE LAB? – Not applicable.
CHARGES – Not applicable.
21 A-L*
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – Complete fields 21A-L through field
24Eby detail line. Enter the ICD diagnosis codes in priority order. A total of 12 codes can be entered.
Required.
ICD Ind – Enter 9 to indicate the diagnosis codes in fields 21A-L are ICD-9 diagnosis codes. Enter 0
to indicate the diagnosis codes in fields 21A-L are ICD-10 diagnosis codes. Required
RESUBMISSION CODE, ORIGINAL REF. NO. – Applicable for Medicare Part B crossover
claims and Medicare Replacement Plan claims. For crossover claims, the combined total of the
Medicare coinsurance, deductible, and psychiatric reduction must be reported on the left side of field
22 under the heading Code. The Medicare paid amount (actual dollars received from Medicare) must
be submitted in field 22 on the right side under the heading Original Ref No. Required, if applicable.
ICD Indicator
22*
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PRIOR AUTHORIZATION NUMBER – The prior authorization (PA) number is not required, but
entry is recommended to assist in tracking services that require PA. Optional.
23
Note: Date of service is the date the specific services were actually supplied, dispensed, or rendered
to the patient.
For services requiring authorization, the FROM date of service cannot be prior to the date the
service was authorized. The TO date of service cannot exceed the date the specific service was
authorized.
24A to 24I
Top Half –
Shaded Area
NATIONAL DRUG CODE INFORMATION – The shaded portion of fields 24A to 24I is used to
report NDC information. Required as of August 1, 2007.
To report this information, begin at field 24A as follows:
1. Enter the NDC qualifier of N4.
2. Enter the NDC 11-digit numeric code.
3. Enter the drug description.
4. Enter the NDC Unit qualifier:
 F2 – International Unit
 GR – Gram
 ML – Milliliter
 UN – Unit
5. Enter the NDC Quantity (Administered Amount) in the format 9999.99.
24A*
Bottom Half
DATE(S) OF SERVICE – Provide the FROM and TO dates in MMDDYY format. Up to six FROM
and TO dates are allowed per form. Required.
24B
PLACE OF SERVICE – Use the POS code for the facility where services were rendered.
For a list of POS codes, go to the Place of Service Codes Overview page on the CMS website at
cms.hhs.gov. Required.
24C
EMG – Emergency indicator. This field indicates services were for emergency care for service lines
with a CPT or HCPCS code in field 24D. Enter Y or N. Required, if applicable.
24D
PROCEDURES, SERVICES, OR SUPPLIES
CPT/HCPCS – Use the appropriate procedure code for the service rendered. Only one procedure code
is provided on each claim form service line. Required.
MODIFIER – Use the appropriate modifier, if applicable. Up to four modifiers are allowed for each
procedure code. Required, if applicable.
24E*
DIAGNOSIS POINTER– Enter letter A-L corresponding to the applicable diagnosis codes in field
21. A minimum of one, and a maximum of four, diagnosis code references can be entered on each line.
Required.
Note: The alpha value of A-L entered for the diagnosis pointer will be systematically converted to
match the Electronic Data Interchange (EDI) value of 1-12 as depicted below:
A
B
C
D
E
F
G
H
I
J
K
L
1
2
3
4
5
6
7
8
9
10
11
12
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24F
$ CHARGES – Enter the total amount charged for the procedure performed, based on the number of
units indicated in field 24G. The charged amount is the sum of the total units multiplied by the single
unit charge. Each line is computed independently of other lines. This is a 10-digit field. Required.
24G
DAYS OR UNITS – Provide the number of units being claimed for the procedure code. Six digits are
allowed, and 9999.99 units is the maximum that can be submitted. The procedure code may be
submitted in partial units, if applicable. Required.
24H
EPSDT Family Plan – If the patient is pregnant, indicate with a P in this field on each applicable line.
24I
Top Half –
Shaded Area
RENDERING ID QUALIFIER – Enter the qualifier indicating what the number reported in the
shaded area of 24J represents – 1D or G2 for IHCP LPI rendering provider number or ZZ or PXC for
rendering provider taxonomy code. Required, if applicaable
1D and G2 are the qualifiers that apply to the IHCP provider number (LPI) for atypical nonhealthcare
providers. The LPI includes nine numeric characters. Atypical providers (for example, certain
transportation and waiver service providers) are required to submit their LPIs.
ZZ and PXC are the qualifiers that apply to the provider taxonomy code. The taxonomy code
includes 10 alphanumeric characters. The taxonomy code may be required for a one-to-one match.
24J
Top Half –
Shaded Area
RENDERING PROVIDER ID – Enter the LPI if entering the 1D or G2 qualifier in 24I or the
taxonomy if entering the ZZ or PXC qualifier in 24I for the Rendering Provider ID or G2. Required,
if applicable.
LPI – The entire nine-digit LPI must be used. If billing for case management, the case manager’s
number must be entered here.
Taxonomy – Enter the taxonomy code of the rendering provider. Optional unless required for a oneto-one match.
24J
Bottom Half
RENDERING PROVIDER NPI – Enter the NPI of the rendering provider. Required if applicable.
25
FEDERAL TAX I.D. NUMBER – Not applicable.
26
PATIENT’S ACCOUNT NO. – Enter the internal patient tracking number. Optional.
27
ACCEPT ASSIGNMENT? – The IHCP Provider Agreement includes details about accepting payment
for services. Optional.
28
TOTAL CHARGE – Enter the total of all service line charges in column 24F. This is a 10-digit field,
such as 99999999.99. Required.
AMOUNT PAID – Enter the payment received from any other source, excluding the traditional
Medicare or Medicare Replacement Plan paid amount. All applicable items are combined and the total
entered in this field. This is a 10-digit field. Required, if applicable.
Other insurance – Enter the amount paid by the other insurer. If the other insurer was billed but paid
zero, enter 0 in this field. Attach denials to the claim form when submitting the claim for adjudication.
29
30*
31
SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS
– An authorized person, someone designated by the agency or organization, must sign and date the
claim. A signature stamp is acceptable; however, a typed name is not. Providers that have signed the
Claims Certification Statement for Signature on File form will have their claims processed when a
signature is omitted from this field. The form is available on the Forms page at indianamedicaid.com.
DATE – Enter the date the claim was filed. Required.
32
SERVICE FACILITY LOCATION INFORMATION – Enter the provider’s name and address where
the services were rendered, if other than home or office. This field is optional, but it helps HP contact
the provider, if necessary. Optional.
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32a
SERVICE FACILITY LOCATION NPI – Not applicable.
32b
SERVICE FACILITY LOCATION QUALIFIER AND ID NUMBER – Not applicable.
33
BILLING PROVIDER INFO & PH # – Enter the provider service location name, address, and the
ZIP Code+4 as listed on the provider enrollment profile. Required.
Note: If the U.S. Postal Service provides an expanded ZIP Code (ZIP Code + 4)
for a geographic area, this expanded ZIP Code must be entered on the claim
form.
33a
BILLING PROVIDER NPI – Enter the billing provider NPI. Required.
33b
BILLING PROVIDER QUALIFIER AND ID NUMBER – Healthcare providers may enter a
billing provider qualifier of ZZ or PXC and taxonomy code. Taxonomy may be needed to establish a
one-to-one NPI/LPI match if the provider has multiple locations.
If the billing provider is an atypical provider, enter the qualifier 1D or G2 and the LPI. Required.
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Figure 8.2 – CMS-1500 Claim Form
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837P Electronic Transaction
Providers must use the standard 837P format to submit electronic professional claims. These standards
are published in the 837P Implementation Guides (IGs). An addendum to most IGs has been published
and must be used to properly implement each transaction. The IGs are available for download through
the Washington Publishing Company website on wpc-edi.com.
Companion Guides
implementation process. Information contained in the IHCP Companion Guides is only intended to
supplement the adopted IGs and provide guidance and clarification as it applies to the IHCP.
Companion Guides are never intended to modify, contradict, or reinterpret the rules established by the
IGs. The IHCP Companion Guides page is located on indianamedicaid.com in the EDI Solutions
section.
Some data elements submitted by providers may not be used in processing the 837P transaction;
however, those data elements may be returned in other transactions, such as the 277 Claim Status
Request and Response or the 835 Remittance Advice transactions. These data elements are necessary
for processing, and failure to append these data elements may result in claim suspension or claim
denial.
Paper data requirements should mirror or be modified to mirror that of the 837P implementation guide
and current claim processing requirements. Paper and electronic billing procedures must also be
aligned for the provider. It is not necessary to maintain separate manuals and procedure rules.
Diagnosis Codes
Providers may submit up to eight ICD-9-CM five-digit diagnosis codes. Providers use these codes to
describe the medical condition of the patient, and the IHCP uses them for processing the transaction.
The IHCP processes the first four diagnosis codes. This rule applies to paper and electronic claims
submissions.
Modifiers
Modifiers may be appended to HCPCS/CPT codes only when clinical circumstances justify the use of
the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass NCCI
editing. The NCCI Policy Manual, located on medicaid.gov, provides specific guidance on proper use
of modifiers. The use of modifiers affects the accuracy of claims billing, reimbursement, and NCCI
editing. In addition, modifiers provide clarification of certain procedures and special circumstances.
Below is a summary of key modifiers used in billing and general guidance for usage.
Modifier 50
Bilateral procedures are performed during the same operative session on both sides of the body by the
same physician. The units billed would be entered as “1,” because one procedure was performed
bilaterally.
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Modifier 51
Multiple procedures or services are performed on the same day or during the same operative session by
the same physician. The additional or secondary procedure or service must be identified by adding
modifier 51 to the procedure or service code.
Modifier 59
Research shows that modifier 59 is often used incorrectly. Modifier 59 indicates that a provider
performed a distinct procedure or service on the same day as another procedure or service. It identifies
procedures and services that are not normally reported together, but are appropriate under the
circumstances. Modifier 59 should be used only when there is no other modifier to correctly clarify the
procedure or service. A distinct procedure may represent the following:
•
A different session or patient encounter
•
A different procedure or surgery
•
A different site or organ system
•
A separate incision or excision
•
A separate lesion
•
A separate injury or area of injury in extensive injuries
If multiple units of the same procedure are performed during the same session, the provider should
report all the units on a single detail line, unless otherwise specified in medical policy.
Modifiers LT and RT
The modifiers LT (left) and RT (right) apply to codes that identify procedures that can be performed
on paired organs such as ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifiers LT and RT should
be used whenever a procedure is performed on only one side to identify which one of the paired organs
was operated on. The CMS requires these modifiers whenever appropriate.
Use of Modifiers
Correct use of modifiers is essential to accurate billing and reimbursement for services provided.
When trying to determine whether or not a modifier is appropriate, providers should ask the following
questions:
•
Will a modifier provide additional information about the services provided?
•
Was the same service performed more than once on the same date?
•
Will the modifier give more information about the anatomic site of the procedure?
If any of these circumstances apply, it may be appropriate to add a modifier to the procedure code. It is
also important that the medical-records documentation supports the use of the modifier.
Also, the following are some of the many resources available for obtaining additional information:
•
The CMS provides carriers with guidance and instructions on the correct coding of claims and
using modifiers through manuals, transmittals, and the CMS website, which providers can access.
•
The National Correct Coding Initiative (NCCI) provides updates each quarter for correct modifier
usage for each CPT code.
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•
Providers must ensure that the use of the modifier is justifiable based on generally accepted coding
guidance (for example, from the American Medical Association or the CMS) that defines the
appropriate use of modifiers.
Note: The only modifiers mandatory for IHCP usage are pricing, processing,
anesthesia, physical status, and medical direction modifiers. However,
providers should always include any modifier that is applicable according to
correct coding criteria.
Using Modifiers with Pathology Codes
Some pathology codes have both professional and technical components. When submitting claims, use
of a modifier depends on whether the entity reporting the service is reporting:
•
The professional services of a pathologist only (billed with modifier 26 added to the code)
•
The technical component of a laboratory only (billed with the TC modifier added to the code)
•
Reporting both the professional and technical components as a global code (billed without any
modifier)
In all instances, the first claim received in the system for a particular pathology code on a single date of
service is the first one considered for payment.
Modifiers are categorized according to type. Table 8.48 lists the definition for each modifier type.
Table 8.49 lists the CMS-1500 modifiers.
Table 8.48 – Types of Modifiers
Type
Definition
Informational
Used for reference. Procedure code linkage is not required for these
modifiers.
Pricing
Used to read a fee segment. A rate is linked to the procedure code
modifier combination. These modifiers must be linked to the procedure
code in IndianaAIM.
Processing
Used to modify a fee segment by a percent or by a dollar amount. These
modifiers must be linked to the procedure code in IndianaAIM.
Review
Causes a claim to suspend for review. Procedure code linkage is not
required for these modifiers.
Anesthesia
Used to route the claim through the anesthesia pricing logic. These
Physical Status
Used to modify the anesthesia units submitted on the claim form. These
Medical
Direction
Used in anesthesia processing. Procedure code linkage is not required for
these modifiers.
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Table 8.49 – CMS-1500 Modifiers
Modifier
Type
Description
21
Informational
Prolonged evaluation and management (E/M) services
22
Review
Unusual services; for use with surgery codes only; must
provide documentation to substantiate
23
Anesthesia
Unusual anesthesia, general anesthesia not usually required
24
Informational
Unrelated E/M service by the same physician during a
postoperative period; requires documentation
25
Informational
Significant, separately identifiable E/M service by the same
physician on the same day of a procedure or other service
26
Pricing
Professional component
27
Informational
Multiple outpatient hospital E/M encounters on the same
date
32
Informational
Mandated services, services related to mandated
consultation and/or related services (for example, third-party
payer, governmental, legislative, or regulatory requirement)
33
Informational
Preventive service
47
Informational
Anesthesia by a surgeon
50
Processing
Bilateral procedure; allowed charge based on pricing 50% of
the normal allowed amount
51
Informational
Multiple procedures
52
Informational
Reduced services
53
Informational
Discontinued procedure
54
Processing
When one physician performs a surgical procedure and
another provides preoperative and/or postoperative
management, surgical services may be identified by adding
the modifier 54 to the usual procedure number
55
Processing
When one physician performed the postoperative
management and another physician performed the surgical
procedure, the postoperative component may be identified
by adding the modifier 55 to the usual procedure number
56
Processing
When one physician performed the preoperative care and
evaluation and another physician performed the surgical
procedure, the preoperative component may be identified by
adding the modifier 56 to the usual procedure number
57
Informational
An E/M service that resulted in the initial decision to
perform the surgery may be identified by adding the
modifier 57 to the appropriate level of E/M service
58
Informational
The physician may need to indicate that a procedure was
planned prospectively at the time of the original procedure
or more extensive than the original procedure or for therapy
following a diagnostic surgical procedure
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Modifier
Type
Description
59
Informational
Under certain instances, the physician may need to indicate
that a procedure was distinct from other services performed
on the same day; modifier 59 is used to identify procedures
that are not normally reported together but may be under the
circumstance
62
Processing
When two surgeons work together as primary surgeons
performing distinct part(s) of a procedure, each surgeon
should report his or her distinct operative work by adding
modifier 62 and any associated add-on code(s) for that
procedure
63
Informational
Procedure performed on infants less than 4 kg
66
Processing
Under some circumstances, highly complex procedures
(requiring the concomitant services of several physicians,
often of different specialties, plus other highly skilled,
specially trained personnel) are carried out under the
surgical team
73
Informational
Under extenuating circumstances or those that threaten the
well-being of the patient, the physician may cancel a
surgical or diagnostic procedure subsequent to the patient's
surgical preparation, but prior to the administration of
anesthesia
74
Informational
Under extenuating circumstances or those that threaten the
well-being of the patient, the physician may terminate a
surgical or diagnostic procedure after the administration of
anesthesia or after the procedure was started
76
Informational
The physician may need to indicate that a procedure or
service was repeated subsequent to the original procedure or
service by the same physician; this circumstance may be
reported by adding the modifier 76 to the repeated
procedure/service
77
Informational
The physician may need to indicate that a basic procedure or
service performed by another physician had to be repeated;
this situation may be reported by adding modifier 77 to the
repeated procedure/service
78
Informational
The physician may need to indicate that another procedure
was performed during the postoperative period of the initial
procedure; when this subsequent procedure is related to the
first and requires the use of the operating room report
modifier 78
79
Informational
The same physician may need to indicate that the
performance of a procedure or service during the
postoperative period was unrelated to the original procedure.
This circumstance may be reported by using the modifier 79
80
Processing
Assistant surgeon
81
Processing
Minimum surgical assistant services are identified by adding
the modifier 81 to the usual procedure number.
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Modifier
Type
Description
82
Processing
The unavailability of a qualified resident surgeon is a
prerequisite for use of modifier 82 appended to the usual
procedure code number(s); this modifier is used when a
qualified resident surgeon is not available
90
Informational
When laboratory procedures are performed by a party other
than the treating or reporting physician, the procedure may
be identified by adding the modifier 90 to the usual
procedure number
91
Informational
In the course of treatment of a patient, it may be necessary to
repeat the same lab test on the same day to obtain
subsequent test results; under these circumstances, the lab
test performed can be identified by its usual procedure and
the modifier 91
99
Review
Suspend for review – Multiple modifiers for anesthesia
8P
Informational
Performance measure reporting modifier
A1
Informational
Dressing for one wound
A2
Informational
Dressing for two wounds
A3
Informational
Dressing for three wounds
A4
Informational
Dressing for four wounds
A5
Informational
Dressing for five wounds
A6
Informational
Dressing for six wounds
A7
Informational
Dressing for seven wounds
A8
Informational
Dressing for eight wounds
A9
Informational
Dressing for nine or more wounds
AA
Anesthesia
Anesthesia services performed personally by
anesthesiologist
AD
Medical
Direction
Medical supervision by a physician, more than four
concurrent anesthesia procedures
AE
Informational
Registered dietician
AF
Informational
Specialty physician
AG
Informational
Primary physician
AH
Processing
Clinical psychologist
AI
Informational
Principal physician of record
AJ
Processing
Clinical social worker
AK
Informational
Nonparticipating physician
AM
Informational
Physician, team member service
AP
Informational
Determination of refractive state was not performed in the
course of diagnostic ophthalmological examination
AQ
Informational
Physician service in an unlisted health professional shortage
area (HPSA)
AR
Informational
Physician provider services in a physician scarcity area
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Modifier
Type
Description
AS
Processing
Physician assistant, nurse practitioner, or clinical nurse
specialist (CNS) services for assistant at surgery
AT
Informational
Acute treatment (used when reporting service 98940, 98941,
or 98942)
AU
Informational
Item furnished in conjunction with a urological, ostomy, or
tracheostomy supply
AV
Informational
Item furnished in conjunction with a prosthetic device,
prosthetic or orthotic
AW
Informational
Item furnished in conjunction with a surgical dressing
AX
Informational
Item furnished in conjunction with dialysis services
AY
Informational
Item or service furnished to an end-state renal disease
(ESRD) patient that is not for the treatment of ESRD
AZ
Informational
Physician providing a service in a dental health professional
shortage area for the purpose of an electronic health record
incentive payment
BA
Informational
Item furnished in conjunction with parenteral and enteral
nutrition (PEN) services
BL
Informational
Special acquisition of blood and blood products
BO
Informational
Orally administered nutrition, not by feeding tube
BP
Informational
The member has been informed of the purchase and rental
options and elected to purchase the item.
BR
Informational
options and has elected to rent the item.
BU
Informational
options, and after 30 days has not informed the supplier of
his or her decision.
CA
Informational
Procedure only payable in the inpatient setting when
performed emergently on an outpatient who expires prior to
admission
CB
Informational
Service ordered by renal dialysis facility (RDF) physician as
part of the ESRD beneficiary’s dialysis benefit is not part of
the composite rate and is separately reimbursable
CC
Informational
Procedure code change (use CC when the procedure code
submitted was changed for administrative reasons or
because an incorrect code was filed)
CD
Informational
Automated Multi-Channel Chemistry (AMCC) test has been
ordered by an ESRD facility or monthly capitation payment
(MCP) to a physician that is part of the composite rate and is
not separately billable
CE
Informational
AMCC test has been ordered by an ESRD facility or MCP to
a physician that is a composite rate test but is beyond the
normal frequency covered under the rate and is separately
reimbursable based on medical necessity
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Modifier
Type
Description
CF
Informational
AMCC test has been ordered by an ESRD facility or MCP to
a physician that is not part of the composite rate and is
separately billable
CG
Informational
Policy criteria applied
CH
Informational
Zero (0) percent impaired, limited or restricted
CI
Informational
At least one (1) percent but less than 20 percent impaired,
limited or restricted
CJ
Informational
At least 20 percent but less than 40 percent impaired, limited
or restricted
CK
Informational
or restricted
CL
Informational
or restricted
CM
Informational
At least 80 percent but less than 100 percent impaired,
limited or restricted
CN
Informational
100 percent impaired, limited or restricted
CR
Informational
Catastrophe/disaster related
CS
Informational
Item or service related, in whole or in part, to an illness,
injury, or condition that was caused by or exacerbated by the
effects, direct or indirect, of the 2010 oil spill in the Gulf of
Mexico, including but not limited to subsequent cleanup
activities
DA
Informational
Oral health assessment by a licensed health professional
other than a dentist
DD
Informational
From diagnostic site to diagnostic site
DE
Informational
From diagnostic site or therapeutic site other than
physician’s office or hospital to a residential or custodial
facility
DG
Informational
From diagnostic site to hospital-based dialysis facility
DH
Informational
Origin – Diagnostic or therapeutic site other than “p” or “h”
destination – Hospital
DI
Informational
From diagnostic site to site of transfer between types of
ambulance
DJ
Informational
From diagnostic site to nonhospital-based dialysis facility
DN
Informational
destination – Skilled nursing facility (SNF)
DP
Informational
From diagnostic or therapeutic site to physician’s office
DR
Informational
destination – Residence
DS
Informational
From diagnostic site to scene of accident
DX
Informational
From diagnostic site to intermediate stop at a physician’s
office en route to the hospital
E1
Informational
Upper left, eyelid
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Modifier
Type
Description
E2
Informational
Lower left, eyelid
E3
Informational
Upper right, eyelid
E4
Informational
Lower right, eyelid
EA
Informational
Erythropoiesis Stimulating Agents (ESA), anemia, chemo
induced
EB
Informational
ESA, anemia, radio induced
EC
Informational
ESA, anemia, nonchemo/radio
ED
Informational
From residential, domiciliary, custodial facility to
designated diagnostic or therapeutic site other than
physician’s office or hospital when these are used as origin
codes
Hematocrit (HCT) greater than 39% or hemoglobin (Hgb)
greater than 13 grams (g) greater than or equal to 3 cycle
EE
Informational
From one residential, domiciliary, custodial facility to
another facility of the same type
HCT greater than 39% or Hgb greater than 13 g less than 3
cycle
EG
Informational
From residential, domiciliary, or custodial facility to
hospital-based dialysis facility
EH
Informational
From residential, domiciliary, or custodial facility to hospital
EI
Informational
From residential domiciliary to site of transfer between two
types of ambulance
EJ
Informational
nonhospital-based dialysis facility
Subsequent claim for epoetin alpha (EPO) injection claims
only
EM
Informational
Emergency reserve supply – For end-stage renal disease
(ESRD) benefit only
EN
Informational
From residential, domiciliary, or custodial facility to SNF
EP
Informational
From residential domiciliary facility to physician’s office
Service provided as part of Medicaid Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) program
ER
Informational
residence
ES
Informational
From residential domiciliary to scene of accident
ET
Informational
Emergency services
EX
Informational
From residential, domiciliary, or custodial facility to hospital
with an intermediate stop at a physician’s office
EY
Informational
No physician or other licensed healthcare provider order for
this item or service
F1
Informational
Left hand, second digit
F2
Informational
Left hand, third digit
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Type
Description
F3
Informational
Left hand, fourth digit
F4
Informational
Left hand, fifth digit
F5
Informational
Right hand, thumb
F6
Informational
Right hand, second digit
F7
Informational
Right hand, third digit
F8
Informational
Right hand, fourth digit
F9
Informational
Right hand, fifth digit
FA
Informational
Left hand, thumb
FB
Informational
Item provided without cost to provider, supplier, or
practitioner, or credit received for replaced device (examples
but not limited to covered under warranty, replaced due to
defect, free samples)
FC
Informational
Part credit, replaced device
FP
Informational
Service provided as part of an Medicaid family planning
program
G1
Informational
Most recent urea reduction ratio (URR) reading of less than
60
G2
Informational
Most recent URR reading of 60 to 64.9
G3
Informational
G4
Informational
G5
Informational
Most recent URR reading of 75 or greater
G6
Informational
ESRD patient for whom less than six dialysis sessions have
been provided in one month
G7
Informational
Pregnancy resulted from rape or incest, or pregnancy
certified by physician as life threatening
G8
Informational
Monitored anesthesia care (MAC) for deep complex,
complicated, or markedly invasive surgical procedure
G9
Informational
MAC for a patient who has history of severe
cardiopulmonary condition
GA
Informational
Waiver of liability statement issued, as required by payer
policy
GB
Informational
Claim being resubmitted for payment because it is no longer
covered under a global payment demonstration
GC
Informational
Service performed in part by a resident under the direction
of a teaching physician
GD
Informational
From hospital-based dialysis facility to a diagnostic or
therapeutic site
Unit of service is greater than MUE value
GE
Informational
Service performed by a resident without the presence of a
teaching physician, under the primary care exception
Hospital-based dialysis facility, hospital, or hospital-related
to a residential, domiciliary, or custodial facility
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Modifier
Type
Description
GF
Informational
Nonphysician services in a critical access hospital (CAH)
GG
Informational
Performance and payment of screening mammogram and
diagnostic mammogram on the same patient, same day
From hospital-based dialysis to hospital-based dialysis
facility
GH
Informational
Diagnostic mammogram converted from screening
mammogram on same day
From hospital-based dialysis facility to hospital
GI
Informational
From hospital-based dialysis to site of transfer between two
types of ambulance
GJ
Informational
OPT OUT physician or practitioner emergency or urgent
service
From hospital-based dialysis facility to nonhospital-based
dialysis facility
GK
Informational
Actual item/service ordered by physician, item associated
with GA or GZ modifier
GL
Informational
Medically unnecessary upgrade provided instead of standard
item, no charge, no advance beneficiary notice (ABN)
GM
Informational
Multiple patients on one ambulance trip
GN
Informational
Service delivered under an outpatient speech language
pathology plan of care
GO
Informational
Service delivered personally by an occupational therapist or
under an outpatient occupational therapy plan of care
GP
Informational
Service delivered personally by a physical therapist or under
an outpatient physical therapy plan of care
From hospital-based dialysis facility, hospital, or hospitalrelated to physician’s office, includes clinic
GQ
Informational
Via asynchronous telecommunications system
GR
Informational
Service performed in whole or in party by resident in a
Department of Veteran’s Affairs (VA) medical center or
clinic, supervised in accordance with VA policy
Hospital-based dialysis facility to residence
GS
Informational
Dosage of EPO or darbepoietin alfa has been reduced and
maintained in response to hematocrit or hemoglobin level
From hospital-based dialysis facility to scene of accident
GT
Informational
Via interactive audio and video telecommunication systems
GU
Informational
Waiver of liability statement issued as required by payer
policy, routine notice
GV
Informational
Attending physician not employed or paid under
arrangement by the patient’s hospice provider
GW
Informational
Service not related to the hospice patient’s terminal
condition
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Modifier
Type
Description
GX
Informational
Notice of liability issued, voluntary under payer policy
GY
Informational
Item or service statutorily excluded – Does not meet the
definition of any Medicare benefit or for non-Medicare
insurers is not a contract benefit
GZ
Informational
Item or service expected to be denied as not reasonable and
necessary
H9
Informational
Court ordered
HA
Informational
Child/adolescent program
HB
Informational
Adult program, nongeriatric
HC
Informational
Adult program, geriatric
HD
Informational
Pregnant/parenting women’s program
From hospital to designated diagnostic or therapeutic site
other than physician’s office or hospital when these are used
as origin codes
HE
Processing
Mental health program
HF
Informational
Substance abuse program
HG
Informational
Opioid addiction treatment program
From hospital to hospital-based dialysis facility
HH
Informational
Integrated mental health/substance abuse program
Discharge/transfer from one hospital to another hospital
HI
Informational
Integrated mental health and intellectually
disabled/developmental disabilities program
From hospital to site of transfer between types of ambulance
vehicles, for example airport or helicopter pad
HJ
Informational
Employee assistance program
From hospital to nonhospital-based dialysis facility
HK
Informational
Specialized mental health programs for high-risk
populations
HL
Informational
Intern
HM
Processing
Less than bachelor’s degree
HN
Informational
Bachelor’s degree level
From hospital to SNF
HO
Informational
Master’s degree level
HP
Informational
Doctoral level
From hospital to physician’s office
HQ
Informational
Group setting
HR
Informational
Family/couple with client present
From hospital to residence
HS
Informational
Family/couple without client present
From hospital to scene of accident
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Modifier
Type
Description
HT
Informational
Multi-disciplinary team
HU
Informational
Funded by child welfare agency
HV
Informational
Funded by state addictions agency
HW
Informational
Funded by state mental health agency
HX
Informational
Funded by county/local agency
From hospital to another hospital with an intermediate stop
at physician’s office
HY
Informational
Funded by juvenile justice agency
HZ
Informational
Funded by criminal justice agency
ID
Informational
From site of transfer between types of ambulance to
diagnostic site
IE
Informational
residential domiciliary
IG
Informational
IH
Informational
From site of transfer between types of ambulance to hospital
II
Informational
From site of transfer between types of ambulance to site of
transfer between types of ambulance
IJ
Informational
nonhospital-based dialysis facility
IN
Informational
From site of transfer between ambulance to SNF
IP
Informational
physician’s office
IR
Informational
residence
IS
Informational
From site of transfer between types of ambulance to scene of
accident
IX
Informational
intermediate stop at a physician’s office en route to hospital
J1
Informational
Competitive acquisition program (CAP) no-pay submission
for a prescription number
J2
Informational
CAP, restocking of emergency drugs after emergency
administration
J3
Informational
CAP, drug not available through CAP as written, reimbursed
under average sales price methodology
J4
Informational
Durable medical equipment, prosthetics, orthotics, and other
supplies (DMEPOS) item subject to DMEPOS competitive
bidding program that is furnished by hospital on discharge
JA
Informational
Administered intravenously
JB
Informational
Administered subcutaneously
JC
Informational
Skin substitute used as a graft
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Modifier
JD
Type
Informational
Description
Nonhospital-based dialysis to a diagnostic or therapeutic site
Skin substitute not used for graft
JE
Informational
From nonhospital-based dialysis facility to residential
facility
Administered via dialysate
JG
Informational
From nonhospital-based dialysis facility to hospital-based
dialysis facility
JH
Informational
From nonhospital-based dialysis facility to hospital
JI
Informational
From nonhospital-based dialysis facility to site of transfer
between types of ambulance
JJ
Informational
From nonhospital-based dialysis facility to nonhospitalbased dialysis facility
JN
Informational
From nonhospital-based dialysis facility to SNF
JP
Informational
From nonhospital-based dialysis facility to physician’s
office
JR
Informational
From nonhospital-based dialysis facility to residence
JS
Informational
From nonhospital-based dialysis facility to scene of accident
JW
Informational
Drug amount discarded/not administered to any patient
JX
Informational
From nonhospital-based dialysis facility to intermediate stop
at a physician’s office en route to hospital
K0
Informational
Lower extremity prosthesis functional level 0
K1
Informational
Lower extremity prosthesis functional level 1 – Has the
ability or potential to use a prosthesis for transfers or
ambulation on level surfaces at fixed cadence; typical of the
limited and unlimited household ambulator
K2
Informational
ability or potential to use a prosthesis for ambulation with
the ability to traverse low-level environmental barriers, such
as curbs, stairs, or uneven surfaces; typical of the limited
community ambulator
New coverage not implemented by managed care
K3
Informational
ability or potential for ambulation with variable cadence;
typical of the community ambulatory that has the ability to
transverse most environmental barriers and may have
vocational, therapeutic, or exercise activity that demands
prosthetic utilization beyond simple locomotion.
K4
Informational
ability or potential for prosthetic ambulation that exceeds the
basic ambulation skills, exhibiting high impact, stress, or
energy levels, typical of the prosthetic demands of the child
or active adult
KA
Informational
Add-on option/accessory
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Modifier
Type
Description
KB
Informational
Beneficiary requested upgrade for ABN, more than four
modifiers identified on claim
KC
Informational
Replacement of special power wheelchair interface
KD
Informational
Drug or biological infused through DME
KE
Informational
Bid under round one of DMEPOS competitive bidding
program for use with a noncompetitive bid base equipment
KF
Informational
Item designated by the Food and Drug Administration
(FDA) as Class III device
KG
Informational
DMEPOS item subject to DMEPOS competitive bidding
program number 1
KH
Informational
DMEPOS item, initial claim, purchase or first month rental
KI
Informational
DMEPOS item, second or third month rental
KJ
Informational
DMEPOS item, parenteral and enteral nutrition (PEN),
pump or capped rental, months four to 15
KK
Informational
program number 2
KL
Informational
DMEPOS item delivered via mail
KM
Pricing
Prosthesis including new impression/moulage
KN
Pricing
Prosthesis using previous master model
KO
Informational
Single drug unit dose formulation
Lower extremity prosthesis Level 0 – Does not have the
ability or potential to ambulate or transfer safely with or
without assistance and a prosthesis does not enhance quality
of life mobility
KP
Informational
First drug of a multiple drug unit dose formulation
KQ
Informational
Second or subsequent drug of a multiple drug unit dose
formulation
KR
Informational
Rental item, billing for partial month
KS
Informational
Glucose monitor supply for diabetic member not treated
with insulin
KT
Informational
Beneficiary resides in a competitive bidding area and travels
to a noncompetitive area and receives item from noncontract
supplier
KU
Informational
program number 3
KV
Informational
DMEPOS item, professional service
KW
Informational
DMEPOS competitive bidding program number 4
KX
Informational
Requirements specified in the medical policy have been met
KY
Informational
DMEPOS competitive bidding program number 5
KZ
Informational
New coverage not implemented by Medicare
LC
Informational
Left circumflex coronary artery
LD
Informational
Left anterior descending coronary artery
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Modifier
Type
Description
LL
Informational
Lease rental – Use when DME equipment rental price is to
be applied against the purchase price
LM
Informational
Left main coronary artery
LR
Informational
Laboratory round trip
LS
Informational
FDA-monitored intraocular lens implant
LT
Informational
Left side (used to identify procedures performed on the left
side of the body)
M2
Informational
Medicare secondary payer (MSP)
MS
Informational
Six-month maintenance and service fee for reasonable and
necessary parts and labor, which are not covered under any
manufacturer or supplier warranty
NB
Informational
Nebulizer system, any type, FDA-cleared for use with
specific drug
ND
Informational
From SNF to designated diagnostic or therapeutic site other
than physician’s office or hospital when they are used as
origin codes
NE
Informational
From SNF to a residential, domiciliary, or custodial facility
NG
Informational
From SNF to hospital-based dialysis facility
NH
Informational
From SNF to hospital
NI
Informational
From SNF to site of transfer between types of ambulance
NJ
Informational
SNF to nonhospital-based dialysis facility
NN
Informational
From SNF to another SNF
NP
Informational
From SNF to physician’s office
NR
Informational
New when rented – DME that was new at the time of rental
is subsequently purchased
From SNF to residence
NS
Informational
From SNF to scene of accident
NU
Pricing
New durable medical equipment purchase
NX
Informational
From SNF to hospital with intermediate stop at physician’s
office
P1
Physical status
Physical status modifier 1 (0 units) for anesthesia; a normal
healthy patient
P2
Physical status
Physical status modifier 2 (0 units) for anesthesia; a patient
with mild systemic disease
P3
Physical status
Physical status modifier 3 (1 unit) for anesthesia; a patient
with severe systemic disease
P4
Physical status
Physical status modifier 4 (2 units) for anesthesia; a patient
with severe systemic disease that is a constant threat to life
P5
Physical status
Physical status modifier 5 (3 units) for anesthesia; a
moribund patient who is not expected to survive without the
operation
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Modifier
Type
Description
P6
Physical status
A declared brain-dead patient whose organs are being
removed for donor purposes
PA
Informational
Surgical or invasive procedure on wrong body part
PB
Informational
Surgical or invasive procedure on wrong patient
PC
Informational
Wrong surgery or other invasive procedure on patient
PD
Informational
From physician’s office to diagnostic site
Diagnostic or related nondiagnostic item or service provided
in a wholly owned or operated entity to a patient who is
admitted as an inpatient within three days
PE
Informational
From physician’s office to residential, domiciliary, or
custodial facility
PG
Informational
From physician’s office, which includes health maintenance
organization (HMO) nonhospital facility and clinic, to
PH
Informational
From physician’s office to hospital
PI
Informational
From physician’s office to site of transfer between types of
ambulance
Positron emission tomography (PET) or PET/computed
tomography (CT) to inform the subsequent treatment
strategy of cancerous tumors when the beneficiary’s treating
physician determines that the PET study is needed to inform
antitumor strategy
PJ
Informational
From physician’s office, which includes HMO nonhospital
facility and clinic, to nonhospital-based dialysis facility
PL
Informational
Progressive additional lenses
PN
Informational
From physician’s office to SNF
PP
Informational
From one physician’s office to another physician’s office
PR
Informational
From physician’s office to residence
PS
Informational
From physician’s office to scene of accident
PET or PET/CT to inform the subsequent treatment strategy
of cancerous tumors when the beneficiary’s treating
physician determines that the PET study is needed to inform
antitumor strategy
PT
Informational
Colorectal cancer screening test; converted to diagnostic test
or other
PX
Informational
From physician’s office to hospital with an intermediate stop
at another physician’s office
Q0
Informational
Invest clinical research
Q1
Informational
Routine clinical research
Q2
Informational
CMS Office of Research, Development, and Information
(ORDI) demonstration project procedure or service
Q3
Informational
Live kidney donor: surgery and related services
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Modifier
Type
Description
Q4
Informational
Service for ordering/referring physician qualifies as a
service exemption
Q5
Informational
Service furnished by a substitute physician under a
reciprocal billing arrangement
Q6
Informational
Service furnished by a locum tenens physician
Q7
Informational
One class A finding
Q8
Informational
Two class B findings
Q9
Informational
One class B and two class C findings
QA
Informational
FDA investigational device exemption
DME – No response to purchase
QC
Informational
Single channel monitoring
QD
Informational
Recording and storage in solid state memory by a digital
recorder
QE
Informational
Prescribed amount of oxygen less than 1 liter per minute
(LPM)
QF
Informational
Prescribed amount of oxygen exceeds 4 LPM
QG
Informational
Prescribed amount of oxygen greater than 4 LPM
QH
Informational
Oxygen-conserving device is being used with an oxygen
delivery system
QJ
Informational
Services or items provided to a prisoner or patient in state or
local custody; however, the state or local government, as
applicable, meets the requirements in 42 CFR 411.4 (b)
QK
Processing
Medical direction of two, three, or four concurrent
anesthesia procedures involving qualified individuals
QL
Informational
Patient pronounced dead after ambulance called
Used for ambulatory surgical center (ASC) to identify type
of service F (for services prior to January 1, 1992)
QM
Informational
Ambulance service provided under arrangement by a
provider of services
QN
Informational
Ambulance service furnished directly by a provider of
services
QP
Informational
Documentation is on file showing that the laboratory test(s)
was ordered individually or ordered as a CPT-recognized
panel other than automated profile codes 80002-80019,
G0058, G0059, and G0060
Beneficiary elected purchase (for services prior to January 1,
1992)
QR
Informational
Item or service provided in a Medicare-specified study
QS
Informational
Monitored anesthesia care service
QT
Informational
Recording and storage on tape by an analog tape recorder
QV
Informational
Item or service provided as routine care in a Medicare
qualifying clinical trial
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Modifier
Type
Description
QW
Informational
Clinical Laboratory Improvement Amendments (CLIA)
waived test
QX
Processing
Certified registered nurse anesthetist (CRNA) service
QY
Informational
Medical direction of one CRNA by an anesthesiologist
QZ
Anesthesia
CRNA service, without medical direction by a physician
RA
Informational
Replacement of a DME, orthotic, or prosthetic item
RB
Informational
Replacement of part of a DME, orthotic, or prosthetic item
furnished as part of repair
RC
Informational
Right coronary artery
RD
Informational
From a residence to a designated diagnostic or therapeutic
site other than a physician’s office or hospital when these
are used as origin codes
Drug administered not incident to
RE
Informational
From residence to residential domiciliary, custodial facility
Furnished in full compliance with FDA-mandated risk
evaluation and mitigation
RG
Informational
Residence to hospital-based dialysis facility, hospital or
hospital-related
RH
Informational
From residence to hospital
RI
Informational
Ramus intermedius coronary artery
RJ
Informational
Residence to nonhospital-based dialysis facility
RN
Informational
From residence to SNF
RP
Informational
Residence to physician’s office
RR
Pricing
Rental of durable medical equipment
RT
Informational
Describes procedures performed on the right side of the
body
RX
Informational
From residence to hospital with an intermediate stop at
physician’s office
SA
Informational
Nurse practitioner rendering service in collaboration with a
physician
SB
Informational
Nurse midwife
SC
Informational
Medically necessary service or supply
SD
Informational
Services provided by registered nurse with specialized,
highly technical home infusion training
From scene of accident to diagnostic site
SE
Informational
State- and/or federally funded programs or services
From scene of accident to residential domiciliary
SF
Informational
Second opinion ordered by a professional review
organization (100% reimbursement – No Medicare
deductible or coinsurance)
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SG
Type
Informational
Description
Ambulatory surgical center (ASC) facility service
From scene of accident to hospital-based dialysis facility
SH
Informational
Second concurrently administered infusion therapy
From scene of accident or acute event to hospital
SI
Informational
From scene of accident to site of transfer between types of
ambulance
SJ
Informational
Third or more concurrently administered infusion therapy
From scene of accident to nonhospital-based dialysis facility
SK
Informational
Member of high-risk population (use only with codes for
immunization)
SL
Informational
State-supplied vaccine
SM
Informational
Second surgical opinion
SN
Informational
Third surgical option
From scene of accident to SNF
SP
Informational
From scene of accident to physician’s office
SQ
Informational
Item ordered by home health
SR
Informational
From scene of accident to residence
SS
Informational
Home infusion services provided in the infusion suite of the
IV therapy provider
ST
Informational
Related to trauma or injury
SU
Informational
Procedure performed in physician’s office
SV
Informational
Pharmaceuticals delivered to patient’s home but not utilized
SW
Informational
Services provided by a certified diabetic educator
SX
Informational
From the scene of an accident or acute event to a hospital
with an intermediate stop at a physician’s office
SY
Informational
Persons who are in close contact with member of high-risk
population
T1
Informational
Left foot, second digit
T2
Informational
Left foot, third digit
T3
Informational
Left foot, fourth digit
T4
Informational
Left foot, fifth digit
T5
Informational
Right foot, great toe
T6
Informational
Right foot, second digit
T7
Informational
Right foot, third digit
T8
Informational
Right foot, fourth digit
T9
Informational
Right foot, fifth digit
TA
Informational
Left foot, great toe
TC
Pricing
Technical component
TD
Informational
Registered nurse (RN)
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Chapter 8
Modifier
Type
Description
TE
Informational
Licensed practical nurse (LPN)/licensed vocational nurse
(LVN)
TF
Informational
Intermediate level of care
TG
Pricing
Complex/high-tech level of care
TH
Informational
Obstetrical treatment/services – Prenatal or postpartum
TJ
Informational
Program group, child and/or adolescent
TK
Informational
Extra patient or passenger, nonambulance
TL
Informational
Early intervention/individualized family service plan
TM
Informational
Individualized education program
TN
Informational
Rural/outside providers’ customary service area
TP
Informational
Medical transport, unloaded vehicle
TQ
Informational
Basic life support transport by a volunteer ambulance
provider
TR
Informational
School-based individualized education program services,
provided outside the public school district responsible for
the student
TS
Informational
Follow-up service
TT
Informational
Individualized service provided to more than one patient in
same setting
TU
Informational
Special payment rate, overtime
TV
Informational
Special payment rates, holidays and/or weekends
TW
Informational
Backup equipment
U1
Informational
Medicaid Level of Care 1, as defined by each state
U2
Informational
U3
Informational
U4
Informational
U5
Informational
U6
Informational
U7
Informational
U8
Informational
U9
Informational
UA
Informational
UB
Informational
UC
Informational
UD
Pricing
Disease management education
UE
Pricing
Used durable medical equipment without a warranty
UF
Informational
Services provided in the morning
UG
Informational
Services provided in the afternoon
UH
Informational
Services provided in the evening
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Modifier
Type
Description
UJ
Informational
Services provided in the night
UK
Informational
Services provided on behalf of the client to someone other
than the client (collateral relationship)
UN
Processing
Two patients served
UP
Processing
Three patients served
UQ
Processing
Four patients served
UR
Processing
Five patients served
US
Processing
Six or more patients served
V5
Informational
Any vascular catheter (alone or with any other vascular
access)
V6
Informational
Arteriovenous graft (or other vascular access not including a
vascular catheter)
V7
Informational
Arteriovenous fistula only (in use with two needles)
VP
Informational
Aphakic patient
Use single-character modifiers in combination for transportation to report services to the CMS. The
first character indicates the transport’s place of origin, and the second character indicates the
destination. Table 8.50 lists the modifiers used for transportation.
Table 8.50 – Transportation Origin and Destination Modifiers
Modifier
Description
D
Diagnostic or therapeutic site, other than P or H
E
Residential, domiciliary, or custodial facility (nursing home, not skilled
nursing facility)
G
Hospital-based dialysis facility (hospital or hospital-related)
H
Hospital
I
Site of transfer between types of ambulance (for example, airport or
helicopter pad)
J
Nonhospital-based dialysis facility
N
Skilled nursing facility (SNF)
P
Physician’s office – Includes health maintenance organization (HMO)
nonhospital facility, clinic, and so forth
R
Residence
S
Scene of accident or acute event
X
Intermediate stop at physician’s office en route to the hospital (can only be
used as a designation code in the second position of a modifier)
Note: CMS does not require the designation of the four PET scan modifiers (N, E,
P, and S).
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Place of Service Codes
Table 8.51 lists the place of service codes.
Table 8.51 – Place of Service Codes
Place of Service Name
01
Pharmacy
02
Unassigned
03
School
04
Homeless Shelter
05
Indian Health Service Freestanding Facility
06
Indian Health Service Provider-based Facility
07
Tribal 638 Freestanding Facility
08
Tribal 638 Provider-based Facility
11
Office
12
Home
13
Assisted Living Facility
14
Group Home
15
Mobile Unit
16
Unassigned
17
Walk-in Retail Health Clinic
18 and 19
Unassigned
20
Urgent Care Facility
21
Inpatient Hospital
22
Outpatient Hospital
23
Emergency Room
24
Ambulatory Surgical Center
25
Birthing Center
26
Military Treatment Facility
27-30
Unassigned
31
Skilled Nursing Facility
32
Nursing Facility
33
Custodial Care Facility
34
Hospice
35-40
Unassigned
41
Ambulance – Land
42
Ambulance – Air or Water
43-48
Unassigned
49
Independent Clinic
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Place of Service Name
50
Federally Qualified Health Center
51
Inpatient Psychiatric Facility
52
Psychiatric Facility – Partial Hospitalization
53
Community Mental Health Center
54
Intermediate Care Facility/Intellectually Disabled
55
Residential Substance Abuse Treatment Facility
56
Psychiatric Residential Treatment Center
57
Nonresidential Substance Abuse Treatment Facility
58-59
Unassigned
60
Mass Immunization Center
61
Comprehensive Inpatient Rehabilitation Facility
62
Comprehensive Outpatient Rehabilitation Facility
63-64
Unassigned
65
End-Stage Renal Disease Treatment Facility
66-70
Unassigned
71
State or Local Public Health Clinic
72
Rural Health Clinic
73-80
Unassigned
81
Independent Laboratory
82-94
Unassigned
95
Family Day Care
96
Community Setting
97
Early Intervention (EI) Class/Program
98
Residential Facility
99
Other Place of Service
Providers must complete the “From” and “To” dates, even if the service was for one single date of
service. All services performed or delivered within the same calendar month and in a consecutive day
pattern, must be billed with the appropriate units of service and “From” and “To” period. Failure to
report the correct date span and the number of units performed during the date span could result in a
claim denial. The following example shows the proper use of span dates to avoid unnecessary MUErelated denials. When similar services are rendered to the same member at multiple service locations
on a single date of service, it is acceptable to bill the total units on a single line item using a single
place of service (POS). Documentation in the medical record must contain the most specific POS for
each service rendered.
Example: A community mental health center (CMHC) provides four units of case management
services to a member in the office at 10 a.m. on July 10, 2010, and on the same day provides an
additional three units of case management at 3 p.m. in the member’s home. The CMHC may bill for
seven units of service on one detail of the claim at POS 11 (office) and document in the medical record
the number of units rendered at each individual POS.
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All providers must follow established policy and coding guidelines for their specialty. Fee-for-service
FQHC or RHC providers should bill only one encounter per IHCP member, per provider, per day
unless the diagnosis differs.
RBMC may have other specific reimbursement guidelines. Providers rendering services in the RBMC
delivery system should contact the MCE with whom they are contracted for information about the
billing of multiple service locations.
U Modifiers
The Office of Medicaid Policy and Planning (OMPP) has specifically designated U modifiers for the
use of Medicaid as defined by state. Modifiers U1 through U9 and UA through UD are defined as
“Medicaid Level of Care 1 – 13, as defined by each state.” The IHCP uses many of these modifiers for
dual purposes.
Use of Span Dates on the CMS-1500 Claim Form
A U modifier indicates a procedure was altered by circumstance, but not changed in meaning. U
modifiers are two-character numeric or alphanumeric codes that providers add to the end of a
CPT/HCPCS code.
The IHCP accepts up to four procedure code modifiers on all professional claims, paper and electronic
CMS-1500, and electronic 837P transactions.
Waiver providers must utilize the modifier U7 for all waiver services. Providers should use modifier
U7 even if other modifiers are required in the procedure code and modifier combination. Failure to add
the U7 modifier and any other required modifier may result in claim denial or an incorrect payment.
Claims for waiver services are currently exempt from NCCI editing.
Substitute Physicians and Locum Tenens
Substitute physicians and locum tenens may fill in for a member’s regular physician. The regular
physician may be the member’s primary care physician or primary medical provider (PMP), or a
specialist that a member sees on a regular basis. The substitute physician or locum tenens must be the
same discipline as the regular physician.
Substitute Physicians
A substitute physician is a physician who is asked by the regular physician to see a member in a
reciprocal agreement when the regular physician is unavailable to see the member. A substitute
physician may be asked to see a member if the regular physician is not available or on call. The
substitute arrangement does not apply to physicians in the same medical group with claims submitted
in the name of the medical group. In addition, a substitute physician arrangement should not exceed 14
days.
In a substitute physician arrangement, the regular physician reciprocates the substitute physician by
paying the substitute the amount received for the service rendered or by providing the same service in
return. In a substitute physician arrangement, the regular physician and the substitute physician must
be enrolled as an IHCP provider. In field 24D of the CMS-1500 claim form, enter the modifier Q5 to
indicate that a substitute physician rendered the services.
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Locum Tenens Physicians
Providers can create a locum tenens arrangement when the regular physician must leave his or her
practice due to illness, vacation, or medical education opportunity and does not want to leave his or her
patients without service during this period. Providers use the locum tenens arrangement in a single or a
group practice, but the locum tenens physician cannot be a member of the group in which the regular
physician is a member. The locum tenens physician usually has no practice of his or her own and
moves from area to area as needed. The physician is usually paid a fixed per diem amount with the
status of an independent contractor, not an employee. The locum tenens physician must meet all the
requirements for practice in Indiana, as well as all the hospital or other institutional credentialing
requirements prior to providing services to IHCP members. The practitioner providing locum tenens
services is not required to be an IHCP provider. The regular physician’s office must maintain
documentation of the locum tenens arrangement, including what services were rendered and when they
were provided.
The regular physician’s office personnel submit claims for the locum tenens services using the regular
physician’s NPI and modifier Q6 in form field 24D of the CMS-1500 claim form.
Locum tenens arrangements should not exceed 90 consecutive days. If the physician is away from his
or her practice for more than 90 days, a new locum tenens would be necessary. If a locum tenens
provider remains in the same practice for more than 90 days, he or she must enroll as an IHCP
provider.
Translation Services in Care Select
The care management organizations (CMOs), ADVANTAGE Health Solutions SM and MDwise, do not
arrange for translation services for healthcare-related services in the provider’s service location for
Care Select members. This has no impact on a provider’s existing obligation under federal civil rights
laws to ensure access to services for members with limited English proficiency (LEP).
The CMOs will continue to access AT&T’s Language Line for member calls. MDwise and
ADVANTAGE have contracted with AT&T’s Language Line to furnish the services of a language
interpreter for customer service representatives needing assistance in communicating with Care Select
members who speak a primary language other than English. AT&T’s Language Line provides
interpreters for more than 140 languages, 24 hours a day, seven days a week.
For hearing impaired services, ADVANTAGE and MDwise use Indiana Relay Service.
Anesthesia Services
The Administrative Simplification requirements of HIPAA mandated adopting the standards for the
anesthesia CPT codes. Providers submit anesthesia services using anesthesia CPT codes 00100 through
01999. Providers must submit anesthesia charges using the anesthesia CPT code that corresponds to
the surgical procedure performed.
Coverage and Billing Procedures
The following types of anesthesia are eligible for separate reimbursement under the IHCP, when
provided by a physician other than the operating surgeon:
•
Epidural
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•
Field block
•
Inhalation
•
Intravenous
•
Nerve block
•
Regional
•
Spinal
General, regional, or epidural anesthesia administered by the same provider performing the surgical or
obstetrical delivery procedure is not reimbursable, because it is included in the surgical delivery fee.
When billing regional anesthesia as the anesthesia type for a given surgical procedure that is performed
by a qualified anesthesia professional, providers bill regional anesthesia in the same manner as a
general anesthetic, such as base units plus time, and it will be reimbursed the same way. Do not use the
bilateral procedure code modifier 50 in conjunction with anesthesia modifiers.
Effective for dates of service on or after August 1, 2011, nonanesthesia services submitted by an
anesthesia provider specialty where the service billed is not normally performed by an anesthesia
provider specialty and nonanesthesia services submitted by an anesthesia provider specialty where
there is a more appropriate anesthesia code that should be used for billing are denied. The anesthesiarelated code auditing rules apply only to providers who are enrolled with the anesthesia specialty.
Multiple specialty providers will not be subjected to this type of code auditing.
Time
Providers should indicate the actual time of the service rendered, in minutes, in field 24G of the CMS1500 claim form. IndianaAIM calculates the time units, and it allows one unit for each 15-minute
period or fraction thereof.
Time starts when the anesthesiologist or certified registered nurse anesthetist (CRNA) begins preparing
the patient for the procedure in the operating room or other appropriate area. Starting to count time
when the preoperative examination occurs is not appropriate. The IHCP reimbursement of the
preoperative exam is included in the base units. Time ends when the anesthesiologist or CRNA
releases the patient to the postoperative unit and is no longer in constant attendance.
Base Units
The IHCP has assigned relative value units (RVUs) or base unit values to each CPT code that would
normally allow for anesthesia services.
Note: Providers do not report the base units on claims. IndianaAIM automatically
determines the base units for the procedure code as submitted on the CMS1500 claim form or the 837P transaction.
Additional Units
IndianaAIM, the claims processing system, recognizes and calculates additional units for the following:
•
Patient age – IndianaAIM applies additional units to the base units for members under 1 year of age
or more than 70 years old.
•
Procedure code 99140 – Providers should bill this service on a separate line item of the claim to
indicate that the anesthesia provided was complicated by emergency conditions. Only one unit of
CPT code 99140 is reimbursable for each anesthesia event. The maximum reimbursement for one
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unit of CPT code 99140 is equivalent to two base anesthesia units. For dates of service on or after
May 1, 2012, claims billed for two or more units of CPT code 99140 for a single anesthesia event
will be cut back to one unit for reimbursement.
•
Physical status – Providers should utilize the appropriate status modifier to denote any conditions
described in the modifier descriptions listed in Table 8.52.
Table 8.52 – Status Modifiers – Anesthesia
Modifier
Description
Elective
P1
A normal healthy patient for an elective operation
0 units
P2
A patient with mild systemic disease
0 units
P3
A patient with severe systemic disease
1 unit
P4
A patient with a severe systemic disease that is a constant threat to
life
2 units
P5
A moribund patient who is not expected to survive without the
operation.
3 units
P6
A declared brain-dead patient whose organs are being removed for
donor purposes.
0 units
Utilization
Anesthesiologists performing the procedures in Table 8.53 must bill with the AA modifier and must
bill these procedures in units:
Table 8.53 – Anesthesia Procedures using AA Modifier
CPT Code
Description
36555 AA
Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of
age
36556 AA
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older
36557 AA
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or
pump; younger than 5 years of age
36558 AA
Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or
pump; age 5 years and older
36560 AA
Insertion of tunneled centrally inserted central venous access device, with subcutaneous
port; younger than 5 years of age
36561 AA
Insertion of tunneled centrally inserted central venous access device, with subcutaneous
port; age 5 years or older
36563 AA
Insertion of tunneled centrally inserted central venous access device with subcutaneous
pump
36565 AA
Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters
via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type
catheter)
36566 AA
Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters
via 2 separate venous access sites; with subcutaneous port(s)
36568 AA
Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port
or pump; younger than 5 years of age.
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CPT Code
Description
36569 AA
Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port
or pump; age 5 years and older
36570 AA
Insertion of peripherally inserted central venous catheter access device, with subcutaneous
port; younger than 5 years of age.
36571 AA
Insertion of peripherally inserted central venous catheter access device, with subcutaneous
port; age 5 years or older
36575 AA
Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous
port or pump, central or peripheral insertion site
36576 AA
Repair of central venous access device, with subcutaneous port or pump, central or
peripheral insertion site
36578 AA
Replacement, catheter only, of central venous access device, with subcutaneous port or
pump, central or peripheral insertion site.
36580 AA
Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without
subcutaneous port or pump, through same venous access.
36581 AA
Replacement, complete, of a tunneled centrally inserted central venous catheter, without
subcutaneous port or pump, through same venous access.
36582 AA
Replacement, complete, of a tunneled centrally inserted central venous device, with
subcutaneous port, through same venous access.
36583 AA
Replacement, complete, of a tunneled centrally inserted central venous device, with
subcutaneous pump, through same venous access.
36584 AA
Replacement, complete, of a peripherally inserted central venous catheter (PICC), without
subcutaneous port or pump through same venous access
36585 AA
Replacement, complete, of a peripherally inserted central venous device with subcutaneous
port, through same venous access
36589 AA
Removal of tunneled central venous catheter, without subcutaneous port or pump
36590 AA
Removal of tunneled central venous access device, with subcutaneous port or pump, central
or peripheral insertion
36595 AA
Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central
venous device via separate venous access.
36596 AA
Mechanical removal of intraluminal (intracatheter) obstructive material from central venous
device through device lumen
36597 AA
Repositioning of previously placed central venous catheter under fluoroscopic guidance
36620 AA
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate
procedure); percutaneous
36625 AA
Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate
procedure); cutdown
93503 AA
Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes
99116 AA
Anesthesia complicated by utilization of total body hypothermia (List separately in addition
to code for primary anesthesia procedure)
Physician or other qualified health care professional attendance and supervision of
hyperbaric oxygen therapy, per session
99183 AA
Do not bill procedure code 99140 – Anesthesia complicated by emergency conditions (specify) with
the AA modifier.
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Anesthesia Reimbursement
IndianaAIM converts minutes to units (one unit equals 15 minutes) and adds the assigned base units in
addition to units for modifying circumstances for a total unit value times the anesthesia conversion
factor.
Base Units + Time Units + Additional Units for age (if applicable) + Additional Units for physical
status modifiers (as applicable) x Anesthesia Conversion Factor = Anesthesia Reimbursement Rate
Providers can add additional reimbursement to the anesthesia reimbursement rate if billing CPT codes
for emergency (99140) or other qualifying circumstances. The current IHCP anesthesia conversion
factor is $13.88.
Medical Direction and Certified Registered Nurse Anesthesiologist Billing
Requirements
Anesthesia services that are medically directed by an anesthesiologist are priced at 30% of the allowed
rate. Anesthesia services that are rendered by a CRNA are priced at 60% of the allowed amount.
Changes to CRNA Coding and Billing
The CPT codes in Table 8.54 indicate procedure codes that CRNAs are allowed to bill beginning with
dates of service on or after January 1, 2013. Table 8.55 indicates procedure codes currently billable by
CRNAs that will continue as billable codes. Procedure codes that do not appear on one of these two
tables are no longer billable by CRNAs, effective for dates of service on or after January 1, 2013.
Table 8.54 – CRNA Billing Codes
CPT Code
Description
00211
Anesthesia for intracranial procedures; craniotomy or craniectomy for
evacuation of hematoma
00326
Anesthesia for all procedures on the larynx and trachea in children
younger than 1 year of age
00529
Anesthesia for closed chest procedures; mediastinoscopy and diagnostic
thoracoscopy utilizing 1 lung ventilation
00539
Anesthesia for tracheobronchial reconstruction
00561
Anesthesia for procedures on heart, pericardial sac, and great vessels of
chest; with pump oxygenator, younger than 1 year of age
00567
Anesthesia for direct coronary artery bypass grafting; with pump
oxygenator
00625
Anesthesia for procedures on the thoracic spine and cord, via an anterior
transthoracic approach; not utilizing 1 lung ventilation
00626
Anesthesia for procedures on the thoracic spine and cord, via an anterior
transthoracic approach; utilizing 1 lung ventilation
00921
Anesthesia for procedures on male genitalia (including open urethral
procedures); vasectomy, unilateral or bilateral
01173
Anesthesia for open repair of fracture disruption of pelvis or column
fracture involving acetabulum
01710
Anesthesia for procedures on nerves, muscles, tendons, fascia, and
bursae of upper arm and elbow; not otherwise specified
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CPT Code
Description
01744
Anesthesia for open or surgical arthroscopic procedures of the elbow;
repair of nonunion or malunion of humerus
01829
Anesthesia for diagnostic arthroscopic procedures on the wrist
01935
Anesthesia for percutaneous image guided procedures on the spine and
spinal cord; diagnostic
01936
Anesthesia for percutaneous image guided procedures on the spine and
spinal cord; therapeutic
01958
Anesthesia for external cephalic version procedure
01965
Anesthesia for incomplete or missed abortion procedures
01966
Anesthesia for induced abortion procedures
01991
Anesthesia for diagnostic or therapeutic nerve blocks and injections
(when block or injection is performed by a different physician or other
qualified health care professional); other than the prone position
01992
Anesthesia for diagnostic or therapeutic nerve blocks and injections
(when block or injection is performed by a different physician or other
qualified health care professional); prone position
01996
Daily hospital management of epidural or subarachnoid continuous drug
administration
20551
Injection(s): single tendon origin/insertion
20552
Injection(s): single or multiple trigger point(s), 1 or 2 muscle(s)
20553
Injection(s); single or multiple trigger point(s), 3 or more muscle(s)
27096
Injection procedure for sacroiliac joint, anesthetic/steroid, with image
guidance (fluoroscopy or CT ) including arthrography when performed
36555 AA
Insertion of non-tunneled centrally inserted central venous catheter;
younger than 5 years of age
36556 AA
Insertion of non-tunneled centrally inserted central venous catheter; age
5 years or older
62263
Percutaneous lysis of epidural adhesions using solution injection (eg,
hypertonic saline, enzyme) or mechanical means (eg, catheter) including
radiologic localization (includes contrast when administered), multiple
adhesiolysis sessions; 2 or more days
62264
Percutaneous lysis of epidural adhesions using solution injection (eg,
hypertonic saline, enzyme) or mechanical means (eg, catheter) including
radiologic localization (includes contrast when administered), multiple
adhesiolysis sessions; 1 day
62310
Injection(s), of diagnostic or therapeutic substance(s) (including
anesthetic, antispasmodic, opioid, steroid, other solution), not including
neurolytic substances, including needle or catheter placement, includes
contrast for localization when performed, epidural or subarachnoid;
cervical or thoracic
62311
Injection(s), of diagnostic or therapeutic substance(s) (including
anesthetic, antispasmodic, opioid, steroid, other solution), not including
neurolytic substances, including needle or catheter placement, includes
contrast for localization when performed, epidural or subarachnoid;
lumbar or sacral (caudal)
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CPT Code
Description
62318
Injection(s), including indwelling catheter placement, continuous
infusion or intermittent bolus, of diagnostic or therapeutic substance(s)
(including anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances, includes contrast for localization when
performed, epidural or subarachnoid; cervical or thoracic
62319
Injection(s), including indwelling catheter placement, continuous
infusion or intermittent bolus, of diagnostic or therapeutic substance(s)
(including anesthetic, antispasmodic, opioid, steroid, other solution), not
including neurolytic substances, includes contrast for localization when
performed, epidural or subarachnoid; lumbar or sacral (caudal)
64416
Injection, anesthetic agent; brachial plexus, continuous infusion by
catheter (including catheter placement)
64446
Injection, anesthetic agent; sciatic nerve, continuous infusion by
64447
Injection, anesthetic agent; femoral nerve, single
64448
Injection, anesthetic agent; femoral nerve, continuous infusion by
64449
Injection, anesthetic agent; lumbar plexus, posterior approach,
continuous infusion by catheter (including catheter placement)
64479
Injection(s), anesthetic agent and/or steroid, transforaminal epidural,
with imaging guidance (fluoroscopy or CT); cervical or thoracic, single
level
64480
with imaging guidance (fluoroscopy or CT); cervical or thoracic, each
additional level (List separately in addition to code for primary
procedure)
64483
with imaging guidance (fluoroscopy or CT); lumbar or sacral, single
level)
64484
with imaging guidance (fluoroscopy or CT); lumbar or sacral, each
additional level (List separately in addition to code for primary
procedure)
64490
Injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image
guidance (fluoroscopy or CT), cervical or thoracic; single level
64517
Injection, anesthetic agent; superior hypogastric plexus
76937
Ultrasound guidance for vascular access requiring ultrasound evaluation
of potential access sites, documentation of selected vessel patency,
concurrent realtime ultrasound visualization of vascular needle entry,
with permanent recording and reporting (List separately in addition to
76942
Ultrasonic guidance for needle placement (eg, biopsy, aspiration,
injection, localization device), imaging supervision and interpretation
77002
Fluoroscopic guidance for needle placement (eg, biopsy, aspiration,
injection, localization device)
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CPT Code
Description
77003
Fluoroscopic guidance and localization of needle or catheter tip for
spine or paraspinous diagnostic or therapeutic injection procedures
(epidural or subarachnoid)
93313
Echocardiography, transesophageal, real-time with image
documentation (2D) (with or without M-mode recording); placement of
transesophageal probe only
93503
Insertion and placement of flow directed catheter (eg, Swan-Ganz) for
monitoring purposes
99140
Anesthesia complicated by emergency conditions (specify) (List
separately in addition to code for primary anesthesia procedure)
Table 8.55 – Procedure Codes Currently Billable by CRNAs that Continue To Be Billable
CPT Code
Description
00100-01999
Anesthesia Codes (except for individual codes within this code range
that are listed on Table 8.53)
20600
Arthrocentesis, aspiration and/or injection; small joint or bursa (eg,
fingers, toes)
20605
Arthrocentesis, aspiration and/or injection; intermediate joint or bursa
(eg, temporomandibular, acromioclavicular, wrist, elbow or ankle,
olecranon bursa)
20610
Arthrocentesis, aspiration and/or injection; major joint or bursa (eg,
shoulder, hip, knee joint, subacromial bursa)
31500
Intubation, endotracheal, emergency procedure
36000
Introduction of needle or intracatheter, vein
36010
Introduction of catheter, superior or inferior vena cava
36011
Selective catheter placement, venous system; first order branch (eg,
renal vein, jugular vein)
36012
Selective catheter placement, venous system; second order, or more
selective, branch (eg, left adrenal vein, petrosal sinus)
36013
Introduction of catheter, right heart or main pulmonary artery
36014
Selective catheter placement, left or right pulmonary artery
36015
Selective catheter placement, segmental or subsegmental pulmonary
artery
36400
Venipuncture, younger than age 3 years, necessitating the skill of a
physician or other qualified health care professional, not to be used for
routine venipuncture; femoral or jugular vein
36405
routine venipuncture; scalp vein
36406
routine venipuncture; other vein
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CPT Code
Description
36410
Venipuncture, age 3 years or older, necessitating the skill of a physician
or other qualified health care professional (separate procedure), for
diagnostic or therapeutic purposes (not to be used for routine
venipuncture)
36415
Collection of venous blood by venipuncture
36420
Venipuncture, cutdown; younger than age 1 year
36425
Venipuncture, cutdown; age 1 and over
36510
Catheterization of umbilical vein for diagnosis or therapy, newborn
36600
Arterial puncture, withdrawal of blood for diagnosis
36620 AA
Arterial catheterization or cannulation for sampling, monitoring or
transfusion (separate procedure); percutaneous
36625 AA
Arterial catheterization or cannulation for sampling, monitoring or
transfusion (separate procedure); cutdown
36660
Catheterization of umbilical artery, newborn, for diagnosis or therapy
36680
Placement of needle for intraosseous infusion
61790
Creation of lesion by stereotactic method, percutaneous, by neurolytic
agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian
ganglion
62273
Injection, epidural, of blood or clot patch
62280
Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced
saline solutions), with or without other therapeutic substance;
subarachnoid
62281
saline solutions), with or without other therapeutic substance; epidural,
cervical or thoracic
62282
saline solutions), with or without other therapeutic substance; epidural,
lumbar, sacral (caudal)
64400
Injection, anesthetic agent; trigeminal nerve, any division or branch
64402
Injection, anesthetic agent; facial nerve
64405
Injection, anesthetic agent; greater occipital nerve
64408
Injection, anesthetic agent; vagus nerve
64410
Injection, anesthetic agent; phrenic nerve
64412
Injection, anesthetic agent; spinal accessory nerve
64413
Injection, anesthetic agent; cervical plexus
64415
Injection, anesthetic agent; brachial plexus, single
64417
Injection, anesthetic agent, axillary nerve
64418
Injection, anesthetic agent; suprascapular nerve
64420
Injection, anesthetic agent; intercostal nerve, single
64421
Injection, anesthetic agent; intercostal nerves, multiple, regional block
64425
Injection, anesthetic agent, iloinguinal, iliohypogastric nerves
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CPT Code
Description
64430
Injection, anesthetic agent, pudendal nerve
64435
Injection, anesthetic agent; paracervical (uterine) nerve
64445
Injection, anesthetic agent, sciatic nerve; single
64450
Injection, anesthetic agent, other peripheral nerve or branch
64505
Injection, anesthetic agent; sphenopalatine ganglion
64508
Injection, anesthetic agent; carotid sinus (separate procedure)
64510
Injection, anesthetic agent; stellate ganglion (cervical sympathetic)
64520
Injection, anesthetic agent; lumbar or thoracic (paravertebral
sympathetic)
64530
Injection, anesthetic agent; celiac plexus, with or without radiologic
monitoring
64600
Destruction by neurolytic agent, trigeminal nerve; supraorbital,
infraorbital, mental, or inferior alveolar branch
64605
Destruction by neurolytic agent, trigeminal nerve; second and third
division branches at foramen ovale
64610
Destruction by neurolytic agent, trigeminal nerve; second and third
division branches at foramen ovale under radiologic monitoring
64612
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve
(eg, for blepharospasm, hemifacial spasm)
64613
Chemodenervation of muscle(s): neck muscle(s) (eg, for spasmodic
torticollis, spasmodiac dysphonia)
64620
Destruction by neurolytic agent; intercostal nerve
64630
Destruction by neurolytic agent; pudendal nerve
64640
Destruction by neurolytic agent; other peripheral nerve or branch
64680
Destruction by neurolytic agent, with or without radiologic monitoring;
celiac plexus
Prior to January 1, 2013, CRNAs enrolled in the IHCP provider program must use anesthesia CPT
codes (00100-01999). CRNAs billing with their individual rendering NPI must not use modifiers listed
in Table 8.56. Anesthesia procedure code modifiers listed in Table 8.56 must be reported to identify
services rendered by CRNAs not enrolled in the IHCP and the anesthesiologist providing medical
direction.
According to 405 IAC 5-10-3(i), reimbursement is available for medical direction of a procedure
involving an anesthetist only when the direction is by an anesthesiologist, and only when the
anesthesiologist medically directs two, three, or four concurrent procedures involving qualified
anesthetists. Reimbursement is not available for medical direction in cases in which an anesthesiologist
is concurrently administering anesthesia and providing medical direction.
Table 8.56 – Procedure Code Modifiers – Anesthesia (CRNAs)
Modifier
Description
QK
Medical direction of two, three, or four concurrent anesthesia
procedures involving qualified individuals
QS
Monitored anesthesia care services
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Modifier
Description
QX
CRNA with medical direction by a physician
QZ
CRNA without medical direction by a physician
Note: CRNA providers use the same physical status modifiers that apply to the
anesthesiologist.
Anesthesiologists billing for medical direction should use the QK modifier.
An anesthesiologist involved in medically directing more than one and up to four procedures cannot be
personally performing procedures at the same time. Criteria for medical direction include the
following:
•
Ensure that only qualified individuals administer the anesthesia
•
Monitor anesthesia at frequent intervals
•
Participate in the most demanding portions of the procedures, including induction and emergence,
if applicable
•
Perform the preoperative evaluation
•
Perform the postoperative evaluation
•
Prescribe anesthesia plan
•
Remain immediately available and not performing other services concurrently
Anesthesia for Vaginal or Cesarean Delivery
Providers billing anesthesia services for labor and delivery use the anesthesia CPT vaginal or cesarean
delivery CPT codes. Billing for obstetrical anesthesia is the same as for any other surgery regardless of
the type of anesthesia provided (such as general or regional), including epidural anesthesia.
When the anesthesiologist starts an epidural for labor, and switching to a general anesthetic for the
delivery becomes necessary, combine and bill the total time for the procedure performed, such as
vaginal delivery or cesarean section (C-section).
Base RVUs are in IndianaAIM for providers, and providers do not list them on the CMS-1500 claim
form or 837P transaction. However, the actual time of the procedure should be indicated in minutes in
field 24G on the CMS-1500 claim form. The same method of billing applies to anesthesia for all
services.
IndianaAIM calculates total units by adding base RVUs to the number of time units, which are
calculated by the system, based on the number of minutes billed on the claim. IndianaAIM converts
each 15-minute block of time to one time unit. However, for procedure codes 01960 and 01967,
IndianaAIM calculates one time unit for each 15-minute block of time billed in the first hour of service
and, for subsequent hours of service, calculates one unit of service for every 60-minute block of time
or portion billed.
When a provider, other than the surgeon or obstetrician, bills for epidural anesthesia, the IHCP
reimburses that provider in the same manner as for general anesthesia.
Table 8.57 is a list of applicable vaginal and cesarean delivery CPT codes.
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Table 8.57 – Procedure Codes – Vaginal or Cesarean Delivery CPT
Procedure
Code
Description
01960
Anesthesia for vaginal delivery only
01961
Anesthesia for cesarean delivery only
01962
Anesthesia for urgent hysterectomy following delivery
01963
Anesthesia for cesarean hysterectomy without any labor
analgesia/anesthesia care
01965
Anesthesia for incomplete or missed abortion procedures
01966
Anesthesia for induced abortion procedures
01967
Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this
includes any repeat subarachnoid needle placement and drug injection
and/or any necessary replacement of an epidural catheter during labor)
01968
Anesthesia for cesarean delivery following neuraxial labor
analgesia/anesthesia (List separately in addition to code for primary
procedure performed)
01969
Anesthesia for cesarean hysterectomy following neuraxial labor
analgesia/anesthesia (List separately in addition to code for primary
procedure performed)
Monitored Anesthesia
Monitored anesthesia care (MAC) involves the intraoperative monitoring of a patient’s vital signs in
anticipation of the need for administration of general anesthesia or the development of adverse
physiological patient reaction to the surgical procedure. MAC also includes the performance of a preanesthetic examination and evaluation, prescription of the anesthesia care required, administration of
any necessary oral or parenteral medications (such as Atropine, Demerol, or Valium), and the
provision of indicated postoperative anesthesia care.
The IHCP allows payment for medically reasonable and necessary MAC services on the same basis as
other anesthesia services. Providers must append the QS modifier to the appropriate CPT code in
addition to other applicable modifiers to identify the services as monitored anesthesia care.
General Anesthesia for Dental Procedures
The IHCP covers general anesthesia for dental procedures for members 21 years old and older if the
procedure is performed in an inpatient or hospital outpatient setting. The IHCP does not cover general
anesthesia for dental procedures performed in a dentist’s office. Adult dental patients who may qualify
for hospital or surgical center general anesthesia include, but are not limited to, adults with the
following medical conditions:
•
Mental incapacitation, such that the member’s ability to cooperate with procedures is impaired,
including intellectually disabled and organic brain disease
•
Previously demonstrated idiosyncratic or severe reactions to IV sedation medication
•
Seizure disorders
•
Severe physical disorders affecting the tongue or jaw movements
•
Significant psychiatric disorders resulting in impairment of the member’s ability to cooperate with
the procedures
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Regional Anesthesia (Epidural, Nerve Block, Spinal)
Regional anesthesia or nerve blocks involve blocking nerve impulses with a local anesthetic, steroid,
narcotic, or other agent. Physicians administer a nerve block, and it requires special techniques and
attention, especially during the initial phase of instituting the block. Providers should bill nerve blocks
performed as a surgical procedure for the treatment of a condition, such as chronic pain, with the
appropriate nerve block code, quantity of one, with no anesthesia modifier.
General, regional, or epidural anesthesia administered by the same provider performing the surgical or
obstetrical delivery procedure is not reimbursable, because it is included in the surgical delivery fee.
Postoperative Pain Management Services
The IHCP reimburses for postoperative epidural catheter management services using procedure code
01996. The IHCP does not pay separately for procedure code 01996 on the same day the epidural is
placed. Rather, providers should bill this code on subsequent days when the epidural is actually being
managed. Providers should use this code for daily management of patients receiving continuous
epidural, subdural, or subarachnoid analgesia. The IHCP limits this procedure to one unit of service for
each day of management. Procedure code 01996 is only reimbursable during active administration of
the drug. Providers should not append a modifier when this procedure is monitored by an anesthesia
provider.
Care Coordination Services
As of July 1, 2011, the IHCP eliminated reimbursement for targeted case management (TCM) services
for Prenatal Care Coordination, Human Immunodeficiency Virus (HIV) Care Coordination, individuals
with a disability residing in a nursing facility, individuals with a traumatic brain injury (closed or open
head injury by an external event) residing in a nursing facility, and individuals with intellectual and
developmental disabilities.
Chiropractic Services
The IHCP provides coverage for chiropractic services for members when the services are provided by
a licensed chiropractor. Services such as office visits, physical medicine treatments, laboratory, X-ray,
and muscle testing are available to all IHCP members pursuant to restrictions outlined in the
individual’s benefit package when necessitated by a condition-related diagnosis. The following
sections outline additional coverage, billing, and PA information for chiropractic services.
Package C
The IHCP provides reimbursement for covered services provided by a licensed chiropractor when
rendered within the scope of the practice. Office visits are limited to five visits and 14 therapeutic
physical medicine treatments per member, per calendar year. Additional treatments may be covered if
the provider obtains PA based on medical necessity.
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Package B
The IHCP provides reimbursement for medically necessary pregnancy-related chiropractic services.
Providers must submit claims for Package B members with one of the diagnosis codes listed in Table
8.58, followed by the appropriate chiropractic diagnosis code and chiropractic procedure code.
Table 8.58 – ICD-9-CM Diagnosis Codes for Package B for Chiropractic Services
Diagnosis
Code
Description
646.93
Unspecified complication of pregnancy – Antepartum condition or complication
648.73
Bone and joint disorders of the back, pelvis, and lower limbs – Antepartum condition or
complication
648.93
Other current conditions classified elsewhere – Antepartum condition or complication
IHCP Members
The IHCP limits reimbursement to a total of 50 units per member per calendar year. The 50 units can
be a combination of office visits, spinal manipulation, or physical medicine treatments. However, the
IHCP limits office visits to five per year; up to five of the 50 units can be office visits. Reimbursement
is not available for DME provided by chiropractors. Additionally, reimbursement is not available for
the following types of extended or comprehensive office visits:
•
New patient detailed
•
New patient comprehensive
•
Established patient detailed
•
Established patient comprehensive
The IHCP does not cover electromyogram (EMG) testing for chiropractors.
A visit code is reportable on the same date as a manipulative treatment only if the visit constitutes a
significant, separately identifiable E/M service. The visit code is then billed with the 25 modifier. The
service must be above and beyond the usual and preservice and postservice work associated with a
manipulation service. Medical record documentation supporting the need for an office visit, in addition
to the manipulation treatment, must be maintained by the provider and is subject to postpayment
review.
Reimbursement for X-rays is limited to one series of full spine X-rays per recipient per year.
Component X-rays of the series are individually reimbursable; however, if components are billed
separately, total reimbursement is limited to the allowable amount for the series. Reimbursement for
localized spine series X-rays and for X-rays of the joints or extremities is allowable only when the Xrays are necessitated by a condition-related diagnosis. Prior authorization is not required.
When requested, chiropractors must provide the actual X-ray films previously taken at no cost to IHCP
members. The IHCP does not reimburse for additional X-rays that could be necessitated by the failure
of a practitioner to forward X-rays or related documentation to a chiropractic provider when requested.
Chiropractors are entitled to receive X-rays from other providers at no charge to the member upon the
member’s written request to the other providers and upon reasonable notice.
The IHCP limits claim payment for chiropractic practitioners (specialty 150) to the CPT procedure
codes and ICD-9-CM diagnosis codes as listed in the following tables.
Tables 8.59 through 8.64 identify the procedure codes that chiropractors should bill to the IHCP.
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Table 8.59 – Covered IHCP Chiropractic Codes for Office Visits
CPT
Code
Description
99201
Office or other outpatient visit for the evaluation and management of a new patient,
which requires these 3 key components: A problem focused history; A problem focused
examination; Straightforward medical decision making. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's
needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10
minutes are spent face-to-face with the patient and/or family.
99202
which requires these 3 key components: An expanded problem focused history; An
expanded problem focused examination; Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health
care professionals, or agencies are provided consistent with the nature of the problem(s)
and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to
moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or
family.
99203
which requires these 3 key components: A detailed history; A detailed examination;
Medical decision making of low complexity. Counseling and/or coordination of care
with other physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's
needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30
minutes are spent face-to-face with the patient and/or family.
99211
Office or other outpatient visit for the evaluation and management of an established
patient that may not require the presence of a physician or other qualified health care
professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are
spent performing or supervising these services.
99212
patient, which requires at least 2 of these 3 key components: A problem focused
history; A problem focused examination; Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health
care professionals, or agencies are provided consistent with the nature of the problem(s)
and the patient's and/or family's needs. Usually, the presenting problem(s) are self
limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or
family.
99213
patient, which requires at least 2 of these 3 key components: An expanded problem
focused history; An expanded problem focused examination; Medical decision making
of low complexity. Counseling and coordination of care with other physicians, other
qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs. Usually, the presenting
problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face
with the patient and/or family.
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Table 8.60 – Covered IHCP Chiropractic Codes for Manipulative Treatment
CPT
Code
Description
98940
Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
98941
Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
98942
Chiropractic manipulative treatment (CMT); spinal, 5 regions
98943
Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions
Chiropractors may perform laboratory tests that fall within their scope of practice for the state of
Indiana. These tests include performance of blood analysis and urinalysis. Additional information on
the scope of practice for chiropractors can be found in IC art 25-10 and IAC Title 846.
Table 8.61 – Covered IHCP Chiropractic Codes for Radiology
CPT
Code
Description
72010
Radiologic examination, spine, entire, survey study, anteroposterior and lateral
72020
Radiologic examination, spine, single view, specify level
72040
Radiologic examination, spine, cervical; 3 views or less
72050
Radiologic examination, spine, cervical; 4 or 5 views
72052
Radiologic examination, spine, cervical; 6 or more views
72069
Radiologic examination, spine, thoracolumbar, standing (scoliosis)
72070
Radiologic examination, spine; thoracic, 2 views
72072
Radiologic examination, spine; thoracic, 3 views
72074
Radiologic examination, spine; thoracic, minimum of 4 views
72080
Radiologic examination, spine; thoracolumbar, 2views
72090
Radiologic examination, spine; scoliosis study, including supine and erect studies
72100
Radiologic examination, spine, lumbosacral; 2 or 3 views
72110
Radiologic examination, spine, lumbosacral; minimum of 4 views
72114
Radiologic examination, spine, lumbosacral; complete, including bending view,
minimum of 6 views
72120
Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views
72170
Radiologic examination, pelvis; 1 or 2 views
72190
Radiologic examination, pelvis; complete, minimum of 3 views
72200
Radiologic examination, sacroiliac joints; less than 3 views
72202
Radiologic examination, sacroiliac joints; 3 or more views
72220
Radiologic examination, sacrum and coccyx, minimum of 2 views
73000
Radiologic examination; clavicle, complete
73010
Radiologic examination; scapula, complete
73020
Radiologic examination, shoulder; 1 view
73030
Radiologic examination, shoulder; complete, minimum of 2 views
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CPT
Code
Description
73050
Radiologic examination; acromioclavicular joints, bilateral, with or without weighted
distraction
73060
Radiologic examination; humerus, minimum of 2 views
73070
Radiologic examination, elbow, 2 views
73080
Radiologic examination, elbow, complete, minimum of 3 views
73090
Radiologic examination; forearm, 2 views
73100
Radiologic examination, wrist; 2 views
73110
Radiologic examination, wrist; complete, minimum of 3 views
73120
Radiologic examination, hand; 2 views
73130
Radiologic examination, hand; minimum of 3 views
73140
Radiologic examination, finger(s), minimum of 2 views
73500
Radiologic examination, hip, unilateral; 1 view
73510
Radiologic examination, hip, complete, minimum of 2 views
73520
Radiologic examination, hips, bilateral, minimum of 2 views of each hip, including
anteroposterior view of pelvis
73550
Radiologic examination, femur, 2 views
73560
Radiologic examination, knee; 1 or 2 views
73562
Radiologic examination, knee; 3 views
73564
Radiologic examination, knee; complete, 4 or more views
73565
Radiologic examination, knee; both knees, standing, anteroposterior
73590
Radiologic examination; tibia and fibula, 2 views
73600
Radiologic examination, ankle; 2 views
73610
Radiologic examination, ankle; complete, minimum of 3 views
73620
Radiologic examination, foot; 2 views
73630
Radiologic examination, foot; complete, minimum of 3 views
73650
Radiologic examination; calcaneus, minimum of 2 views
73660
Radiologic examination, toe(s), minimum of 2 views
Table 8.62 – Covered Chiropractic Codes for Physical Medicine Services
CPT
Code
Description
95831
Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or
trunk
95832
Muscle testing, manual (separate procedure) with report; hand with or without
comparison with normal side
97012
Application of a modality to 1or more areas; traction, mechanical
97014
Application of a modality to 1 or more areas; electrical stimulation (unattended)
97016
Application of a modality to 1 or more areas; vasopneumatic devices
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CPT
Code
Description
97018
Application of a modality to 1 or more areas; paraffin bath
97022
Application of a modality to 1 or more areas; whirlpool
97024
Application of a modality to 1or more areas; diathermy (eg, microwave)
97026
Application of a modality to 1 or more areas; infrared
97028
Application of a modality to 1 or more areas; ultraviolet
97032
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15
minutes
97033
Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97034
Application of a modality to 1 or more areas; contrast baths, each 15 minutes
97035
Application of a modality to 1 or more areas; ultrasound, each 15 minutes
97036
Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
97039
Unlisted modality (specify type and time if constant attendance)
97110
Therapeutic procedure,1 or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility
97112
develop strength and endurance, range of motion and flexibility; neuromuscular
reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities
97113
develop strength and endurance, range of motion and flexibility; aquatic therapy with
therapeutic exercises
97116
develop strength and endurance, range of motion and flexibility; gait training (includes
stair climbing)
97124
develop strength and endurance, range of motion and flexibility; massage, including
effleurage, petrissage, and/or tapotement (stroking, compression, percussion)
97139
Unlisted therapeutic procedure (specify)
97140
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage,
manual traction), 1 or more regions, each 15 minutes
Table 8.63 identifies the appropriate primary ICD-9-CM diagnosis codes for billing chiropractic
services to the IHCP.
Table 8.63 – Primary ICD-9-CM Codes for Chiropractic Services
Diagnosis Code
Description
739.0
Nonallopathic lesions, not elsewhere classified;
head region
739.1
cervical region
739.2
thoracic region
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Diagnosis Code
Description
739.3
lumbar region
739.4
sacral region
739.5
pelvic region
739.6
lower extremities
739.7
upper extremities
739.8
rib cage
Table 8.64 identifies the secondary diagnosis codes that chiropractors should bill to the IHCP.
Table 8.64 – Secondary ICD-9-CM Codes for Chiropractic Services
Diagnosis Code
Description
307.81
Tension headache
333.83
Spasmodic torticollis
346.00
Migraine with aura without mention of intractable migraine without mention of status
migrainosus
346.01
Migraine with aura with intractable migraine, so stated, without mention of status
migrainosus
346.02
Migraine with aura, without mention of intractable migraine, , with status
migrainosus
346.03
Migraine with aura, with intractable migraine, so stated, with status migrainosus
346.10
Migraine without aura without mention of intractable migraine without mention of
status migrainosus
346.11
Migraine without aura with intractable migraine, so stated, without mention of status
migrainosus
346.20
Variants of migraine, not elsewhere classified without mention of intractable
migraine without mention of status migrainosus
346.21
Variants of migraine, not elsewhere classified with intractable migraine, so stated,
without mention of status migrainosus
346.31
Hemiplegic migraine, with intractable migraine, so stated, without mention of status
migrainosus
346.32
Hemiplegic migraine, without mention of intractable migraine with status
migrainosus
346.33
Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus
346.40
Menstrual migraine, without mention of intractable migraine without mention of
status migrainosus
346.41
Menstrual migraine, with intractable migraine, so stated, without mention of status
migrainosus
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Diagnosis Code
Description
346.42
Menstrual migraine, without mention of intractable migraine with status migrainosus
346.43
Menstrual migraine, with intractable migraine, so stated, with status migrainosus
346.50
Persistent migraine aura without cerebral infarction, without mention of intractable
346.51
Persistent migraine aura without cerebral infarction, with intractable migraine, so
stated, without mention of status migrainosus
346.52
Persistent migraine aura without cerebral infarction, without mention of intractable
migraine with status migrainosus
346.53
Persistent migraine aura without cerebral infarction, with intractable migraine, so
stated, with status migrainosus
346.60
Persistent migraine aura with cerebral infarction, without mention of intractable
346.61
Persistent migraine aura with cerebral infarction, with intractable migraine, so stated,
without mention of status migrainosus
346.62
Persistent migraine aura with cerebral infarction, without mention of intractable
migraine with status migrainosus
346.63
Persistent migraine aura with cerebral infarction, with intractable migraine, so stated,
with status migrainosus
346.70
Chronic migraine without aura, without mention of intractable migraine without
mention of status migrainosus
346.71
Chronic migraine without aura, with intractable migraine, so stated, without mention
of status migrainosus
346.72
Chronic migraine without aura, without mention of intractable migraine with status
migrainosus
346.73
Chronic migraine without aura, with intractable migraine, so stated, with status
migrainosus
346.80
Other forms of migraine without mention of intractable migraine without mention of
status migrainosus
346.81
Other forms of migraine with intractable migraine, so stated, without mention of
status migrainosus
346.82
Other forms of migraine, without mention of intractable migraine with status
migrainosus
346.83
Other forms of migraine, with intractable migraine, so stated, with status migrainosus
346.90
Migraine, unspecified without mention of intractable migraine without mention of
status migrainosus
346.91
Migraine, unspecified, with intractable migraine, so stated, without mention of status
migrainosus
346.92
Migraine, unspecified, without mention of intractable migraine with status
migrainosus
346.93
Migraine, unspecified, with intractable migraine, so stated, with status migrainosus
353.0
Brachial plexus lesions
353.1
Lumbosacral plexus lesions
353.2
Cervical root lesions, not elsewhere classified
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Diagnosis Code
Description
353.3
Thoracic root lesions, not elsewhere classified
353.4
Lumbosacral root lesions, not elsewhere classified
353.8
Other nerve root and plexus disorders
353.9
Unspecified nerve root and plexus disorder
354.4
Causalgia of upper limb
354.8
Other mononeuritis of upper limb
354.9
Mononeuritis of upper limb, unspecified
646.93
Unspecified complication of pregnancy, antepartum
648.73
Bone and joint disorders of maternal back, pelvis, and lower limbs, antepartum
648.93
Other current maternal conditions classifiable elsewhere, antepartum
719.40
Pain in joint, site unspecified
719.48
Pain in joint, other specified site
719.49
Pain in joint, multiple site
720.0
Ankylosing spondylitis
720.1
Spinal enthesopathy
721.0
Cervical spondylosis without myelopathy
721.1
Cervical spondylosis with myelopathy
721.3
Lumbosacral spondylosis without myelopathy
721.6
Anklyosing vertebral hyperostosis
721.7
Traumatic spondylopathy
721.90
Spondylosis of unspecified site; without mention of myelopathy
722.0
Displacement of cervical intervertebral disc without myelopathy
722.10
Displacement of lumbar intervertebral disc without myelopathy
722.11
Displacement of thoracic intervertebral disc without myelopathy
722.2
Displacement of intervertebral disc, site unspecified, without myelopathy
722.30
Schmorl’s nodes; unspecified region
722.31
Schmorl’s nodes; thoracic region
722.32
Schmorl’s nodes; lumbar region
722.4
Degeneration of cervical intervertebral disc
722.51
Degeneration of thoracic or thoracolumbar intervertebral disc
722.52
Degeneration of lumbar or lumbosacral intervertebral disc
722.6
Degeneration if intervertebral disc, site unspecified
722.80
Postlaminectomy syndrome; unspecified region
722.81
Postlaminectomy syndrome; cervical region
722.82
Postlaminectomy syndrome; thoracic region
722.83
Postlaminectomy syndrome; lumbar region
722.90
Other and unspecified disc disorder; unspecified region
722.91
Other and unspecified disc disorder; cervical region
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Diagnosis Code
Description
722.92
Other and unspecified disc disorder; thoracic region
722.93
Other and unspecified disc disorder; lumbar region
723.0
Spinal stenosis in cervical region
723.1
Cervicalgia
723.2
Cervicocranial syndrome
723.3
Cervicobrachial syndrome (diffuse)
723.4
Brachia neuritis or radiculitis, NOS
723.5
Torticollis, unspecified
723.8
Other syndromes affecting cervical region
723.9
Unspecified musculoskeletal disorders and symptoms referable to neck
724.00
Spinal stenosis, unspecified region
724.01
Spinal stenosis, thoracic region
724.02
Spinal stenosis, lumbar region, without neurogenic claudication
724.09
Spinal stenosis, other
724.1
Pain in thoracic spine
724.2
Lumbago
724.3
Sciatica
724.4
Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.5
Backache, unspecified
724.6
Disorders of sacrum
724.70
Unspecified disorder of coccyx
724.79
Disorders of coccyx, other
724.8
Other symptoms referable to back, facet syndrome
724.9
Other unspecified back disorders
728.71
Plantar fascial fibromatosis
728.85
Spasm of muscle
729.1
Myalgia and myositis
729.4
Fascilitis, unspecified
732.0
Juvenile osteochondrosis of spine
737.0
Adolescent postural kyphosis
737.10
Kyphosis (acquired) (postural)
737.12
Kyphosis, postlaminectomy
737.19
Kyphosis, other
737.20
Lordosis, (acquired) (postural)
737.21
Lordosis, postlaminectomy
737.22
Other postsurgical lordosis
737.29
Lordosis (acquired) – Other
737.30
Scoliosis (and kyphoscoliosis), idiopathic
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Diagnosis Code
Description
737.31
Resolving infantile idiopathic scoliosis
737.32
Progressive infantile idiopathic scoliosis
737.34
Thoracongenic scoliosis
737.39
Kyphoscoliosis and scoliosis, other
737.40
Curvature of spine associated with other conditions – Curvature of spine, unspecified
737.41
Curvature of spine associated with other conditions – Kyphosis
737.42
Curvature of spine associated with other conditions – Lordosis
737.43
Curvature of spine associated with other conditions – Scoliosis
737.8
Other curvatures of spine
737.9
Unspecified curvature of spine
738.4
Acquired spondylolisthesis
739.0
Nonallopath lesion – Head
739.1
Nonallopath lesion – Cervical
739.2
Nonallopath lesion – Thoracic
739.3
Nonallopath lesion – Lumbar
739.4
Nonallopath lesion – Saral
739.5
Nonallopath lesion – Pelvic
739.6
Nonallopath lesion – Lower extremity
739.7
Nonallopath lesion – Upper extremity
739.8
Nonallopath lesion – Rib cage
754.1
Certain congenital musculoskeletal deformities of sternocleidomastoid muscle
754.2
Certain congenital musculoskeletal deformities of spine
756.11
Spondylolysis, lumbrosacral region
756.12
Spondylolisthesis
784.0
Headache
839.00
Cervical vertebra dislocation, closed – Cervical vertebra, unspecified
839.01
Cervical vertebra dislocation, closed – First cervical vertebra
839.02
Cervical vertebra dislocation, closed – Second cervical vertebra
839.03
Cervical vertebra dislocation, closed – Third cervical vertebra
839.04
Cervical vertebra dislocation, closed – Fourth cervical vertebra
839.05
Cervical vertebra dislocation, closed – Fifth cervical vertebra
839.06
Cervical vertebra dislocation, closed – Sixth cervical vertebra
839.07
Cervical vertebra dislocation, closed – Seventh cervical vertebra
839.08
Cervical vertebra dislocation, closed – Multiple cervical vertebra
839.20
Lumbar vertebra dislocation, closed
839.21
Thoracic vertebra dislocation, closed
846.0
Sprains and strains of sacroiliac region, lumbosacral (joint) (ligament)
846.1
Sprains and strains of sacroiliac region, sacroiliac ligament
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Description
846.2
Sprains and strains of sacroiliac region, sacrospinatus (ligament)
846.3
Sprains and strains of sacroiliac region, sacrotuberous (ligament)
846.8
Sprains and strains of sacroiliac region, other specified sites of sacroiliac region
846.9
Sprains and strains of sacroiliac region, unspecified site of sacroiliac region
847.0
Sprains and strains of other and unspecified parts of back – Neck
847.1
Sprains and strains of other and unspecified parts of back – Thoracic
847.2
Sprains and strains of other and unspecified parts of back – Lumbar
847.3
Sprains and strains of other and unspecified parts of back – Sacrum
847.4
Sprains and strains of other and unspecified parts of back – Coccyx
847.9
Sprains and strains of other and unspecified parts of back – Unspecified site of back
907.3
Late effect of injury to nerve root(s), spinal plexus(es), and other nerves of trunk
953.0
Injury to nerve roots and spinal plexus, cervical root
953.1
Injury to nerve roots and spinal plexus, dorsal root
953.2
Injury to nerve roots and spinal plexus, lumbar root
953.3
Injury to nerve roots and spinal plexus, sacral root
953.4
Injury to nerve roots and spinal plexus, brachial plexus
953.5
Injury to nerve roots and spinal plexus, lumbrosacral plexus
956.0
Injury to peripheral nerve(s) of pelvic girdle and lower limb, sciatic nerve
956.1
Injury to peripheral nerve(s) of pelvic girdle and lower limb, femoral nerve
956.2
Injury to peripheral nerve(s) of pelvic girdle and lower limb, posterior tibial nerve
956.3
Injury to peripheral nerve(s) of pelvic girdle and lower limb, peroneal nerve
956.4
Injury to peripheral nerve(s) of pelvic girdle and lower limb, cutaneous sensory
nerve, lower limb
956.5
Injury to peripheral nerve(s) of pelvic girdle and lower limb, other specified nerve(s)
of pelvic girdle and lower limb
956.8
Injury to peripheral nerve(s) of pelvic girdle and lower limb, multiple nerves of pelvic
girdle and lower limb
956.9
Injury to peripheral nerve(s) of pelvic girdle and lower limb, unspecified nerve of
pelvic girdle and lower limb
Comprehensive Outpatient Rehabilitation Facility
A comprehensive outpatient rehabilitation facility (CORF) is a facility that is primarily engaged in
providing outpatient rehabilitation to the injured and disabled, or to patients recovering from illness
with a plan of treatment under the supervision of a physician. The purpose of a CORF is to permit the
member to receive multidisciplinary rehabilitation services per 515 IAC 2-1-3, at a single location, in a
coordinated fashion. CORF services include the following:
•
Outpatient mental health services in accordance with 405 IAC 5-20-8 (required service)
•
Physical therapy (required service)
•
Physician services (required service)
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•
Speech-language therapy
•
Billing
CORF services are to be billed on a CMS-1500 Professional claim form or the HIPAA 837P
transaction with place-of-service code 62 – Comprehensive outpatient rehabilitation facility.
Facility charges are not separately reimbursed.
Exception: If a crossover claim is transmitted from Medicare on the UB-04 Institutional claim format,
it will be processed.
Diabetes Self-Care Management Training Services
The IHCP covers diabetes self-care management training services. The IHCP defines self-care
management training as services provided in accordance with the terms and provisions of IC 27-814.5-6. The IHCP intends these services to enable the patient, or enhance the patient’s ability to
properly manage a diabetic condition, thereby optimizing the therapeutic regimen. The following are
examples of diabetes self-care management training activities:
•
Accessing community healthcare systems and resources
•
Behavior changes, strategies, and risk factor reduction
•
Blood glucose self-monitoring
•
Instruction regarding the diabetic disease state, nutrition, exercise, and activity
•
Insulin injection
•
Foot, skin, and dental care
•
Medication counseling
•
Preconception care, pregnancy and gestational diabetes
The IHCP limits coverage to eight units or a total of four hours per member, per rolling calendar year.
Providers can prior authorize additional units. The IHCP covers diabetes self-management training
services for Package C members.
Note: For RBMC members, send claims to the appropriate MCE.
Practitioners Eligible to Provide Services
Healthcare practitioners, licensed, registered, or certified under applicable Indiana law, with
specialized training in the management of diabetes that meets community standards, must provide the
diabetes self-care management training services.
Practitioners eligible to provide diabetes self-management training services, but not currently enrolled
as IHCP providers, can obtain additional information in Chapter 4: Provider Enrollment, Eligibility,
and Responsibilities of this manual. Eligible practitioners, such as pharmacists, who work for or own
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IHCP-enrolled pharmacies should bill for services rendered through the enrolled entity where services
are provided. MCE contact information is included in Chapter 1: General Information, Section 2 of
this manual.
The following are examples of IHCP practitioners who may enroll and bill for direct care services or
supervision of services:
•
Audiologists
•
Chiropractors
•
Dentists
•
Hearing aid dealers
•
Nurses
•
Occupational therapists
•
Optometrists
•
Pharmacists
•
Physical therapists
•
Physicians
•
Podiatrists
•
Respiratory therapists
•
Speech and language pathologists
The following are examples of IHCP practitioners who may not enroll in the IHCP. Practitioners in
this list must bill under the supervising practitioner’s IHCP NPI:
•
Athletic trainers
•
Dietitians
•
Environmental health specialists
•
Health facility administrators
•
Marriage and family therapists
•
Physician assistants
•
Psychologists
•
Social workers
Providers are not entitled to reimbursement for any services provided to the general public at no
charge. Adherence to this program parameter is closely monitored by the IHCP Program Integrity
Department.
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Procedure Codes and Units of Service
Providers must bill for the service only on the CMS-1500 or 837P transaction using procedure code
G0108 – Diabetes outpatient self-management training services, individual per 30 minutes, or G0109 –
Diabetes self- management training service, group session (2 or more), 30 minutes. Providers should
not round up to the next unit. Instead, providers should accumulate billable time equivalent to whole
units and then bill. Limit service to eight units per member, or the equivalent of four hours, per rolling
calendar year, applicable under any of the following circumstances:
•
Receipt of a diagnosis of diabetes
•
Receipt of a diagnosis that represents a significant change in the member’s symptoms or condition
•
Re-education or refresher training
Providers can request authorization for additional units through the standard PA process. The IHCP
reviews the documentation for additional requested units of service for evidence of medical necessity.
Providers should bill the usual and customary charge for the units of service rendered.
Billing and rendering practitioners should maintain sufficient documentation of the respective
functions to substantiate the medical necessity of the service rendered and the provision of the service
itself. This requirement is in accordance with existing policies and regulations. Physicians and
podiatrists ordering the service should maintain documentation in the usual manner. Examples of
documentation that the provider of the service should maintain include (but are not limited to) written
orders for the service, date rendering the service, amount of time used for the training session, general
content of the training session, units of service billed, charge amount, pertinent patient history and
clinical data, and practitioner notes from the training sessions.
Diabetic Test Strips
The IHCP accepts Medicare crossover claims for diabetic test strip procedure codes with dates of
service that span 90 days. Providers can use Web interChange to submit these claims electronically.
The affected procedure codes and descriptions are listed in Table 8.65.
Table 8.65 – HCPCS Codes for Diabetic Testing
HCPCS Code
Description
A4233
Replacement battery, alkaline (other than J cell), for use with medically
necessary home blood glucose monitor owned by patient, each
A4234
Replacement battery, alkaline, J Cell, for use with medically necessary home
blood glucose monitor owned by patient, each
A4235
Replacement battery, lithium, for use with medically necessary home blood
glucose monitor owned by patient, each
A4236
Replacement battery, silver oxide, for use with medically necessary home
A4244
Alcohol or peroxide, per pint
A4245
Alcohol wipes, per box
A4246
Betadine or pHisoHex solution, per pint
A4247
Betadine or iodine swabs/wipes, per box
A4250
Urine test or reagent strips or tablets (100 tablets or strips)
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HCPCS Code
Description
A4253
Blood glucose test or reagent strips for home blood glucose monitor, per 50
strips
A4253
Billed with modifier NU, now crosses over from Medicare
A4255
Platforms for home blood glucose monitor, 50 per box
A4256
Normal, low, and high calibrator solution/chips
A4257
Replacement lens shield cartridge for use with laser skin piercing device,
each
A4258
Spring-powered device for lancet, each
A4259
Lancets, per box of 100
HCPCS procedure codes A4253 – Blood glucose test or reagent strips for home blood glucose
monitor, per 50 strips and A4259 – Spring-powered device for lancet, each have a maximum quantity
limitation. Providers are permitted to bill up to four units of A4253 or 200 strips per 30 days, effective
for claims with dates of service on or after January 1, 2010. Additional units of A4253 will deny unless
PA is obtained.
Providers are permitted to bill up to two units of A4259 (200 lancets) per 30 days effective for claims
with dates of service on or after January 1, 2010. Additional units of A4259 will deny unless PA is
obtained.
The following PA criteria are required for additional units of A4253 and A4259:
•
A signed statement of medical necessity
•
A clear medical recommendation of the number of additional units required to meet the patient’s
medical need
•
A hemoglobin A1C test dated within 90 days prior to the request for additional units
To align with current IHCP policy, the following are exceptions to the NCCI MUE unit limit:
•
A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips: The
MUE unit limit is two and IHCP policy allows four units (or 200 test strips) per month.
•
A4259 – Lancets, per box of 100. The MUE unit limit is one and the IHCP policy allows two units
per month.
The OMPP has chosen Abbott Diabetes Care and Roche Diagnostics as preferred vendors to supply
blood glucose monitors and diabetic test strips for all Indiana Medicaid and Healthy Indiana Plan
members.
Effective January 1, 2011, the following Preferred Diabetic Supply List (PDSL) is for professional
claims, including paper CMS-1500 and electronic 837P. This requirement affects all Web interChange,
batch, and professional Medicare crossover claims with dates of service on or after January 1, 2011.
Implementation is dependent upon approval from the CMS. This information does not apply to other
diabetic supplies, including but not limited to syringes, pen needles, lancets, lancing devices, alcohol
swabs, control solutions, ketone strips, or blood ketone test strips. The IHCP is not changing its
reimbursement policy pertaining to blood glucose monitors or diabetic test strips at this time. Claims
for these products continue to be priced according to the fee schedule available on
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Table 8.66 – Preferred Diabetic Supply List
Blood Glucose Monitor
Corresponding Test Strip
Freestyle Lite System Kit
Freestyle Lite Test Strips
Freestyle Freedom Lite System Kit
Freestyle Lite Test Strips
FreeStyle InsuLinx Meter
FreeStyle InsuLinx Test Strips
Precision Xtra Meter
Precision Xtra Test Strips
Accu-chek Aviva Care Kit
Accu-chek Aviva/Accu-chek Aviva Plus
Accu-chek Nano Smartview Meter
Accu-chek Smartview Test Strips
Professional claims, including paper CMS-1500, electronic 837P, and Medicare crossover claims for
blood glucose monitors and diabetic test strips, must be submitted to the FFS medical benefit for all
Indiana Medicaid and Healthy Indiana Plan members. NU and RR modifiers are not used for E0607,
E0607 U1, A4253, and A4253 U1 for supplies that are on the PDSL. Medicare crossover claims
require the appropriate modifier, and TPL claims for nonpreferred PDSL require the U1. The
corresponding 11-digit National Drug Code (NDC) will also be required to identify the product being
dispensed. If the NDC is missing, invalid, not in the proper format, or does not correspond with the
procedure code and modifier provided, claims will be denied. This requirement includes Medicare
crossover claims.
The modifiers NU (indicating a new product) and RR (indicating a rental product) will not be used for
the PDSL products.
Claims for procedure codes E0607 – Home blood glucose monitor and A4253 – Blood glucose test or
reagent strips for home blood glucose monitor, per 50 strips with dates of service on or after January
1, 2011, require the NDC or NDC and modifier, depending on the vendor of the product being
dispensed.
Claims billed for an NDC included on the PDSL will not require the addition of modifier U1. If
modifier U1 is included with a preferred blood glucose monitor or diabetic test strip NDC, the claim
will be denied. Claims billed for a blood glucose monitor or diabetic test strip not listed in Table 8.65
will require the addition of modifier U1, along with the NDC and appropriate procedure code. Claims
billed for an NDC not on the PDSL will be denied.
All diabetic test strips will continue to be limited to a quantity of 200 strips per month. Quantities
exceeding 200 strips per month will continue to require PA.
Blood glucose monitors and diabetic test strips not included on the PDSL will require PA. The OMPP
advises prescribers to prescribe only the products listed on the PDSL. This eliminates the need to
obtain prior authorization for a product not listed on the PDSL. Prescribers may also write the
prescription in a generic version (“Blood glucose monitor and/or diabetic test strips”) to allow for
dispensation of the blood glucose monitor or diabetic test strip product, included on the PDSL, by the
pharmacy or DME provider. If a member has a unique circumstance that requires the use of a product
not listed on the PDSL, the prescriber must obtain prior authorization. Prior authorization will be
granted for members based on medical necessity.
Drug-Related Medical Supplies and Medical Devices
Some drug-related medical supplies and medical devices are reimbursed on an FFS basis. Table 8.67
lists drug-related medical supplies and medical devices that are paid for by the FFS medical benefit for
all Hoosier Healthwise and Healthy Indiana Plan (HIP) health plan members. These claims should be
billed on the CMS-1500 claim form or an 837P transaction. Services must be provided by an IHCPLibrary Reference Number: PRPR10004
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enrolled pharmacy or DME provider. This list is subject to change. Providers will be notified via an
IHCP provider bulletin or other formal communication at least 30 calendar days prior to the change.
Only the drug-related medical supplies and medical devices listed below are reimbursable by the FFS
medical benefit. Claims submitted to the FFS, Hoosier Healthwise, or HIP health plan pharmacy
benefits, will be denied.
Table 8.67 – Drug-Related Medical Supplies and Medical Devices
Procedure Code
Description
A4206
Syringe with needle, sterile, 1cc or less, each
A4207
Syringe with needle, sterile 2cc, each
A4208
Syringe with needle, sterile 3cc, each
A4209
Syringe with needle, sterile 5cc or greater, each
A4210
Needle-free injection device, each
A4211
Supplies for self-administered injection
A4213
Syringe, sterile, 20cc or greater, each
A4215
Needle, sterile, any size, each
A4233
Replacement battery, alkaline (other than J cell), for use with medically
necessary home blood glucose monitor owned by patient, each
A4234
Replacement battery, alkaline, J cell, for use with medically necessary
home blood glucose monitor owned by patient, each
A4235
Replacement battery, lithium, for use with medically necessary home
A4236
Replacement battery, silver oxide, for use with medically necessary home
A4244
Alcohol or peroxide, per pint
A4245
Alcohol wipes, per box
A4250
Urine test or reagent strips or tablets (100 tablets or strips)
A4253
Blood glucose test or reagent strips for home blood glucose monitor, per
50 strips
A4256
Normal, low, and high calibrator solutions/chips
A4258
Spring-powered device for lancet, each
A4259
Lancets, per box of 100
A4261
Cervical cap for contraceptive use
A4266
Diaphragm for contraceptive use
A4267*
Contraceptive supply, condom, male, each
A4268*
Contraceptive supply, condom, female, each
A4269*
Contraceptive supply, spermicide (e.g., foam, gel), each
A4627
Spacer, bag or reservoir, with or without mask, for use with metered dose
inhaler
A7018
Water, distilled, used with large volume nebulizer, 1000 ml
E0607
Home blood glucose monitor
E2100
Blood glucose monitor with integrated voice synthesizer
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Procedure Code
Description
E2101
Blood glucose monitor with integrated lancing/blood sample
S8100
Holding chamber or spacer for use with an inhaler or nebulizer; without
mask
S8101
Holding chamber or spacer for use with an inhaler or nebulizer; with
mask
* Not covered by Healthy Indiana Plan
The Hoosier Healthwise and HIP health plans remain responsible for the following services:
•
Procedure-coded drugs billed by entities other than IHCP-enrolled pharmacy providers
•
Medical supplies and medical devices not included in Table 8.67
•
DME
•
Enteral or oral nutritional supplements
Durable Medical Equipment and Home Medical Equipment
405 IAC 5-19-2 and IC 25-26-21 define durable medical equipment (DME) and home medical
equipment (HME) as equipment that can withstand repeated use, is primarily and customarily used to
serve a medical purpose, and generally is not useful to a member in the absence of illness or injury.
For all DME or HME, a physician must make the order for the equipment or supply in writing. The
written order must be maintained on file for retrospective review purposes.
Per 405 IAC 5-25-3(a), a physician’s written order and plan of treatment are required as follows: “All
Medicaid covered services other than transportation and those services provided by chiropractors,
dentists, optometrists, podiatrists, and psychologists certified for private practice require a physician’s
written order or prescription.”
For items that the OMPP has identified as requiring frequent or substantial servicing, reimbursement is
limited to rentals only and does not reimburse for a purchase of the item.
For Package C, the IHCP covers medical supplies and equipment, including prosthetic devices,
implants, and hearing aids, when medically necessary. Pursuant to 407 IAC 3-6-1(b), the benefit limit
on DME and HME for Package C members is a maximum benefit of $2,000 per year, or $5,000 per
lifetime, for DME. This does not include eyeglasses. Members can purchase or rent the equipment,
depending on which is more cost-efficient.
The IHCP does not reimburse claims for medical supplies, nonmedical supplies, and routine DME or
HME items for members residing in long-term care facilities. Long-term care facilities include nursing
facilities, ICFs/IID, and community residential facilities for the developmentally disabled (CRFs/DD).
The IHCP policy stipulates that providers cannot bill the IHCP directly for medical supplies,
nonmedical supplies, or routine DME or HME items provided to an IHCP member residing in a longterm care facility. The facility per diem rate includes the costs for these services, and the medical
supplier or DME or HME company should bill the long-term care facility directly for such services.
For further information, see 405 IAC 5-13-3 and 405 IAC 5-31-4. Providers that use HCPCS codes for
medical supplies, nonmedical supplies, or routine DME items billed to the IHCP for members residing
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in long-term care facilities, receive a denial with explanation of benefits (EOB) code 2034 – Medical
and nonmedical supplies and routine DME items are covered in the per diem rate paid to the long term
care facility and may not be billed separately to the IHCP.
Manually Priced Supplies, DME, and HME
For DME or HME services, equipment, and supplies that providers bill with a nonspecific HCPCS
code with a description, such as unspecified, unclassified, or miscellaneous, the IHCP bases
reimbursement on manual pricing. An example of a manually priced HCPCS code is E1399 – Durable
medical equipment – Miscellaneous.
For dates of service on or after July 1, 2011, the IHCP revised the methodology used to establish
maximum reimbursement rates for medical supplies procedure codes that are currently manually
priced. Reimbursement is based on Medicare’s established fee schedule, if available. If a rate cannot be
established based on Medicare’s fee schedule, a rate may be established using acquisition cost
information. If a maximum reimbursement rate cannot be established, procedure codes that remain
manually priced will be reimbursed at 75% of the manufacturer’s suggested retail price (MSRP), for
dates of service on or after July 1, 2011. Providers will be required to submit documentation of the
MSRP and the manufacturer’s cost invoice for medical supplies codes that do not have established
rates when submitting the claim for adjudication. These changes apply to all Traditional Medicaid,
Hoosier Healthwise, and Care Select claims, including Medicare crossover and Medicare Replacement
Plan claims.
If billing for an item that has no MSRP, the provider should identify on the cost invoice that the
“MSRP is not available for the product billed.” When this is noted on the cost invoice, the IHCP will
contact the manufacturer directly to confirm there is no MSRP for the product being billed. Manually
priced medical supply and DME procedure codes that have no MSRP will be reimbursed at the
provider’s cost plus 20%, in accordance with List of Sections Affected (LSA) document #11-441(E),
published in the Indiana Register August 3, 2011. If the manufacturer informs the IHCP that an MSRP
is available for the product, the detail being reviewed will be denied with Explanation of Benefit
(EOB) 6126 – The IHCP has verified with the manufacturer that MSRP pricing is available. Please
resubmit the claim with the proper documentation.
The following are considered acceptable documentation of the MSRP:
•
Manufacturer’s catalog page showing MSRP, suggested retail price, or retail price
•
Manufacturer’s invoice showing MSRP, suggested retail price, or retail price
•
Quote from the manufacturer showing the MSRP, suggested retail price, or retail price
Documentation of MSRP must clearly come from the manufacturer of the DME or supply item. Claims
on which the provider has handwritten the MSRP or modified the MSRP documentation will be denied
with EOB 6169 – The MSRP documentation submitted with the claims is not acceptable for
adjudication.
Prior to July 1, 2011, payment for manually priced HCPCS codes, related to DME or HME services, is
specific to the item being billed. Providers must submit documentation supporting the cost of the item,
including a listing of all materials. The IHCP determined reimbursement using the following
guidelines:

If the provider submits an itemized sales invoice from the manufacturer listing all materials or
supplies purchased and showing the price paid for individual items, the IHCP reimburses the claim
at the billed amount, up to 30% above the invoice amount. The IHCP does not accept a
manufacturer’s price list as proof of purchase price for this level of reimbursement.
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
If a provider submits a retail price list from the manufacturer, the IHCP reimburses the claim at
90% of the price on the manufacturer’s retail price list, not to exceed the billed amount.

If the provider submits a copy of the provider’s own retail price list or an invoice from the
provider’s own company, which indicates the price that a provider charges the general public for
products or supplies, the IHCP reimburses the claim at 90% of the invoice or price list, not to
exceed the billed amount.

Providers must identify on each attachment which service corresponds to the procedure code and
amount identified on the claim form.

Invoices must be within one year from the date of service (DOS).
Effective for dates of service on or after May 18, 2012, Table 8.187 – HCPCS Codes Requiring
Attachments includes the HCPCS codes that no longer require submission of a manufacturer’s cost
invoice with the claim for adjudication. A manufacturer’s retail invoice or an MSRP continues to be
required as acceptable documentation. To clarify what is considered acceptable forms of
documentation for MSRP:
•
Manufacturer’s cost invoice showing MSRP, suggested retail price or retail price
•
Quote from the manufacturer showing the MSRP, suggested retail price or retail price
•
Manufacturer’s catalog page showing the MSRP, suggested retail price, or retail price (the
publication date of the catalog must clearly show on the documentation)
•
MSRP pricing from the manufacturer’s website (the manufacturer’s web address must be visible on
printed documentation from its website)
The documentation submitted with each claim may be monitored or subject to a postpayment review.
This means that the MSRP documentation provided from the manufacturer must match the
manufacturer’s cost invoice during a postpayment review.
Providers must not bill more than their usual and customary charge for any item.
When providers request prior authorization for miscellaneous services, they must include an itemized
list of materials in the PA request. For any item providers identify under a miscellaneous code on the
PA form, they must identify a specific number of units for billing purposes and claim adjudication.
Effective September 24, 2010 through May 17, 2012, certain HCPCS codes for DME, supplies, and
hearing aids that are currently manually priced will require a cost invoice to be submitted with the
claim in conjunction with the retail invoice for claim adjudication. A cost invoice is an itemized bill
issued directly from the seller of the supply to the provider listing the goods supplied and stating the
sum of money due to the supplier. Providers that historically submit claims with a cost invoice are not
required to make any modifications to their current claim submission procedures.
Retail invoices (for example, MSRP or invoices custom generated by the provider) that include the
price of the goods plus the provider’s margin must be accompanied by a manufacturer’s cost invoice
for HCPCS codes identified in Table 8.187 – HCPCS Codes Requiring Attachments (Custom-molded
items are an exception – see the note in this section).
In the event the cost invoice contains more than one item, providers must identify on each attachment
which item corresponds to the procedure code and amount identified on the claim form. Claims will
continue to be reimbursed using the retail invoice, unless no retail invoice is submitted by the provider.
The cost invoice will be used to aid the OMPP with its continued efforts to establish reimbursement.
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Note: Providers that are creating or manufacturing custom-molded items specific
to an individual member’s needs, such as a custom-molded seating system
produced in house, may continue to submit only a retail invoice for
processing the claim. The item should be identified as “custom” in the
description field on the attached invoice. A cost invoice is not required in
this circumstance.
Repair and Replacement
Provisions related to the repair of purchased DME or HME and replacement of DME or HME items
are outlined in 405 IAC 5-19-4 and 405 IAC 5-19-5. The rules are summarized as follows:
•
Repair of purchased DME/HME may require PA based on the HCPCS codes billed.
•
The IHCP does not pay for repair of equipment still under warranty.
•
The IHCP does not authorize payment for repair necessitated by member misuse or abuse, whether
intentional or unintentional. The provider must obtain documentation from the member stating the
member understands the service is noncovered by IHCP, and the member will assume
responsibility for the repairs.
•
Repairs for rental equipment are the responsibility of the rental provider.
•
The IHCP does not cover payment for maintenance charges of properly functioning equipment.
•
Repair costs for DME or HME included in a long-term care (LTC) facility’s per diem rate are not
separately reimbursable.
•
The IHCP does not authorize replacement of large DME or HME items more than once every five
years per member. The IHCP allows more frequent replacement only if there is a change in the
member’s medical needs, documented in writing, significant enough to warrant a different type of
equipment.
Procedure code K0739 – Repair or nonroutine service for durable medical equipment other than
oxygen equipment requiring the skill of a technician, labor component, per 15 minutes is a replacement
code for E1340 – Repair or nonroutine service for durable medical equipment requiring the skill of a
technician, labor component, per 15 minutes.
Rental versus Purchase
Providers should base their decision to rent or purchase DME or HME on the least expensive option
available for the anticipated period of need. DME or HME items purchased with IHCP funds become
the property of the OMPP. Providers must notify the local county office of the Division of Family
Resources (DFR) to make arrangements to return the equipment when a member no longer needs the
equipment.
Used DME not Reimbursed by Medicaid
The IHCP does not reimburse for used DME, except for A4638 – Replacement battery for patientowned ear pulse generator, each and A7046 – Water chamber for humidifier, used with positive airway
pressure device, replacement, each. A new item placed with a member initially as a rental item will be
considered a new item by the OMPP at the time of purchase. A used DME item placed with a member
initially as a rental item will be replaced by the supplier with a new item before being purchased by the
OMPP.
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Prior Authorization
Items including, but not limited to, the following are examples of DME and HME that require prior
authorization when medically necessary:
•
Hospital beds
•
Wheelchairs
•
Ventilators
•
Heated and nonheated humidifiers
•
Oxygen
•
Patient lifts
•
Standers
•
Wheelchair seat cushions
•
Power seating systems
The IHCP requires PA for all DME and HME rented or purchased with IHCP funds, as set forth in 405
IAC 5-19-6, except for oxygen and supplies and equipment for delivery to nursing facility (NF)
residents, included in the per diem. This requirement excludes parenteral infusion pumps when used in
conjunction with parenteral hyperalimentation, including central venous catheters, codes B9004 and
B9006. Table 8.68 lists the HCPCS codes for DME and HME that do not require PA.
Note: For RBMC members, contact the appropriate MCE for PA.
Table 8.68 – HCPCS Codes – DME/HME That Do Not Require PA
DME/HME
HCPCS Codes
Surgical/elastic support hose
A4490, A4495, A4500, A4510, A6530 –
A6541, A6544
Battery, heavy duty; replacement for
patient-owned ventilator
A4611
Battery cables; replacement for patientowned ventilator
A4612
Battery charger; replacement for patientowned ventilator
A4613
Nasal cannula
A4615
Breathing circuits
A4618
Oxygen tubing
A4616
Oxygen mouthpiece
A4617
Oxygen face tent
A4619
Oxygen concentration mask
A4620
Tracheostomy mask/collar
A7525, A7526
Crutches
E0110 – E0114, E0116, E0117
Canes
E0100, E0105
Walkers
E0130, E0135, E0140, E0141, E0143,
E0147 – E0149, E0153 – E0159
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DME/HME
HCPCS Codes
Commodes
E0163, E0165, E0167, E0168, E0175
Decubitis Care
E0181, E0182, E0184 – E0191, E0199
Bilirubin light
E0202
Heat/cold application
E0200, E0202, E0203, E0205, E0210,
E0215, E0217,E0218, E0221, E0225,
E0231, E0232, E0235, E0236, E0238,
E0239
Bath and toilet aids
E0241 – E0246
Bedpans
E0275, E0276
Urinals
E0325, E0326
Oximeter for blood oxygen levels
E0445
Humidifiers
E0550, E0555, E0560
Compressors
E0565
Nebulizers
E0570 ,E0572, E0574, E0575, E0580,
E0585
Suction pumps
E0600
Continuous positive airway pressure
(CPAP) device
E0601
Vaporizers
E0605
Monitoring equipment
E0607
Apnea monitors
E0618, E0619
Pacemaker monitor
E0610, E0615
Patient lifts
E0621
Pneumatic compressors
E0650 – E0652, E0655-E0657, E0660,
E0665 – E0669, E0670, E0671 – E0673
Belt/harness
E0700
Restraints
E0710
IV poles
E0776
Parenteral infusion pumps
E0779, E0781 – E0783, E0785, E0780,
E0791
Traction
E0840, E0849, E0850, E0855,E0860,
E0870, E0880,E0890, E0900
Trapeze equipment
E0910 – E0912, E0920, E0930, E0935,
E0936, E0940 – E0942, E0948
Wheelchair accessories
E0950 – E0952, E0959 – E0961, E0966,
E0970, E0971, E0978, E0980, E0994,
E0995, E2601
Rollabout chair
E1031
Repairs and replacement supplies
K0739
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DME/HME
HCPCS Codes
Dialysis equipment
E1510, E1520, E1530, E1540, E1550,
E1560, E1570, E1575, E1580, E1590,
E1592, E1594, E1600, E1610, E1615,
E1620, E1625, E1630, E1632, E1634 –
E1637, E1699
Jaw motion rehab system
E1700 – E1702
Cervical collars
L0112, L0113, L0120, L1030, L1040,
L1050, L1060, L1070, L1072, L0174
Thoracic-lumbar-sacral orthosis (TLSO)
L0450 L0452, L0454, L0456, L0458,
L0460, L0462,L0466, L0468, L0470,
LO472, L0480, L0482, L0484, L0486,
L0488, L0490 – L0492
Lumbar-sacral orthosis
L0621 – L0640
Back supportive devices, such as corsets
L0970, L0972, L0974, L0976
Orthotics for scoliosis
L1000, L1005, L1010, L1020, L1025,
L1030, L1040, L1050, L1060, L1070,
L1080, L1085, L1090, L1100, L1110,
L1120, L1200, L1210, L1220, L1230,
L1240, L1250, L1260, L1270, L1280,
L1290, L1300, L1310, L1499, L1500,
L1520
Lower limb orthotics
L1600, L1610, L1620, L1630, L1640,
L1650, L1652, L1660, L1680, L1685,
L1686, L1690, L1700, L1710, L1720,
L1730, L1755, L1810, L1820, L1830 –
L1832, L1834, L1836, L1840, L1843 –
L1847, L1850, L1860, L1900, L1902
L1904, L1906, L1907, L1910, L1920,
L1930, L1932, L1940, L1945, L1950,
L1951, L1960, L1970, L1971, L1980,
L1990, L2000, L2005, L2010, L2020,
L2030, L2034 – L2038
Torsion control orthotics
L2040, L2050, L2060, L2070, L2080,
L2090
Fracture orthotics
L2106, L2108, L2112, L2114, L2116,
L2126, L2128, L2132, L2134, L2136,
L2180, L2182, L2184, L2186, L2188,
L2190, L2192, L2200, L2210, L2220,
L2230, L2232, L2240, L2250, L2260,
L2265, L2270, L2275, L2280, L2300,
L2310, L2320, L2330, L2335, L2340,
L2350, L2360, L2370, L2375, L2380,
L2385, L2387, L2390, L2395, L2397,
Q4001 – Q4051
Knee additions
L2405, L2415, L2425, L2430, L2492
L2500, L2520, L2525, L2526, L2530,
L2540, L2550
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HCPCS Codes
Pelvic-thoracic control
L2570, L2580, L2600, L2610, L2620,
L2622, L2624, L2627, L2628, L2630,
L2640, L2650, L2660, L2670, L2680
Abduction bars
L3650, L3660, L3670, L3671, L3674,
L3675, L3677, L3702, L3710, L3720,
L3730, L3740, L3760, L3762 – L3766,
L3806, L3807
Additions to upper limb
L3891, L3900, L3901
External power orthotics
L3904, L3905
Wrist/hand orthosis
L3906, L3908, L3912, L3913, L3915,
L3917, L3919, L3921, L3923, L3925,
L3927, L3929, L3931, L3933, L3935,
L3956
Upper limb orthosis
L3960 – L3962, L3964 – L3969
Additions to mobile arm supports
L3970 – L3978
Upper limb fracture orthosis
L3980, L3982, L3984, L3995 – L3999
Orthotic repairs
L4000, L4002, L4010, L4020, L4030,
L4040, L4045, L4050, L4055, L4060,
L4080, L4090, L4100, L4110, L4130,
L4205 – L4210
Ancillary orthotic services
L4350, L4360, L4370, L4380, L4386,
L4392, L4394, L4396, L4398, L4631
Prosthetic procedures
L5000, L5010, L5020, L5050, L5060,
L5100, L5105, L5150, L5160, L5200,
L5210, L5220, L5230, L5250, L5270,
L5280, L5301, L5311, L5321, L5331,
L5341 – L5658, L5661 – L5666, L5668,
L5670 – L5673, L5676 – L5707, L5710
– L5845, L5848 – L5988, L5990, L5999
– L6638, L6640 – L6698, L6703 –
L6714, L6721 – L6722, L6805, L6810,
L6881 – L7045, L7170 – L7600, L7900
– L8049
Hernia trusses
L8300, L8310, L8320, L8330
Prosthetic socks
L8400, L8410, L8415, L8417, L8420,
L8430, L8435, L8440, L8460, L8465,
L8470, L8480, L8485, L8499
Artificial larynx
L8500
Tracheostomy speaking valve
L8501
Prosthetic implants
L8603, L8604, L8606, L8609, L8610,
L8612 – L8614, L8621 – L8624, L8630,
L8631, L8641 – L8642, L8658 – L8670
Medical and Surgical Supplies
HCPCS Codes
Vascular catheters
A4301, A4305, A4306
Slings
A4565, A4566
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DME/HME
HCPCS Codes
Supplies for oxygen and related
respiratory equipment
A4611 – A4620, A4623 – A4629
Supplies for other DME
A4630, A4633 – A4640, A5083
Supplies for ESRD
A4653, A4660, A4663, A4680, A4690
Enteral and parenteral therapy
B9000, B9002, B9004, B9006, B9998,
B9999
Optometric Services
Prosthetic eyes
HCPCS Codes
V2623 – V2629
The physician must provide a written, signed prescription describing the item needed, as well as the
quantity required, for the member to receive the equipment. The rendering provider, as well as the
physician ordering the services or the durable medical equipment, must keep appropriate
documentation on file.
In accordance with 405 IAC 5-3-10, PA requests can be submitted and signed by the following
provider types:
•
Doctor of medicine (MD)
•
Doctor of osteopathy (DO)
•
Dentist
•
Optometrist
•
Podiatrist
•
Chiropractor
•
Psychologist endorsed as a health service provider in psychology (HSPP)
•
Home health agency (authorized agent)
•
Hospitals (authorized agent)
•
Transportation providers (authorized agent)
The provider must approve the request by personal signature or providers and their designees may use
signature stamps. Providers that are agencies, corporations, or business entities may authorize one or
more representatives to sign requests for PA.
If a provider, other than those listed above, submits an electronic 278 request transaction (electronic
PA request), the requester must submit additional documentation indicating the service or supply is
physician-ordered. The additional documentation is sent in the form of an attachment and must be
received on paper, by mail or fax. The original 278 request transaction is suspended for documentation
of the physician’s order. Failure to submit additional documentation within 30 calendar days of the
request results in denial of the request. If a provider does not fall into one of the groups listed above,
the PA is suspended for proof of physician signature.
The above procedures are intended to streamline the PA process. The IHCP Program Integrity
Department evaluates provider profiles and performs retrospective reviews of services no longer
requiring PA.
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Notes: All services provided to 590 Program members with a billed amount greater
than $500 per procedure require PA.
For residents of nursing facilities and ICFs/IID, the IHCP reimburses the
items in Table 8.68 only through the approved per diem rate for the facility.
Administrative staff of the facilities should be aware that these changes to
the PA requirements do not affect the reimbursement rule that includes
supplies and DME/HME items in the provider’s per diem rate. Under no
circumstances should the facility provider or any other provider bill
separately for DME/HME and supply items that are included in the per diem.
Customized Items
The IHCP defines custom equipment as equipment uniquely constructed or substantially modified to
meet the specific needs of an individual patient. For example, the IHCP would consider a customized
molded seating system, billed using code E1399, as a customized item. Due to the unique aspects,
providers cannot group these items with similar items for purposes of payment.
Suppliers must submit documentation of the costs of the item, including the cost of labor and types of
materials used in customizing the item. They must attach a materials and labor itemization and a
manufacturer’s cost invoice to the claim when submitted for payment. The IHCP reviews each item on
the invoice when calculating the reimbursement amount for all customized items. The IHCP
reimburses the materials needed for repair at 30% above the manufacturer’s cost to the provider.
The IHCP considers the following factors when reviewing PA requests for customized equipment:
•
The costs and changes for construction of the item can vary widely from one patient to another.
Some items, while individually constructed, may have standard costs and charges. Providers can
most often identify and bill these items using existing HCPCS codes, and the items are not
considered custom equipment.
•
A wheelchair assembled by a supplier or ordered from a manufacturer that makes available special
features, modifications, or components cannot be considered a customized wheelchair. The HCPCS
contains many different codes to categorize wheelchairs. The IHCP may make additional payment
for modifications such as attachments to convert a wheelchair to a one-arm drive, brake extensions,
wheelchair hand rims, and antitipping devices.
Capped Rental Items
The IHCP limits certain procedure codes to 15 months of continuous rental. The IHCP defines
continuous rental as rental without interruption for a period of more than 60 days. A change in provider
does not cause an interruption in the rental period.
Providers should bill DME and HME rentals on the CMS-1500 or 837P transaction. The IHCP handles
claims submitted for rental of DME and HME in the following manner:
•
The allowed charge is the lower of the IHCP rental fee schedule amount or the actual submitted
charge.
•
The IHCP pays claims until the number of rental payments made to date reaches the capped rental
number of 15 months.
•
The IHCP evaluates requests for approval of DME/HME capped rental items for documentation of
long-term need. In long-term situations, the IHCP may make a decision to purchase the item.
•
The procedure codes listed in Table 8.69 are subject to the 15-month capped rental period.
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The use of a piece of equipment during a rental period may be interrupted; however, if the patient
resumes use of the equipment within 60 days of the last payment, the original 15-month period remains
active. If the interruption period exceeds the 60-day period, and the interruption reasons are justified,
providers must submit a new PA request to begin a new 15-month rental period. The supplier must
document the reason for the greater-than-60-day break in the rental period on the universal PA form,
the Indiana Health Coverage Programs Prior Authorization Request Form. Justification for a break in
the rental period more than 60 days may include the following:
•
Change in medical necessity
•
Hospitalization
•
Nursing facility stay
A physician must provide justification. Unless the IHCP receives a new PA requesting a new rental
period, the original 15-month period remains active. A change in the provider does not result in a new
15-month rental period. If a member becomes inactive for a period of more than 60 days, the IHCP
requires a new PA to resume services.
Table 8.69 lists the procedure codes that are subject to the 15-month capped rental period.
Table 8.69 – Procedure Codes – DME/HME Capped Rental Items
A9273
B9000*
B9002*
B9004*
B9006*
E0165
E0170
E0171
E0181*
E0182*
E0186*
E0187*
E0196
E0218*
E0221*
E0231*
E0232*
E0235*
E0236*
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0277
E0290
E0291
E0292
E0293
E0294
E0295
E0297
E0296
E0301
E0302
E0303
E0305
E0316
E0371
E0372
E0373
E0445*
E0459
E0462*
E0481
E0482
E0483
E0550*
E0565*
E0572*
E0574*
E0585*
E0600*
E0601*
E0603
E0606
E0607*
E0617
E0618*
E0619*
E0630
E0635
E0636
E0638
E0740
E0744
E0745
E0770
E0749
E0779*
E0781*
E0784
E0791*
E0910*
E0920*
E0930*
E0936
E0940*
E0941
E0946*
E0955
E0956
E0957
E0958*
E0959
E0960
E0967
E0968
E0969
E0970
E0971
E0973
E0974
E0978
E0980
E0981
E0982
E0983
E0984
E0985
E0988
E0990
E0992
E0994
E1011
E1014
E1015
E1016
E1017
E1018
E1020
E1028
E1029
E1030
E1031*
E1035
E1037
E1038
E1039
E1050
E1060
E1070
E1083
E1084
E1085
E1086
E1087
E1088
E1089
E1090
E1092
E1093
E1100
E1110
E1130
E1140
E1150
E1160
E1161
E1170
E1171
E1172
E1180
E1190
E1195
E1200
E1221
E1222
E1223
E1224
E1225
E1226
E1227
E1228
E1231
E1232
E1233
E1234
E1235
E1236
E1237
E1238
E1240
E1250
E1260
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E1270
E1280
E1285
E1290
E1295
E1800
E1801
E1802
E1805
E1806
E1810
E1811
E1815
E1816
E1818
E1821
E1825
E1830
E1840
E1902
E2000*
E2100
E2101
E2202
E2203
E2204
E2205
E2206
E2209
E2210
E2211
E2212
E2213
E2214
E2215
E2216
E2217
E2218
E2219
E2220
E2221
E2222
E2223
E2224
E2225
E2226
E2291
E2292
E2293
E2294
E2321
E2322
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2331
E2340
E2341
E2342
E2343
E2358
E2359
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2368
E2369
E2370
E2371
E2372
E2373
E2374
E2375
E2376
E2377
E2381
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2389
E2390
E2391
E2392
E2394
E2395
E2396
E2397
E2601
E2602
E2603
E2604
E2605
E2606
E2607
E2608
E2609
E2611
E2612
E2613
E2614
E2615
E2616
E2617
E2619
E2620
E2621
K0010
K0011
K0012
K0014
K0606
K0733
K0735
K0800
K0801
K0802
K0812
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0828
K0829
K0835
K0836
K0837
K0838
K0839
K0840
K0841
K0842
K0843
K0848
K0849
K0850
K0851
K0852
K0853
K0854
K0855
K0856
K0857
K0858
K0859
K0860
K0861
K0862
K0863
K0864
K0868
K0869
K0870
K0871
K0877
K0878
K0879
K0880
K0884
K0885
K0886
K0890
K0891
K0898
*Note: These codes do not require PA.
The IHCP denies claims submitted using these procedure codes with rental in excess of 15 months.
Capped rental items are also subject to replacement or servicing when certain criteria are met. The
IHCP does not authorize replacement of capped rental items more often than once every five years per
member, unless there is a change in the member’s medical needs, documented in writing, significant
enough to warrant a different type of equipment.
As previously indicated, the IHCP makes rental payments through the 15 th month. At the end of the 15month rental period, the IHCP considers the DME/HME equipment purchased, and in accordance with
405 IAC 5-19-8, the equipment becomes the property of the OMPP. During the capped rental period,
the equipment supplier must supply and service the item for as long as the member continues to need it
at no additional charge to the IHCP. However, subject to prior approval parameters, for repairs not
covered by warranty, the IHCP does not reimburse more frequently than six months after the 15 th
month and every six months thereafter, for as long as the equipment is medically necessary.
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Providers should use HCPCS code E1399 – Durable medical equipment, miscellaneous to bill DME
materials that do not have a specific HCPCS code available. HME providers should bill labor costs
associated with servicing and repairs with HCPCS code K0739 – Repair or nonroutine service for
durable medical equipment other than oxygen equipment requiring the skill of a technician, labor
component, per 15 minutes. Providers must attach a materials and labor itemization to the claim when
submitting it for payment.
The IHCP makes no payment for rental for any month the patient is in an institution that does not
qualify as his or her home or is outside the United States for an entire month. However, if the patient is
at home on the first day of a rental month, the IHCP may make payment for the entire rental month.
Similarly, if a member returns an item of rental equipment to the supplier before the end of a payment
month, the IHCP may make payment for the entire rental month.
Items Requiring Frequent or Substantial Servicing
For items requiring frequent or substantial servicing, the IHCP reimburses providers for rental
payments only, as long as the equipment is deemed medically necessary. The IHCP denies claims for
the purchase of these items. As noted in 405 IAC 5-19-4, repair of rental items is the responsibility of
the rental provider.
Table 8.70 represents a list of equipment and supplies requiring frequent or substantial servicing that
are available on a rental basis. The IHCP denies these codes if providers bill them as a purchase. This
list is not all-inclusive.
Table 8.70 – Procedure Codes Classified as Frequent and Substantial Servicing by the IHCP
Procedure Code
Description
E0450
Volume control ventilator, without pressure support mode, may include pressure
control mode, used with invasive interface (e.g., tracheostomy tube)
E0460
Negative pressure ventilator, portable or stationary
E0461
Volume control ventilator, without pressure support mode,, may include pressure
control mode, used with noninvasive interface (e.g., mask)
E0500
IPPB machine, all types, with built-in nebulization; manual or automatic valves;
internal or external power source
E0575
Nebulizer, ultrasonic, large volume
E0935
Continuous passive motion exercise device for use on knee only
The IHCP does not allow any provider to bill the IHCP for medical or nonmedical supplies and
equipment or therapies provided to residents in LTC facilities. The IHCP rules for separate billing and
reimbursement also exclude food supplements, nutritional supplements, and infant formulas (except
for medically necessary infant formula as outlined in Chapter 6: Prior Authorization of this manual).
The IHCP includes all medical and nonmedical supplies, routine medical equipment, and therapies in
the NF per diem rate.
Ancillary and Therapy Billing for LTC Facility Residents
Providers can bill parenteral and enteral services and therapies received by dual-eligible members
(Medicare and Traditional Medicaid, as well as Care Select) to Medicare and the IHCP as crossovers
or Medicare Replacement Plans. The provider must submit these services on the UB-04 claim form.
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Automatic External Defibrillators and Wearable Cardioverter Defibrillators
The IHCP covers two types of automatic external defibrillators (AEDs) with PA for individual use.
The IHCP covers the AED, E0617 – External defibrillator with integrated electrocardiogram analysis
and the wearable cardioverter defibrillator (WCD), K0606 – Automatic external defibrillator, with integrated
electrocardiogram analysis, garment type.
The AED (E0617) is similar to a manual defibrillator, except the AED detects and analyzes heart
rhythms automatically. Various manufacturers make the AED devices. Each device uses a battery pack
and electrode defibrillator pads, and the initial supplies are usually included with the device.
The WCD (K0606) consists of a vest-like or garment-like device worn under a patient’s clothing that
holds a monitor, electrodes, a battery, and a small alarm module. The monitor is designed to
automatically sense abnormal heart rhythms and deliver electrical therapy through the electrodes after
alerting the patient to avoid improper defibrillation. Nonwearable components include a battery
charger, a computer modem, a modem cable, a computer cable, WCDNET, and the diagnostic test.
WCDNET is a secure web-based data storage and retrieval system that allows the physician to access
the patient’s electrocardiogram (ECG) data stored by the WCD monitor. The physician uses the
diagnostic tester to program the WCD to identify specific heart rates and rhythms for data storage.
Additional components included with the WCD are a second battery to be used when the first is
charging and an extra garment for use when the first is cleaned.
The AED (E0617) and WCD (K0606) are indicated for members who normally are candidates for an
implanted cardioverter defibrillator (ICD), but for whom an ICD is contraindicated or needs to be
removed. Members use these devices for an average time of approximately two to three months,
although some members awaiting transplant have used the device for more than one year.
The IHCP covers an AED (E0617) or a WCD (K0606), based on the physician’s clinical assessment of
the member’s medical needs. Table 8.71 lists examples of factors that providers may consider when
choosing which defibrillator is most appropriate for the member.
Table 8.71 – Defibrillator Factors
Factors for Choosing E0617
Factors for Choosing K0606
Inability to wear a WCD vest due to obesity
Lack of assistant who can operate an AED
Skin irritation from wearing electrodes 24 hours per
day
Frequency that the member is away from home
Limited or lack of mobility
Mobility of the member
Availability of an assistant to operate the AED
Frequently unstable heart rhythms
Tables 8.72 and 8.73 list the HCPCS code and description for the WCD, AED, and accessories. The
WCD and the AED are capped rental items. K0607 and K0608 are inexpensive and routinely
purchased items.
Table 8.72 – Wearable Cardioverter Defibrillator
HCPCS Code
Description
K0606
Automatic external defibrillator with integrated electrocardiogram analysis,
garment type
K0607*
Replacement battery for automated external defibrillator, garment type only, each
K0608
Replacement garment for use with automated external defibrillator, each
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HCPCS Code
Description
Replacement electrodes for use with automated external defibrillator, garment
type only, each
K0609*
*
These HCPCS codes are used for the automatic external defibrillator and
wearable cardioverter defibrillator.
Table 8.73 – Automatic External Defibrillator
HCPCS Code
Description
E0617
External defibrillator with integrated electrocardiogram analysis
K0607*
Replacement battery for automated external defibrillator, garment type only, each
K0609*
Replacement electrodes for use with automated external defibrillator, garment
type only, each
*
These HCPCS codes are used for the automatic external defibrillator and
wearable cardioverter defibrillator.
Prior Authorization Criteria for Accessories K0607 – K0609
The IHCP bases PA criteria for accessories on the estimated average life expectancies of the
accessories. AED (E0617) and WCD (K0606) use the accessories replacement batteries, K0607, and
replacement electrodes, K0609.
K0607 – Replacement Battery
1. The member must currently be renting or have purchased an AED (E0617) or WCD (K0606 with
integrated electrocardiogram analysis, garment type).
2. The battery being replaced must be at least 11 months old or completely discharged.
K0608 – Replacement Garment (only for WCD)
1. The member must currently be renting or have purchased a WCD with integrated electrocardiogram
analysis, garment type (K0606).
2. The garment must be damaged or worn beyond repair and have been in use at least five months.
K0609 – Replacement Electrodes
1. The member must currently be renting or have purchased an AED (E0617) or the WCD with
integrated electrocardiogram analysis, garment type (K0606).
2. The electrodes being replaced must have been used for at least 22 months, or the provider must
prove that the equipment is broken or damaged beyond repair.
Casting Supplies
The IHCP allows reimbursement for cast supplies in conjunction with the initial fracture care service.
The IHCP also allows cast supplies when billed in conjunction with the application of a cast, strap, or
splint, when billing CPT codes 29000 through 29799, when applied initially, without restorative
fracture care, or when applied as a replacement when restorative care has been previously provided.
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Continuous Passive Motion – Continuous Passive Motion Device
The following information outlines the billing parameters for a continuous passive motion (CPM)
device:
•
PA is not required.
•
Units of service: One unit of service equals one day.
For CPM devices, providers should bill using the appropriate HCPCS procedure code E0935 –
Continuous passive motion exercise device for use on knee only or E0936 – Continuous passive
motion exercise device for use other than knee and must append the modifier RR.
Cranial Remolding Orthosis
The IHCP considers HCPCS code S1040 for cranial remolding orthosis to be medically necessary for
members aged 4 to 24 months with benign positional plagiocephaly, plagiocephaly with torticollis,
brachycephaly, dolichocephaly, and scaphocephaly due to conditions such as in utero or intra partum
molding, premature or multiple births, and supine positioning. A pediatrician, general surgeon with a
specialty in pediatrics, pediatric surgeon, craniofacial surgeon, or craniofacial anomalies team member
must sign the prescription for the cranial remolding orthosis. The prescribing physician must document
the medical necessity and prior authorization criteria in the patient’s chart. The prescribing physician
must sign the prior authorization form, but the prescribing physician or DME or HME supplier may
also submit it.
Providers must meet the following prior authorization criteria for the cranial remolding orthosis to be
considered for approval for IHCP members between 4 months and 24 months of age:
•
Providers must submit documentation that shows the member received a minimum of a two-month
trial of aggressive repositioning and stretching exercises recommended by the American Academy
of Pediatrics and has failed to improve. Exercise should include at least four of the following
activities:
- Alternating back and side sleeping
- Supervising “tummy time”
- Rearranging the crib relative to the primary light source
- Limiting time spent in a supine position
- Limiting time in strollers, carriers, and swings
- Rotating activity
- Exercising neck motion
The member must meet one of the following criteria:
•
Moderate to severe positional plagiocephaly, with or without torticollis, documented by an
anthropometric asymmetry greater than 6 mm in the measurement of the cranial base, cranial vault,
or orbitotragial depth
•
Brachycephaly documented by a cephalic index 2 standard deviations above or below the mean
(approximately 78%)
•
Scaphocephy or dolichochaly in premature or breech infants with a cephalic index significantly less
than 78%
•
Further correction or asymmetry for members after surgical treatment of craniosynostosis,
considered on a case-by-case basis
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• Moderate to severe residual plagiocephaly after surgical correction of plagiocephaly
- The pediatric neurosurgeon or craniofacial surgeon who performed the corrective procedure
must provide documentation of medical necessity.
The IHCP considers treatment for approval on a case-by-case basis for members aged 12 months to 24
months with severe plagiocephaly and who are considered to have a reasonable likelihood of continued
skull growth. A pediatric neurosurgeon, craniofacial surgeon, or craniofacial anomalies team member
must provide documentation of medical necessity. The member must have documented trial of
repositioning and stretching exercises as described in the first criteria to be considered for approval.
The following are contraindications to receiving cranial remolding orthosis:
•
Members older than 24 months old
•
Unmanaged hydrocephalus
•
Craniosynostosis
Home Infusion – Parenteral and Enteral Therapy Services
Note: Refer to Chapter 9: IHCP Pharmacy Services Benefit of this manual for
Billing Procedures for Home Infusion and Enteral Therapy Services
information.
The billing procedures listed in this section apply to parenteral and enteral therapy when provided in a
member’s home. Enteral therapy may include enteral feeding within or by way of the intestine, or
enteral tube feeding that includes the provision of nutritional requirements through a tube into the
stomach or small intestine. Parenteral therapy includes any route other than the alimentary canal such
as intravenous, subcutaneous, intramuscular, or mucosal, and total parenteral nutrition (TPN).
The following three provider types may bill for these services:
•
HME and DME medical supply dealers
•
Home health agencies
•
Pharmacies
Providers must bill separately for the components for home infusion and enteral therapy. HME
providers bill all supplies and formulas used for home infusion and enteral therapy on the CMS-1500
claim form or 837P transaction using the appropriate HCPCS codes. Home health agencies bill
services provided by an RN, LPN, or home health aide on a UB-04 claim form or 837I transaction
using the appropriate HCPCS codes for services provided. Providers must bill the IHCP for such
services using HCPCS codes billed on the CMS-1500 claim form.
Providers enrolled as multiple provider types, such as pharmacy, DME, HME, and home health
agencies, can bill all three components using the proper billing forms and appropriate codes.
The IHCP does not routinely use HCPCS S codes when other national codes are available for the same
services. The IHCP does not reimburse HCPCS S codes for home infusion therapy and enteral therapy,
with the exception of S9349 – Home tocolytic infusion therapy. Providers must separately bill the
appropriate national codes, using the proper billing format, to receive reimbursement for services
described in HCPCS S codes for home therapy, including home infusion and enteral therapy.
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Home Infusion – Parenteral and Enteral Nutrition Pumps
Parenteral and enteral nutrition (PEN) pumps are not in the capped rental fee schedule category;
however, the payment policies are similar. The IHCP makes no more than 15 monthly rental payments,
just as with the capped rental. At the end of the 15-month rental period, the pump becomes the
property of the IHCP. If there is medical necessity for rental of the pump past the 15-month rental
limit, the supplier is entitled to periodic servicing payments.
For enteral pumps, the IHCP pays no more than one-half the rental payment every six months,
beginning six months after the last rental payment. For parenteral pumps, the IHCP pays no more than
one-half the rental payment every three months, beginning three months after the last rental payment.
The supplier should keep written proof of servicing of enteral and parenteral pumps on file.
PEN pumps include HCPCS codes B9000, B9002, B9004, and B9006. The IHCP requires the
Certification of Medical Necessity: Parenteral and Enteral Nutrition for all PEN pumps. Providers
must submit a copy of the Certification of Medical Necessity (CMN) with the initial, and each
subsequent, PA request for enteral nutrition items.
The IHCP does not require PA for the total parenteral nutrition or infusion pumps when used in
conjunction with parenteral hyperalimentation, including central venous catheters.
Necessary servicing of pumps may include repairs that require specialized testing equipment not
available to the member or nursing home. The IHCP pays for only actual servicing. However,
providers must obtain prior authorization for reimbursement for repair or servicing not covered by
warranty. When requesting PA for repair services, providers must include an itemized list of materials
and labor with the PA request. When submitting the claim for payment, providers must attach a
materials and labor itemization plus a manufacturer’s invoice to the claim submitted for payment. The
IHCP reimburses the materials needed for repair at 30% above the manufacturer’s cost to the provider.
Enteral Nutrition
The IHCP does not require PA for the total parenteral nutrition or infusion pumps when used in
conjunction with parenteral hyperalimentation, including central venous catheters.
The IHCP requires PA for enteral nutrition. The IHCP requires a CMN for enteral nutrition and allows
someone other than the ordering physician to complete the CMN. However, the ordering physician
must review for the accuracy of the information, sign, and date the CMN to indicate agreement.
Providers should photocopy CMN forms, because the contractor does not supply this form as a routine
item. Providers must submit a copy of the CMN with each PA request (including the initial request) for
enteral nutrition items.
After the initial PA of enteral nutrition items, the IHCP requires subsequent PA after three, nine, and
18 months of therapy to document the member’s continued need for therapy. After two years, the
IHCP determines the need for further PA on a case-by-case basis. If the member does not medically
require enteral nutrition services for two consecutive months, the IHCP requires a new PA, and the
required extension schedule starts again.
For the initial PA or extensions of initial PA, providers must include additional documentation to
support medical necessity of the following orders:
•
The need for special nutrients
•
The need for total caloric intake less than 20 cal/kg/day or greater than 35 cal/kg/day
•
The need for a pump
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Table 8.74 provides a list of the parenteral nutrition solution, kit, and pump HCPCS codes. See the
IHCP fee schedule at indianamedicaid.com for a comprehensive list of covered procedures.
Table 8.74 – HCPCS Codes – Parenteral Nutrition Solution/Kit/Pump
B4164
B4185
B4199
B4224
B9004
B4168
B4189
B4216
B5000
B9006
B4176
B4193
B4220
B5100
B9999
B4180
B4197
B4222
B5200
E0776
Table 8.75 provides HCPCS codes that the IHCP covers for enteral nutrition formula, kit, tubing, and
pump. See the IHCP fee schedule at indianamedicaid.com for a comprehensive list of covered
procedures.
Table 8.75 – HCPCS Codes – Enteral Nutrition Formula/Kit/Tubing/Pump
B4034
B4082
B4152
B9000
B4035
B4083
B4153
B9002
B4036
B4150
B4154
B9998
B4081
B4149
B4155
E0776
Clarification on Billing Food Thickener, HCPCS Code B4100
The IHCP covers food thickener (B4100 – Food thickener, administered orally, per oz), when ordered
by a physician, based on medical necessity, and subject to prior authorization. According to the
HIPAA, only drugs and biologics may be reported on the pharmacy claim form with a NDC.
Nutritional supplements are not considered drugs or biologics and therefore should not be billed on a
pharmacy claim form. Please bill nutritional supplements utilizing the appropriate HCPCS procedure
code on the CMS-1500 paper claim form or using the 837P electronic transaction. B4100 – Food
thickener, administered orally, per oz, requires prior authorization and must be billed on a CMS-1500
claim form.
Humidifiers, Nonheated or Heated
The IHCP covers a nonheated (E0561) or a heated (E0562) humidifier for use with a noninvasive
respiratory assistive device (RAD) (E0470 and E0471) or a CPAP (E0601), when ordered by a
physician, based on medical necessity, and subject to prior authorization.
Providers must meet the following criteria for reimbursement:
•
The IHCP considers humidifiers E0561 and E0562 for use with a RAD or a CPAP for coverage
only when physician documentation supports the medical necessity of the humidifier.
•
Documentation must indicate that the member is suffering from nosebleeds, extreme dryness of the
upper airways, or other conditions that interfere with compliance or use of the RAD or a CPAP,
and that the humidifier could improve this condition.
HCPCS codes E0561 and E0562 are single patient use devices, categorized as inexpensive and
routinely purchased items available for purchase only for Traditional Medicaid members. The IHCP
covers rental temporarily for crossover and Medicare Replacement Plan claims only and no longer
requires a rental trial period before purchase of nonheated or heated humidifiers.
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Incontinence, Ostomy, and Urological Mail Order Supplies
All fee-for-service members, which include those in the Traditional Medicaid and Care Select
programs, are required to obtain incontinence, ostomy, and urological supplies through mail order from
one of the contracted providers listed below.
Effective June 1, 2008 through January 31, 2012, the IHCP contracted with the following three
vendors to provide incontinence, ostomy, urological, and other supplies including diapers, underpads,
ostomy bags, and gloves:
•
Binson’s Home Health Care Centers
binsons.com
Telephone: 1-888-217-9610
•
Healthcare Products Delivery (HPD), Inc.
hpdinc.net
Telephone: 1-800-291-8011
•
J&B Medical Supply Company
jandbmedical.com
Telephone: 1-866-674-5850
Effective February 1, 2012, the following two vendors are contracted with the IHCP to provide
incontinence, ostomy, and urological supplies, including diapers, underpads, ostomy bags, and gloves,
to fee-for-service (FFS) members.
•
Binson’s Home Health Care Centers
binsons.com
Telephone: 1-888-217-9610
•
J&B Medical Supply Company
jandbmedical.com
Telephone: 1-866-674-5850
Claims for supplies from noncontracted providers are systematically denied. Members enrolled in the
590 Program, Medical Review Team (MRT), First Steps, Pre-Admission Screening Resident Review
(PASRR), Long Term Care (LTC), and RBMC programs are excluded from this policy.
Members with Medicare or third-party insurance must follow the guidelines of Medicare and/or their
primary insurance plan to receive reimbursement of these products. Crossover claims and claims with
a third-party payment amount indicated for these supplies are not affected by this policy.
If Medicare or the primary carrier does not cover this type of service, the claims will process following
Medicaid rules as though Medicaid is primary. In this case, claims from a noncontracted vendor will be
denied.
Table 8.76 lists the procedure codes for supplies affected by this policy. Claims for these supplies will
be denied if billed by noncontracted providers.
Table 8.76 – Procedure Codes Covered Under Contract
T4521
T4526
T4531
T4536
T4542
T4522
T4527
T4532
T4537
T4543
Covered Procedure Codes
T4523
T4524
T4528
T4529
T4533
T4534
T4539
T4540
A4310
A4311
T4525
T4530
T4535
T4541
A4312
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A4313
A4321
A4331
A4340
A4352
A4357
A4366
A4372
A4378
A4383
A4389
A4394
A4399
A4407
A4412
A4417
A4423
A4428
A4433
A5053
A5063
A5082
A5113
Covered Procedure Codes
A4315
A4316
A4326
A4327
A4333
A4334
A4346
A4349
A4354
A4355
A4361
A4362
A4368
A4369
A4375
A4376
A4380
A4381
A4385
A4387
A4391
A4392
A4396
A4397
A4404
A4405
A4409
A4410
A4414
A4415
A4419
A4420
A4425
A4426
A4430
A4431
A4458
A5051
A5055
A5061
A5072
A5073
A5102
A5105
A5126
A5131
A4314
A4322
A4332
A4344
A4353
A4358
A4367
A4373
A4379
A4384
A4390
A4395
A4400
A4408
A4413
A4418
A4424
A4429
A4434
A5054
A5071
A5093
A5114
A4320
A4328
A4338
A4351
A4356
A4363
A4371
A4377
A4382
A4388
A4393
A4398
A4406
A4411
A4416
A4422
A4427
A4432
A5052
A5062
A5081
A5112
High-end incontinence products require PA and are currently limited to only HCPCS T codes listed in
Table 8.77. For high-end products, provider must submit claim with U9 modifier for the claim to
process correctly.
Table 8.77 – Procedure Codes Billable with U9 Modifier
Covered Procedure Codes with U9 Modifier
T4521
T4522
T4523
T4524
T4525
T4526
T4527
T4528
T4529
T4530
T4531
T4532
T4533
T4534
T4536
T4539
T4543
There are instances when the use of tapes, adhesives, gloves, and other supplies are not related to
incontinence, ostomy, or urological conditions. IHCP members will not be restricted to purchasing the
supplies listed below only through mail order from one of the three contracted vendors. Therefore, the
following codes are billable by appropriate providers:
•
A4364 (adhesive liquid)
•
A4456 (adhesive remover wipes)
•
A4402 (lubricant)
•
A4450 and A4452 (tape)
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•
A4455 (adhesive remover)
•
A4927 (gloves)
•
A5120, A5121, and A5122 (skin barrier)
For members with a primary payer, the following apply:
•
Incontinence supplies are covered for members 3 years old or older.
•
A maximum of $162.50 is allowed per member per month for all incontinence supplies.
•
A maximum of $1,950 is allowed per member per rolling calendar year for all incontinence
supplies.
•
Providers may only supply such services to an IHCP member in 30-day increments.
Incontinence supplies for members in LTC facilities are reimbursed through the per diem rate for the
facility and cannot be billed separately by the facility, a pharmacy, or other provider. Providers must
work with families to provide cost-effective supplies that meet the needs of the member.
Documentation Required for All Incontinence Supplies
The IHCP requires documentation of medical necessity for all incontinence supplies. The physician
should maintain documentation of the medical necessity for the supplies in the patient’s record. The
supplier must maintain a signed physician’s order in the IHCP member’s record for audit purposes.
The order must include a start and stop date and a detailed list of the incontinence supplies ordered.
Providers must renew the physician’s order annually at minimum. For example, an order written on
February 15, 2012, is effective for a maximum of 12 months through February 14, 2013. The supplier
must obtain a new order to cover dates of service starting February 15, 2013, through February 14,
2014. The supplier must have a current order to initiate or continue the provision of supplies to an
IHCP member.
In addition to the signed physician’s order, the supplier must maintain documentation of proof of
delivery. Documentation must include the date of delivery, address of delivery, and signature of the
IHCP member, caregiver, or family member who received the supplies.
Incontinence Supplies for Group Homes, Intermediate Care Facilities for the
Intellectually Disabled, and Long-Term Care Facility Residents
Please note that the IHCP reimburses incontinence supplies for members residing in group homes,
intermediate care facilities for individuals with intellectual disability (ICFs/IID, formerly ICFs/MR),
and LTC facilities through the per diem rate for the facility, and the facility or any other provider
cannot bill separately.
Out-of-State Providers
The following designated cities are exempt from the out-of-state prior authorization (PA) rules:
•
Danville, Illinois
•
Watseka, Illinois
•
Louisville, Kentucky
•
Owensboro, Kentucky
•
Sturgis, Michigan
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•
Cincinnati, Ohio
•
Hamilton, Ohio
•
Harrison, Ohio
•
Oxford, Ohio
•
Chicago, Illinois
Note: Providers in these cities need to follow the same prior authorization rules as
in-state providers for all members in the Care Select and Traditional
Medicaid programs. See Chapter 6: Prior Authorization for information
about the prior authorization process. This change includes all active
providers with locations in the ZIP Codes of 606XX, 607XX, and 608XX.
A4927 – Nonsterile Gloves, per 100
One unit of A4927 equals 100 gloves. Per IHCP guidelines, code A4927 is limited to five units per
month (one unit = 100 gloves). Providers are reminded that nonsterile gloves are only reimbursable
when used by the patient, family, or other nonpaid caregiver.
Examples of a medical need for a nonsterile glove include, but are not limited to, the following uses:
•
A bowel program requiring manual evacuation
•
An ostomy care program
•
A wound care program
Note: The IHCP does not separately reimburse providers for nonsterile gloves
supplied for end-stage renal disease (ESRD)/dialysis services. Payment for
gloves is included in the payment for dialysis services. Payment for gloves is
included in the nursing facility per diem rate; therefore, gloves are not
separately billable by the nursing facility or another provider.
A4930 – Gloves, Sterile, per Pair
Sterile gloves are reimbursable when medically necessary using procedure code A4930 – Gloves,
sterile, per pair. Sterile gloves are often included in sterile procedure kits, such as catheter insertion
kits and suture removal kits. Items in these kits are not billed separately.
General Guidelines Applicable to Nonsterile and Sterile Gloves
Documentation of medical need is required for all gloves, nonsterile and sterile. The supplier must
maintain a signed physician’s order in the patient record with a start and stop date, frequency of
treatment, and type of treatment that makes the gloves medically necessary. Documentation must
indicate the reason the physician ordered the gloves as part of the plan of care. Physicians must renew
their orders at least every 12 months to ensure ongoing need for gloves.
Providers are reminded that code A4927 should not be used for billing gloves supplied for
ESRD/dialysis services. Reimbursement for these gloves is included in the payment for dialysis
services.
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Nonsterile gloves will be reimbursed only when used by the patient, family, or other nonpaid
caregiver. Providers cannot bill the IHCP for any amount that exceeds their usual and customary
charge to the general public. Providers should bill single nonsterile gloves in partial units by
completing form locator 24G on the CMS-1500 claim form or Service Unit Count, Data Element 380
on the 837P electronic transaction. The partial unit is billed by using the appropriate decimal indicator
for the number of gloves used. For example, two gloves would be billed as 0.02; 40 gloves would be
billed as 0.40.
Orthopedic or Therapeutic Footwear
With a physician’s written order, the IHCP provides reimbursement for members of all ages for the
following:
•
Corrective features built into shoes such as heels, lifts, wedges, arch supports, and inserts
•
Orthopedic footwear, such as, shoes, boots, and sandals
•
Orthopedic shoe additions
If a member currently has a brace, the IHCP covers the shoes and supportive devices if providers
document continued medical necessity.
The IHCP also provides coverage for therapeutic shoes for members with severe diabetic foot disease.
The HCPCS codes listed in Table 8.78 are the only codes that providers can use to bill for these
services. Providers should not use these codes in any other circumstances.
Table 8.78 – HCPCS Codes – Therapeutic Shoes for Severe Diabetic Foot Disease
A5500
A5501
A5503
A5504
A5505
A5506
A5507
A5508
A5510
A5512
A5513
The IHCP’s policy mirrors Medicare’s coverage of inserts and diabetic shoes. The IHCP allows for
one of the following:
•
One pair of custom molded shoes (A5501) and two additional pairs of inserts (A5512 or A5513)
•
One pair of depth shoes (A5500) and three pairs of inserts (A5512 or A5513)
- A5513 is limited to two inserts per date of service per rolling 12-month period
The member is eligible for a total of three pairs of inserts each calendar year. A5512 has a maximum
unit of six per date of service. A5513 has a maximum unit of two per date of service. If the provider
dispenses inserts independently of diabetic shoes, the member must have appropriate footwear into
which to place the insert.
Providers should submit claims using the appropriate HCPCS codes with one unit of service for each
code. If a member needs shoes and inserts, providers should submit claims using the appropriate
HCPCS codes with two as the unit of service for each code.
The IHCP considers payment for the certification of the need for therapeutic shoes and the prescription
of the shoes to be included in the office visit or consultation payment. Providers cannot bill for
encounters for the sole purpose of dispensing or fitting shoes. The IHCP makes no payment for an
office visit or consultation provided on the same day as the fitting or dispensing of shoes by the same
physician.
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Osteogenic Bone Growth Stimulators
The IHCP covers osteogenic bone growth stimulators (OBGS) with prior authorization. The equipment
requires thorough education be provided to the member and his or her caregivers. OBGS are
inexpensive and routinely purchased DME.
Noninvasive Stimulators – E0747 and E0748
The IHCP covers the noninvasive stimulator devices only for the following indications:
•
Nonunion of long bone fractures
•
Congenital pseudoarthroses
•
As an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis due to previously
failed spinal fusion at the same site, or for those undergoing multiple-level fusion
- A multiple-level fusion involves three or more vertebrae.
Invasive or Implantable Stimulator – E0749
The IHCP covers the implantable invasive stimulator for the following indications:
•
Nonunion of long bone fractures
•
As an adjunct to spinal fusion surgery for patients at high risk of pseudarthrosis due to previously
failed spinal fusion at the same site, or for those undergoing multiple-level fusion
- A multiple-level fusion involves three or more vertebrae.
Ultrasound Stimulator – E0760
The IHCP covers the ultrasound stimulator for the following indications:
•
Nonunion of a fracture documented by a minimum of two sets of radiographs obtained prior to
starting treatment with the ultrasound stimulator, separated by a minimum of 90 days, each
including multiple views of the fracture site, and with a written interpretation by a physician stating
that there has been no clinically significant evidence of the fracture healing between two sets of
radiographs
•
Not concurrent use with other noninvasive osteogenic devices
This policy relates to nonunion fractures. The diagnosis of a nonunion fracture must meet the
following criteria:
•
Serial radiographs must confirm that the fracture healing has ceased for three or more months prior
to starting treatment with an osteogenic stimulator.
•
Serial radiographs must include a minimum of two sets of radiographs, each including multiple
views of the fracture site separated by a minimum of 90 days.
The IHCP excludes nonunions of the skull, vertebrae, and those that are tumor-related from coverage.
The IHCP does not cover treatment for fresh fractures and nonunion associated with osteomyelitis.
Oximetry
The following information outlines the billing parameters for oximetry:
•
PA is not required.
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•
Use procedure code 94762 – One unit of service equals one day for billing oximetry service on a
daily basis, up to and including a maximum of eight units of service per month.
•
Use HCPCS code E0445 RR – One unit of service equals one month for billing oximetry service
monthly, such as more than eight units per month. Purchase of an Oximetry System, E0445 NU, is
appropriate for an expected long-term need where the cost to purchase the system is less than the
expected monthly rental charges.
Oxygen and Home Oxygen Equipment
Oxygen and oxygen equipment reimbursement includes the system for furnishing oxygen, the vessels
that store the oxygen, the tubing and administration sets that allow the safe delivery of the oxygen, and
the oxygen contents. The oxygen and oxygen equipment classification does not fall under capped
rental guidelines. Medical necessity is the determining criteria.
Only rented oxygen systems, HCPCS codes E0424, E0431, E0434, E0439, E1390, E1405, and E1406,
are reimbursable.
The IHCP includes oxygen contents HCPCS codes E0441 through E0444 in the rental allowance and
reimburses them separately only when the IHCP, or another third-party payer, has purchased an
oxygen system and rented or purchased only a portable oxygen system.
The IHCP also includes accessories, including but not limited to cannulas, masks, and tubing, HCPCS
codes A4615, A4616, A4619, A4620, A7525, and A7526, in the allowance for rented systems; and
does not allow separate billing of these unless they are used with a purchased oxygen system.
For all oxygen codes, one unit equals one month. Providers must indicate one month of service by
including a 1 in the Units of Service field on the CMS-1500 or 837 transaction.
Spare tanks of oxygen or emergency oxygen inhalators will be denied as medically unnecessary,
because they are considered precautionary and not therapeutic in nature.
The facility, pharmacy, or other provider cannot bill the IHCP for oxygen, oxygen equipment, and
supplies for oxygen delivery for the usual care and treatment of members in LTC facilities. The IHCP
reimburses for these in the facility per diem rate. The IHCP requires PA for nonstandard equipment
and associated repair costs. Providers can bill separately for these. Facilities cannot require members to
purchase or rent such equipment with the member’s personal funds.
Prior Authorization Requirements
The IHCP requires PA for all oxygen and associated equipment and supplies, including concentrators
and portable oxygen equipment, for members receiving oxygen services in a home setting. The
ordering physician must complete, sign, and date a CMN and submit it with the PA request for
members receiving service at home. The IHCP accepts the same CMN for oxygen currently accepted
by Medicare. Providers must keep the CMN or CMS 484.2 on file. Providers should use this form for
initial PA, subsequent PA extensions, and changes in the prescriptions. The IHCP does not require a
separate order because the order information is incorporated in the CMN. Providers should photocopy
CMN forms because the contractor does not supply this form as a routine item.
Note: For RBMC members, contact the appropriate MCE for PA.
The IHCP requires PA renewals at least annually. Providers should submit a new PA and CMN
whenever there is a change in the oxygen prescription, such as an increase or decrease in oxygen flow
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rate or different equipment ordered, or if there is a change in the attending physician. In addition, the
IHCP may require subsequent extensions in individual cases.
The IHCP uses Medicare’s coverage criteria and medical policy to determine medical necessity for
prior approval. The following coverage and payment rules apply to oxygen therapy when supplied for
members in the home setting. The IHCP requires recertification three months after initial certification
for inpatients in the following cases:
•
For inpatient members whose arterial PO2 (oxygen partial pressure) was 56 mm Hg or greater or
whose oxygen saturation was 89% or greater on the initial certification.
•
For inpatient members whose physician’s initial estimate of length of need for oxygen was one to
three months.
•
If the first situation applies, repeat testing must be performed between the 61st and the 90th days of
home oxygen therapy.
For members for whom the IHCP does not require recertification at three months, the IHCP requires
recertification at 12 months after the initial certification.
The IHCP requires initial certification and three-month recertification when the initial PO2 is 56mm
Hg or greater or oxygen saturation is 89% or greater. Documentation must include the results of a
recently performed arterial blood gas (ABG) or oximetry test. The IHCP does not require retesting for
recertification at 12 months, but providers must include on the form the results of the most recent ABG
or oximetry test representing the patient’s chronic stable state. The form must specify whether tests
were performed while on room air or on oxygen and specify the amount. The form must specify
whether the patient was at rest, sleeping, or exercising when the test was performed.
Coverage and Payment Rules
The IHCP covers home oxygen therapy only for patients with significant hypoxemia in the chronic
stable state, provided the following are met:
•
The attending physician has determined that the patient has a severe lung disease or hypoxia-related
symptoms that might be expected to improve with oxygen.
•
The patient’s blood gas levels indicate the need for oxygen therapy.
•
The physician has tried or considered alternative treatment measures and has deemed them
clinically ineffective.
Note: The IHCP accepts transcutaneous oximetry in lieu of arterial or capillary
blood gases for oxygen monitoring. A physician or provider other than a
DME supplier, certified to conduct such tests, must conduct the measurement
of these tests. The IHCP does not extend this prohibition to tests conducted
by a hospital that may also be furnishing home oxygen therapy to the patient
directly or through an associated organization.
The patient needs to meet the criteria in one of the following categories to receive approval of home
oxygen therapy:
Group I Criteria – The patient meets the criteria with any of the following:
•
An arterial PO2 at or below 55mm Hg or an arterial oxygen saturation at or below 88%, taken at
rest.
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• The IHCP provides coverage only for nocturnal use of oxygen in the following cases:
- The patient demonstrates an arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation
at or below 88% taken during sleep, and the patient demonstrates an arterial PO 2 at or above
56mm Hg or an arterial oxygen saturation at or above 89% while awake.
- The patient demonstrates a greater than normal fall in oxygen level during sleep, a decrease in
arterial PO2 more than 10mm Hg, or a decrease in arterial oxygen saturation of more than 5%,
associated with symptoms or signs reasonably attributable to hypoxemia, such as cor pulmonale,
P pulmonale on EKG, documented pulmonary hypertension, and erythrocytosis.
•
The IHCP provides coverage only during exercise if the patient demonstrates an arterial PO 2 at or
below 55mm Hg or an arterial oxygen saturation at or below 88% (taken during exercise) and an
arterial PO2 at or above 56mm Hg or an arterial oxygen saturation at or above 89% (taken during
the day while at rest). In this case, the IHCP provides supplemental oxygen during exercise if it is
documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise
when the patient was breathing room air.
Group II Criteria – The patient meets the criteria when the patient demonstrates an arterial PO 2 of 56
to 59mm Hg or an arterial blood oxygen saturation of 89% and any of the following:
•
Dependent edema suggesting congestive heart failure
•
Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery
pressure, gated blood pool scan, echocardiogram, or P pulmonale on EKG, P wave greater than
3mm in standard leads II, III, or AVF
•
Erythrocythemia with a hematocrit greater than 56%
Group III Criteria – The IHCP requires additional documentation to substantiate use of oxygen when
the patient demonstrates an arterial PO2 level at or above 60mm Hg or arterial blood oxygen saturation
at or above 90%. Providers should ensure that additional documentation appears on the PA form or an
attached form, indicating the type, frequency, and severity of incidents or episodes. Examples include,
but are not limited to, the following:
•
Apnea conditions
•
Bronchopulmonary dysplasia
•
Cerebral Palsy
•
Cyanotic congenital heart disease
•
Episodic attacks of acute and severe asthma
•
Intermittent cyanosis or dyspnea documented by clinical observation
•
Intermittent upper airway obstruction
•
Neuromuscular disorders extensive enough to affect pharyngeal and chest muscles and that
clinically interfere with normal breathing
•
Severe recurrent attacks of epilepsy
•
Significant intellectual disability with repetitive episodes of respiratory difficulties
•
Tracheal laryngeal malacia
The IHCP may give PA to patients who fall into Group III for three, six, or 12 months, depending on
the medical necessity demonstrated in the documentation provided. If not waived, the IHCP
determines whether to require retesting using ABG or transcutaneous oximetry readings when and if
authorization is granted. Providers must include such results, or the results of the latest ABG or
oximetry readings, on the CMN form when submitted with the new PA request.
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Oxygen – Portable Systems
The IHCP covers a portable oxygen system if the patient is mobile within the home.
The IHCP does not reimburse for spare tanks of oxygen or emergency oxygen inhalators as medically
unnecessary because they are precautionary and not therapeutic in nature.
The IHCP does not cover respiratory therapists’ services under the DME benefit.
Nebulizer with Compressor
The following information outlines the billing parameters for a nebulizer with compressor:
•
PA not required, unless a new rental purchase
•
Units:
- For purchase, one unit equals one nebulizer
- For rental, one unit equals one month
Table 8.79 lists billing codes and parameters for nebulizers with compressors.
Table 8.79 – Billing Codes and Parameters – Nebulizer with Compressor
Procedure Code
Modifier
Description
E0570
NU
Purchase
E0570
RR
Rental
Phototherapy (Bilirubin Light)
The following information outlines the billing parameters for phototherapy:
•
PA is not required.
•
One unit of service equals one day. This service is limited to 15 units per lifetime of the member.
Table 8.80 lists the billing code and parameter for phototherapy.
Table 8.80 – Billing Code and Parameter – Phototherapy
Procedure Code
E0202
Modifier
RR
Description
Rental
Pneumograms
Providers should bill pneumograms using CPT code 94772 – Circadian respiratory pattern recording
(pediatric pneumogram), 12-24 hour continuous recording, infant. The IHCP does not require prior
authorization for pneumograms. The IHCP considers one pneumogram, with any number of channels,
to be one unit. The IHCP does not separately reimburse for oximetry during a pneumogram because it
is included in the pneumogram reimbursement. CPT code 94772 includes technical and professional
components of service. Providers should use modifier TC when billing only the technical component,
or modifier 26 when billing only the professional component. Table 8.81 lists billing codes and
parameters for pneumograms.
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Table 8.81 – Billing Codes and Parameters – Pneumograms
Procedure Code/Modifier
Description
94772
Circadian respiratory pattern recording (pediatric
pneumogram), 12-24 hour continuous recording, infant
94772 TC
Technical component only
94772 26
Professional component only
Prosthetic Devices
The IHCP reimburses for prosthetic devices under the following conditions:
•
A physician, optometrist, or dentist must order all prosthetic devices in writing.
•
When the basic prosthesis is approved, all customizing features are exempt from PA. Glasses do
not require PA.
•
The IHCP does not cover prosthetic devices dispensed for purely cosmetic reasons, such as contact
lenses, hairpieces, or makeup.
ThAIRapy Vest™
The IHCP covers the ThAIRapy Vest™ device for use only for cystic fibrosis. The ThAIRapy Vest™
is a mechanical device that uses a vest and a generator to assist in loosening bronchial secretions and
clearing the airway. All requests for this DME device require PA with an appropriate clinical summary
and physician prescription. The vest and generator components of the ThAIRapy Vest™ are only
authorized as a purchase. The IHCP requires rental of the generator and hoses for the ThAIRapy Vest
for three months prior to purchase of these components.
Trend Event Monitoring and Apnea Monitors
The IHCP covers trend event monitoring with an apnea monitor that has recording features. HCPCS
code E0619 is billed for the actual monitor. Providers must use the appropriate CPT code for
monitoring, recording, transmission, and interpretation to bill for these services. Table 8.82 shows
current coding options.
Providers should use HCPCS code E0618 when a member requires an apnea monitor without a
recording feature.
Table 8.82 – Coding for Trend Event Monitoring and Apnea Monitors
Procedure Code
Description
E0618 RR (Rental)
Apnea monitor, without recording feature
E0618 NU (Purchase)
Apnea monitor, without recording feature
E0619 RR (Rental)
Apnea monitor, with recording features
E0619 NU (Purchase)
Apnea monitor, with recording features
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Procedure Code
Description
93268
External patient and, when performed, auto activated electrocardiographic rhythm
derived event recording with symptom-related memory loop with remote download
capability up to 30 days, 24-hour attended monitoring; includes transmission,
review and interpretation by a physician or other qualified health care professional
93270
capability up to 30 days, 24-hour attended monitoring; recording (includes
connection, recording, and disconnection)
93271
capability up to 30 days, 24-hour attended monitoring; transmission and analysis
93272
capability up to 30 days, 24-hour attended monitoring; review and interpretation by
a physician or other qualified health care professional
Ventricular Assist Devices
The IHCP considers ventricular assist devices (VADs) medically necessary under the following
conditions.
The IHCP covers treatment of postcardiotomy cardiogenic shock when ventricular dysfunction
continues after maximum medical therapy or as a means of myocardial recovery support for
individuals who are unable to be weaned from cardiopulmonary bypass with maximal inotropic
support and use of an intra-aortic balloon pump.
The IHCP covers bridge-to-transplant for members who meet the following criteria:
•
The member must be at risk of imminent death from nonreversible left ventricular failure (New
York Heart Association [NYHA] Class III or IV).
•
The member has received prior authorization for a heart transplant (excluding dual eligible
members).
•
The member is listed as a candidate for heart transplantation by a Medicare- and/or Medicaidapproved heart transplant center.
•
If the VAD is implanted at a different site than the Medicare- and/or Medicaid-approved transplant
center, the implanting site must receive written permission from the Medicare- and/or Medicaidapproved center where the patient is listed for transplant prior to implantation of the VAD.
The IHCP covers destination therapy for members who meet the following criteria:
•
The member must not be a candidate for a heart transplant.
•
The member must have chronic end-stage heart failure (NYHA Class IV) for at least 90 days, and
have a life expectancy of less than two years.
•
The member’s Class IV heart failure symptoms must have failed to respond to optimal medical
therapy for at least 60 of the last 90 days. Medical therapy must include salt restriction, diuretics,
digitalis, beta-blockers, and angiotensin receptor blockers (ARBs) or angiotensin-converting
enzyme (ACE) inhibitors (if tolerated).
•
Left Ventricular Ejection Fraction (LVEF) must be less than 25%.
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•
The member has demonstrated functional limitation with a peak oxygen consumption of less than
12ml/kg/min; or continued need for IV inotropic therapy due to symptomatic hypotension,
decreasing renal function, or worsening pulmonary congestion.
•
The member has the appropriate body size (greater than or equal to 1.5m2) to support the Left
Ventricular Assist Device (LVAD) implantation.
•
VAD implantation must occur at a Medicare- or Medicaid-approved heart transplant center.
A VAD is a covered service for postcardiotomy cardiogenic shock or bridge-to-transplant only if it has
received approval from the FDA for the intended purpose, and only if it is used according to the FDAapproved labeling instructions for that intended purpose. A VAD is a covered service for destination
therapy only if it has received approval from the FDA for destination therapy or as a bridge-totransplant, or has been implanted as part of an FDA investigational device exemption trial for one of
these two indications.
Noncovered Services
•
VADs are noncovered for all conditions not listed above.
•
Use of a non-FDA approved VAD is considered investigational and a noncovered service.
•
The artificial heart (for example, AbioCor, CardioWest) as a replacement heart for a diseased heart
is noncovered by the IHCP.
Prior Authorization
VADs and their surgical implantation do not require PA. However, members who receive bridge-totransplant or destination therapy, and who can continue therapy on an outpatient basis, require
accessory equipment for use with the VAD. The patient supplies and replacement equipment for the
VAD require PA.
Stationary Power Base and Display Module
The power base is the electrical supply unit for the VAD. It provides tethered functioning of the VAD
by powering the VAD and simultaneously recharging the batteries. The display module provides pump
functioning information for the physician to evaluate patient status.
The hospital or DME provider purchases the power base as a capital expense and loans it to the
member. The hospital or DME provider is reimbursed a rental payment while the equipment is used on
an outpatient basis by the member.
The physician must submit a PA request for HCPCS code L9900 – Orthotic and prosthetic supply,
accessory, and/or service component of another HCPCS L code and modifier RR – Rental use.
Patient Supplies and Replacement Equipment
PA is required for patient supplies and replacement equipment.
Patient supplies and replacement equipment include the system controller, rechargeable batteries,
travel case, shower kit, and other miscellaneous supplies. The hospital or DME provider must supply
the replacement parts.
IHCP-covered services for implantation of VADs for postcardiotomy cardiogenic shock, bridge-totransplant, and destination therapy are subject to postpayment review. Providers must maintain
documentation in the member’s medical record that indicates that all criteria listed previously have
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been met for implantation of a VAD. If all the criteria for implantation are not satisfied, reimbursement
of funds may be recouped, including surgical fees, professional fees, and equipment costs.
Billing Instructions for Outpatient Equipment Utilizing the CMS-1500 Claim Form
1. PA must be obtained for VAD accessory equipment for outpatient therapy.
2. The description of the power unit and display module should be entered on a detail line with HCPCS
code L9900, placed in locator 24d of the CMS-1500 claim form. The total rental price may not
exceed the purchase price.
3. The description of the replacement supplies should be placed on a second detail line with the
appropriate HCPCS code in locator 24d of the CMS-1500 claim form.
4. An invoice for each detail must accompany the CMS-1500 claim form when submitted.
Wheelchairs – Motorized
Providers should determine which of the codes is the most appropriate to use, based on the Wheelchair
Product Classification List published by Medicare’s Statistical Analysis Durable Medical Equipment
Regional Carrier (SADMERC). This listing itemizes the manufacturers and specific power wheelchair
models and details the exact HCPCS code associated with each product and model type.
Providers cannot bill separately for programmable electronic systems, which come standard on the
specific motorized or power wheelchair model provided as the total reimbursement for the motorized
or power wheelchair with programmable electronics is an all-inclusive rate. The IHCP allows separate
reimbursement only for programmable electronic system upgrades, determined to be medically
necessary for the patient, made on motorized/power wheelchair bases. Any such upgrades must have
PA, and providers must bill the service under HCPCS code K0108 with a KA modifier. Providers must
bill the wheelchair base with HCPCS code K0014 (covered only for certain programs). For claims
submission, providers must attach a cost invoice and retail price invoice to document the cost or price
of the wheelchair base and the upgraded electronic system. The IHCP allows separate reimbursement
only if an electronic system is an upgrade to a system that comes standard on a specific wheelchair
model. Certain patients may need adaptive switch controls such as a sip and puff, or patients with
degenerative diseases whose prognosis could worsen in the future may need additional drive controls
and programming not available on the basic one-drive electronic system. In this instance, a physiatrist
must confirm the medical necessity to support the need of the programmable electronic system upgrade
and the physician must document it in the patient record, as well as on a completed IHCP medical
clearance form for motorized/power wheelchairs. Documentation requirements for motorized or power
wheelchairs are described in more detail in Chapter 6: Prior Authorization of this manual.
The IHCP covers motorized wheelchairs only when the member is enrolled in a school, sheltered
workshop, or work setting, or if the member is left alone for a significant period of time. Providers
must document the member can safely operate the vehicle and that the member does not have the
upper extremity function necessary to operate a manual wheelchair.
A physical medicine and rehabilitation practitioner (physiatrist) must complete a medical clearance
form for the IHCP to consider requests for power wheelchairs or similar motorized equipment for
approval. A physiatrist must review the medical necessity documentation and sign the medical
clearance forms. The IHCP does not require that the member initially be seen by the physiatrist, but
only that the physiatrist reviews the documentation supporting the request for a motorized or power
wheelchair. However, a physiatrist must review the medical necessity form, and approve and sign the
medical clearance form prior to submitting the form to the appropriate MCE or CMO PA Department.
The IHCP requires a member to see the physiatrist only if the physiatrist requests to see the member
after a review of the documentation. Additionally, the IHCP does not require that the physiatrist be
located within a certain distance of the physician or the member. If the physiatrist requests to see the
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member after reviewing the documentation, the member is then required to travel to visit the
physiatrist.
Wheelchairs – Nonmotorized
The IHCP covers purchase of a nonmotorized wheelchair or motorized wheelchair subject to prior
authorization review. Requests for nonmotorized wheelchairs or similar motorized vehicles require that
the provider submits a medical clearance with the PA request before the IHCP reviews the request.
The IHCP includes standard nonmotorized wheelchairs in the per diem rate, for LTC facilities, per 405
IAC 5-13-3-4 and 405 IAC 5-13-3-7. Requests should be submitted to the appropriate MCE for
approval only if there is a medical necessity for the custom wheelchair. For example, if the member’s
diagnosis requires sitting in a particular upright position due to a breathing difficulty, the member may
need a customized wheelchair. Providers must follow the normal PA process using IHCP PA and
medical clearance forms. LTC members receive 24-hour care in a nursing facility. This care includes
safety, propulsion, evaluation of the member for skin breakdown, and an active plan of care to prevent
and treat decubitus ulcers. Therefore, providers should not request custom wheelchairs for the sole
purpose of providing safety, preventing decubitus ulcers, allowing self-propulsion, or providing
restraint.
Wheelchair – Power Seating
The IHCP has determined HCPCS codes E1002, E1003, E1004, E1005, E1006, E1007, and E1008 for
power seating systems; E1010 for power-elevating leg rests; and E2310 and E2311 for electric
connectors to be medically necessary items. The IHCP covers these HCPCS codes as inexpensive and
routinely purchased items for rental or purchase with prior authorization.
Wheelchair – Seat Cushions
The IHCP covers codes E2601 – E2609 and E2622 – E2625 for adjustable seat cushions.
Adjustable cushions are purchase-only items. Providers must attach the NU modifier when billing
adjustable seat cushions. The adjustable cushions do not have to be listed on the SADMERC
classification list to be reimbursed by the IHCP.
Wheelchair Accessories
Providers must use HCPCS code E1028 – Wheelchair accessory, manual swingaway, retractable or
removable mounting hardware for joystick, other control interface or positioning accessory, for PA and
billing. The IHCP denies requests for approval of the universal headrest plate using HCPCS code
E1399 – Durable medical equipment, miscellaneous for appropriate coding. Providers should submit
their usual and customary charge using HCPCS code E1028.
Reimbursement of the universal headrest plates are subject to the following PA criteria:
•
The IHCP covers universal headrest plates when the initial headrest ordered for a new wheelchair
does not meet the member’s needs upon the first or subsequent fittings. On the PA request, the
provider must document the brand name and model of the original headrest, and include an
explanation of why the headrest did not meet the member’s needs. In addition, the provider must
indicate the brand name and model of the subsequent headrest that will be used on the wheelchair.
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•
The IHCP covers universal headrest plates for a used wheelchair if the member’s condition
changes, and the wheelchair back is not predrilled for the headrest. The provider must provide
documentation of the medical necessity for the headrest.
•
The IHCP covers replacement universal headrest plates with documentation of an explanation for
the replacement (for example, the plate is damaged due to high tone or spasticity of the patient).
The IHCP does not cover universal headrest plates for the initial headrest ordered for use on a new
wheelchair. The wheelchair back should be predrilled to accommodate the headrest initially ordered
with the wheelchair.
Documentation Required for Medical Supplies and Equipment
All medical supplies and equipment require a written order by a physician, optometrist, or dentist.
According to 405 IAC 5-19-1(i), “Medical supplies shall be for a specific medical purpose, not
incidental or general purpose usage.” Verbal orders, communicated by the prescriber to the supplier,
are permitted when appropriately documented; however, verbal orders must be followed up with
written orders. Suppliers must maintain the written physician’s order to support medical necessity
during postpayment review. Per 405 IAC 5-25-3(a), a physician’s written order and plan of treatment
are required as follows: “All Medicaid covered services other than transportation and those services
provided by chiropractors, dentists, optometrists, podiatrists, and psychologists certified for private
practice require a physician’s written order or prescription.”
The IHCP has identified instances when medical supplies were dispensed in excess of medically
reasonable and necessary amounts. This information serves to clarify the IHCP standards for
prescribing and dispensing medical supplies, including but not limited to items such as surgical
dressings, catheters, and ostomy bags. This information does not eliminate any other IHCP
requirements for DME and medical supplies at the time services are rendered.
Prescribers of DME, HME, and Medical Supplies
Physicians must be aware their signature on an order for DME, HME, and medical supplies
authorizes those items to be dispensed to the patient. When writing an order for such items, the
physician must consider the following questions:
•
Are specific instructions, such as frequency of use, directions for use, duration of need, and so
forth, listed on the order?
•
Is the quantity authorized by the physician medically reasonable and necessary for the patient’s
medical condition?
The prescriber is also responsible for maintaining documentation in the member’s medical record that
supports the medical necessity of specific DME, HME, and medical supplies prescribed. To ensure that
the appropriate quantity and type of item are dispensed, it is especially important that the written order
be detailed. Providing a detailed written order does not eliminate the need for other IHCP requirements
in effect at the time services are rendered. The written order for DME, HME, and medical supplies
should include, at a minimum, the following information, when applicable:
•
Patient’s name
•
Date ordered
•
Physician’s signature
•
Area of body for use (for items that may be appropriate for multiple sites)
•
Type and size of the product
•
Quantity intended for use
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•
Frequency of use (for example, change dressing three times per day)
•
Anticipated duration of need
•
Indication of refill authorization and the number of refills
- As needed or PRN (when necessary), refill authorization must be medically necessary and
reasonable.
- The need for long-term use must be documented in the patient’s medical record.
Note: Orders and physician signatures may be verified retrospectively by the
OMPP or the designated contractor.
Suppliers of DME, HME, and Medical Supplies
Suppliers of DME, HME, and medical supplies must maintain the prescriber’s written order in
the member’s medical record.
Suppliers are responsible for ensuring the written order contains the necessary information to complete
the order. If the physician’s order lacks information necessary to accurately dispense the appropriate,
specific DME, HME, and medical supplies, including type or quantity, the supplier must contact the
physician’s office for written clarification. Suppliers must maintain the written physician’s order to
support medical necessity during postpayment review.
Note: The IHCP requires that Medicaid providers maintain medical records for a
period of seven years, per 405 IAC 1-5-1(b). Services may be subject to
recoupment if the physician orders are modified after the service is rendered
or if orders are obtained after the provision of service.
Emergency Department Physicians
The IHCP provides coverage to emergency department physicians who render emergency services to
IHCP eligible members. This section provides additional information about billing procedures for
emergency department physicians.
IC 12-15-15-2.5 addresses reimbursement of emergency department physicians. In accordance with
this, Care Select members no longer require PMP authorization for federally required medical
screening examinations performed by a physician in the emergency department of a hospital.
Table 8.83 lists the CPT codes, which reflect the appropriate level of screening exam that providers
must bill on a CMS-1500 or 837P transaction.
Table 8.83 – CPT Codes – Appropriate Level of Screening Exam
CPT Codes
99281
Definitions
Emergency department visit for the evaluation and management of a
patient, which requires these 3 key components: A problem focused
history; A problem focused examination; and Straightforward medical
decision making. Counseling and/or coordination of care with other
physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's
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Table 8.83 – CPT Codes – Appropriate Level of Screening Exam
CPT Codes
Definitions
and/or family's needs. Usually, the presenting problem(s) are self
limited or minor.
99282
patient, which requires these 3 key components: An expanded problem
focused history; An expanded problem focused examination; and
Medical decision making of low complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of low to moderate severity.
99283
patient, which requires these 3 key components: An expanded problem
focused history; An expanded problem focused examination; and
Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified health care
professionals, or agencies are provided consistent with the nature of the
problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of moderate severity.
For related services provided to Care Select members such as facility charge, lab, and X-ray that do
not have an emergency diagnosis and emergency indicator on the claim, the IHCP may suspend the
claim for review to determine whether the prudent layperson standard has been met. If the IHCP
review determines that the prudent layperson standard has not been met, the IHCP will deny the claim.
Note: For members enrolled in the RBMC delivery system, providers must contact
the member’s MCE for more specific guidelines.
Evaluation and Management Services
Per 405 IAC 5-9-1 the IHCP offers reimbursement for office visits limited to a maximum of 30 per
calendar year, per IHCP member, without PA, and subject to the restrictions in 405 IAC 5-9-2. The
Evaluation and Management (E/M) services CPT codes listed in Table 8.84 are subject to the
limitations.
Table 8.84 – Evaluation and Management Services Codes Subject to Limitation
CPT Code
Description
99201-99205
Office or other outpatient visit for the evaluation and management of a
new patient
99211-99215
Office or other outpatient visit for the evaluation and management of
an established patient
99241-99245
Office consultation for a new or established patient
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CPT Code
Description
99381-99387
Initial comprehensive preventive medicine – New patient
99391-99397
Initial comprehensive preventive medicine – Established patient
Per 405 IAC 5-9-2(a), office visits should be appropriate to the diagnosis and treatment given and
properly coded.
Providers must submit professional services rendered during the course of a hospital confinement on
the CMS-1500 or 837P transaction. The IHCP reimburses in accordance with the appropriate
professional fee schedule. The inpatient diagnosis-related group (DRG) reimbursement methodology
does not provide payment for physician fees, including hospital-based physician fees.
New patient office visits are limited to one visit per member, per provider within a three-year period.
For purposes of this subsection, new patient means one patient who has not received any professional
services from the provider or another provider of the same specialty that belongs to the same group
practice.
If a physician uses an emergency department as a substitute for the physician’s office for
nonemergency services, providers should bill these visits with a CPT code usually used for a visit in
the office with the site of service indicated. The IHCP will apply a site of service reduction in the
reimbursement.
If a provider performs a surgical procedure during the course of an office visit, the IHCP generally
considers the surgical fee includes the office visit. However, the provider may report the visit
separately for the following reasons:
•
The provider has never seen the member prior to the surgical procedure.
•
The provider determines whether to perform surgery during the evaluation of the patient.
•
The patient is seen for evaluation of a separate clinical condition.
Providers must use the following modifiers with the E/M visit code to identify these exceptional
services. Use modifier 25 to show that there was a significant, separately identifiable E/M service by
the same physician on the same day of a procedure. Use modifier 57 to show that an E/M service
resulted in the initial decision to perform surgery. The medical record must include appropriate
documentation to substantiate the need for an office visit code in addition to the procedure code on the
same date of service.
Consultations
The IHCP reimburses for the following two categories of consultation:
•
Office or other outpatient consultation
•
Inpatient consultation
Office Consultation
A consultation is a type of service provided by a physician whose opinion or advice about evaluation
and management of a specific problem is requested by another physician or other appropriate
source. A physician consultant may initiate diagnostic or therapeutic services. Providers should not
use consultation codes for the evaluation of a self-referred or nonphysician-referred patient, because a
consultation implies collaboration between the requesting and the consulting physician. Providers
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should use consultation codes 99241– 99245. Providers should use office visit codes for established
patients, 99211–99215, to report follow-up visits in the consultant’s office or other outpatient facility
initiated by the physician consultant. When the attending physician receives an additional request for
an opinion or advice about a new problem and documents it in the medical record, the provider may
use the office consultation codes again.
When the provider is billing consultation codes, the medical record must contain written
documentation of the request for consultation by the requesting physician. The provider should
maintain this documentation in the patient’s medical record at the requesting and receiving physician’s
office. When a provider performs a consultation, the consulting physician customarily responds in
writing to the requesting physician about the opinion or advice of the consulting physician.
Inpatient Consultation
The IHCP recognizes CPT codes 99251–99255 for inpatient consultations with new or established
patients in the inpatient hospital setting. Consultants may report only one consultation per admission.
Providers must document the request for consultation. Subsequent services are reported using
Subsequent Hospital Care Codes 99231–99233.
Hospital Observation or Inpatient Care Services
The IHCP recognizes CPT codes 99234–99236 for observation or inpatient hospital care services
provided to patients admitted and discharged on the same date of service. When a patient is admitted to
the hospital from observation status on the same date, the physician should report only the initial
hospital care code. The initial hospital care code includes all services related to the observation status
services the physician provided on the same date of an inpatient admission. The IHCP recognizes CPT
codes 99217, 99218–99220 or 99221–99223, and 99238–99239 for patients admitted for observation
or inpatient care and discharged on a different date.
Hospital Discharge Services
Providers should report hospital discharge day management by using CPT codes 99238 or 99239,
depending on the amount of time spent discharging the patient. Providers should document this amount
of time in the medical record to substantiate the code being billed. For a patient admitted and
discharged from observation or inpatient status on the same date, report the service using CPT codes
99234–99236. Providers should report separately for hospital discharge services, using CPT codes
99238 and 99239, performed on the same day as a NF admission by the same provider.
The IHCP recognizes CPT codes 99291–99292 for reporting critical care services performed by a
physician. The IHCP has adopted the guidelines set forth in the CPT manual, and providers can find a
complete definition of critical care services in the current version of the CPT manual.
Table 8.85 lists the CPT codes to be used when billing consultation services and hospital care services.
Table 8.85 – Consultation and Hospital Care Service CPT Codes Subject to Limitations
Office Consultations
CPT Codes
99241-99245
Description
Office consultation for a new or established patient
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Office Consultations
CPT Codes
99211–99215
Description
Office or other outpatient visit for the evaluation and management
of an established patient (follow-up)
Inpatient Consultations
CPT Codes
Description
99251–99255
Inpatient consultation for a new or established patient
99231–99233
Subsequent hospital care, per day, for evaluation and management
of a patient
Hospital Observation or Inpatient Care Services
CPT Codes
Description
99234–99236
Observation or inpatient hospital care for evaluation and
management of a patient including admission and discharge on the
same date
99217
Observation care discharge day management
(This code is to be utilized to report all services provided to a patient
on discharge from "observation status" if the discharge is on other
than the initial date of "observation status." To report services to a
patient designated as "observation status" or "inpatient status" and
discharged on the same date, use the codes for Observation or
Inpatient Care Services [including Admission and Discharge
Services, 99234-99236 as appropriate.])
99218–99220
Initial observation care, per day, for evaluation and management of
a patient
(This code can be used for patients admitted for observation or
inpatient care and discharged on a different date.)
99221–99223
Initial hospital care, per day, for the evaluation and management of
a patient
Hospital Discharge Services
CPT Codes
99238–99239
Description
Hospital discharge day management
CPT Codes
99291–99292
Description
Critical care, evaluation and management of the critically ill or
critically injured patient
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Family Planning
Family planning coverage is for services provided to individuals of childbearing age to temporarily or
permanently prevent or delay pregnancy. Family planning services include the following:
•
Diagnosis and treatment of sexually transmitted diseases (STDs), if medically indicated
•
Follow-up care for complications associated with contraceptive methods issued by the family
planning provider
•
Health education and counseling necessary to make informed choices and understand
contraceptive methods
•
Laboratory tests, if medically indicated as part of the decision-making process for choice of
contraceptive methods
•
Limited history and physical examination
•
Pregnancy testing and counseling
•
Provision of contraceptive pills, devices, and supplies
•
Screening, testing, and counseling of members at risk for HIV and referral and treatment
•
Tubal ligation or hysteroscopic sterilization with an implant device
•
Vasectomy
Note: Family planning services are not covered under Package P – Presumptive
Eligibility. See the Qualified Provider Presumptive Eligibility Manual,
located on the Manuals page of indianamedicaid.com, for more information.
Family planning services can include Pap smears if performed according to the United States
Preventative Services Task Force Guidelines. The guidelines specify cervical cancer screening every
one to three years; however, Pap smear annual frequency may be reduced if three or more annual
smears are normal.
Based on the CMS’ policies, the IHCP considers initial STD diagnosis and treatment, HIV testing, and
counseling provided during a family planning encounter to be part of the family planning services.
Ongoing follow-up of STDs and visits for treatment of chronic STDs are not considered to be a part of
family planning services. Family planning services are self-referred in each of the managed care
programs, but they require appropriate HCPCS or CPT codes and ICD-9-CM diagnosis combinations
for CMS-1500 or 837P billing.
Table 8.86 provides family planning ICD-9-CM codes.
Table 8.86 – Diagnosis Codes – Family Planning ICD-9-CM
Diagnosis Codes
Definition
V2501
Prescription of oral contraceptives
V2502
Initiation of other contraceptive measures
V2503
Encounter for emergency contraceptive counseling
and prescription
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Diagnosis Codes
Definition
V2504
Counseling and instruction in natural family
planning to avoid pregnancy
V2509
Other – Family Planning Advice
V2511
Encounter for insertion of intrauterine contraceptive
device
V2512
Encounter for removal of intrauterine contraceptive
device
V2513
Encounter for removal and reinsertion of intrauterine
contraceptive device
V252
Sterilization
V253
Menstrual extraction
V2540
Contraceptive surveillance, unspecified
V2541
Contraceptive pill
V2542
Intrauterine contraceptive device (IUD)
V2543
Implantable subdermal contraceptive
V2549
Other contraceptive method
V255
Insertion of implantable subdermal contraceptive
V258
Other specified contraceptive management
V259
Contraceptive management, unspecified
Service and Supplies
Providers must bill services and supplies not classified as drugs or biologicals using the CMS-1500 or
837P with the appropriate CPT or HCPCS codes and appropriate ICD-9-CM diagnosis codes for
services rendered or condition treated. For example, use ICD-9-CM diagnosis codes V25.01 through
V25.9 for contraceptive management, and use ICD-9-CM diagnosis code 099.53 for acute chlamydial
vaginitis.
Providers must ensure the member’s chart contains the date of the office visit, the NDC code, and
name of the product dispensed, as well as the amount of the item dispensed, such as four boxes of 30
items. The IHCP no longer covers the Norplant System; however, reimbursement is available for
removal of the Norplant Systems. Providers removing Norplant Systems must bill using CPT code
11976.
Table 8.87 – CPT Codes for Contraception Implants
CPT Code
Description
11981
Insertion, non-biodegradable drug delivery implant
11982
Removal, non-biodegradable drug delivery implant
11983
Removal with insertion, non-biodegradable drug delivery
implant
The IHCP covers HCPCS codes J7303 – Contraceptive supply, hormone containing vaginal ring, each,
and J7304 – Contraceptive supply, hormone containing patch, each. Providers must bill J7303 and
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J7304 instead of a miscellaneous supply code as these codes are more specific to the service being
supplied.
Table 8.88 – CPT Codes for Contraceptive Supplies
CPT Code
Description
J7303
Contraceptive supply, hormone containing vaginal ring, each
J7304
Contraceptive supply, hormone containing patch, each
S4993
Contraceptive pill for birth control
Limits and Restrictions for Depo-Provera Contraceptive Injection
HCPCS code J1050 – Injection, medroxyprogesterone acetate, 1mg. This service is only covered for
female members. The allowable units per date of service (DOS) will be limited to one.
According to the U.S. FDA, Depo-Provera Contraceptive Injection (CI) is a long-term contraceptive
for women and is indicated only for the prevention of pregnancy. The recommended dose to women is
150 mg every three months. An appropriate HCPCS code for billing medroxyprogesterone for
noncontraceptive use is J1050 – Injection, medroxyprogesterone acetate, 1mg, which may be billed for
multiple units, per member, on a single DOS.
Managed Care Program Considerations
Direct billing questions for Traditional IHCP and Care Select to Customer Assistance at (317) 6553240 in the Indianapolis local area or 1-800-577-1278. For Hoosier Healthwise RBMC questions,
providers should contact the MCE to which the member has been assigned.
Family Planning Services – New Eligibility Program
See Section 7: Family Planning Eligibility Program for information on the new IHCP program,
effective January 1, 2013.
Federally Qualified Health Centers and Rural Health Clinics
Federally Qualified Health Centers
FQHCs receive funds through the Public Health Service (PHS) and are designated as such. FQHC
look-alikes meet the criteria but do not receive PHS funding and have not been given FQHC status by
CMS. For information regarding this process, contact the Indiana Primary Health Care Association at
(317) 630-0845. To enroll as an FQHC, providers should forward the CMS letter, which grants the
FQHC status, to the HP Provider Enrollment Unit with the completed application. The provider must
also contact the IHCP’s rate-setting contractor, Myers and Stauffer, LC, to submit the proper financial
documents to have a rate determined for the FQHC. Myers and Stauffer, LC forwards the rate
document to the Provider Enrollment Unit so the encounter rate can be loaded into IndianaAIM. Each
time the facility expands the scope of service and receives an adjustment to its encounter rate, Myers
and Stauffer, LC must forward a new rate letter to the Provider Enrollment Unit to ensure
reimbursement remains accurate. In the Care Select network, FQHC provider specialties are not
entitled to receive the monthly administrative fee payment.
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Rural Health Clinics
RHCs receive Medicare designation through CMS. The clinics must contact the Indiana State
Department of Health (ISDH) to request RHC status for the IHCP. The IHCP requires all RHCs to
submit finalized (reviewed or audited) cost reports and copies of their Medicare rate letters to Myers
and Stauffer, LC. RHC services are defined in 42CFR 405.2411 and 42 CFR 440.20. For more
information about becoming an RHC under the IHCP, contact the ISDH, the Indiana Primary Health
Care Association at (317) 630-0845, or other practice consultants. Each time the facility expands its
scope of service and receives an adjustment to its encounter rate, Myers and Stauffer, LC must forward
the new rate letter to the Provider Enrollment Unit to ensure that reimbursement remains accurate. In
the Care Select network, RHC provider specialties are not entitled to receive the monthly
administrative fee payment.
Service Coverage
According to 405 IAC 5-16-5, IHCP reimbursement is available to RHCs and FQHCs for services
provided by the following providers:
•
Physician
•
Physician assistant
•
Nurse practitioner
•
Clinical psychologist
•
Clinical social worker
The IHCP also provides reimbursement to RHCs and FQHCs for services provided by the following
providers:
•
Dentist
•
Dental hygienist
•
Podiatrist
•
Optometrist
The IHCP also reimburses for services and supplies incidental to such services, which the IHCP would
otherwise cover if furnished by a physician or incident to a physician’s services. The IHCP covers
services to a homebound individual only in the case of those FQHCs located in an area with a shortage
of home health agencies, as determined by the OMPP. The IHCP considers any other ambulatory
service included in the Medicaid state plan to be a covered FQHC service if the FQHC offers such a
service. FQHC services are defined the same as services provided by RHCs. FQHCs and RHCs should
contact Myers and Stauffer, LC for information about cost reports and interim cost settlements.
FQHC and RHC Covered Services
In accordance with Section 702 of the Medicare, Medicaid, and State Children’s Health Insurance
Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA), the IHCP implemented
the Prospective Payment System (PPS) for reimbursing FQHC and RHC for IHCP covered services.
All FQHC and RHC facilities are required to submit claims using HCPCS Level III codes, including
code T1015 – Clinic, visit/encounter, all-inclusive, and Level I and Level II HCPCS procedure codes.
FQHCs and RHCs continue to receive a facility-specific PPS rate determined by Myers and Stauffer,
LC. Myers and Stauffer, LC forwards the specific PPS rate information to HP, and the HP Provider
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Enrollment Unit loads the rate for reimbursement of T1015 to the specific provider enrollment file for
reimbursement.
Providers must submit claims for valid FQHC and RHC encounters with a place of service of 11, 12,
31, 32, 50, or 72. Providers must use the T1015 – Clinic visit/encounter, all-inclusive code and CPT or
HCPCS codes. The claim logic compares the other CPT or HCPCS codes used to a list of valid CPT
and HCPCS codes approved by the OMPP. If the claim contains T1015 and one of the allowable
procedure codes from the encounter criteria, the CPT or HCPCS codes correctly are denied for EOB
6096 – The CPT/HCPCS code billed is not payable according to the PPS reimbursement methodology.
The encounter rate (T1015) is reimbursed according to the usual and customary charge (UCC)
established by Myers and Stauffer, LC from the provider-specific rate on the provider file. The
provider should not resubmit CPT or HCPCS codes separately that were denied for EOB 6096 – The
CPT/HCPCS code billed is not payable according to the PPS reimbursement methodology.
Providers should identify all services provided during the visit using all the appropriate CPT and
HCPCS codes. If the CPT or HCPCS codes billed do not contain one of the procedure codes included
in the list of allowable procedure codes from the encounter criteria for place of service 11, 12, 31, 32,
50, or 72, the claim is denied for EOB 4124 – The CPT/HCPCS code billed is not a valid encounter.
Providers should not resubmit claims denied for EOB 4124 – The CPT/HCPCS code billed is not a
valid encounter for payments. Additionally, claims submitted with a place of service 11, 12, 31, 32, 50,
or 72 with CPT or HCPCS codes that do not have the T1015 present on the claims are denied for EOB
4121 – T1015 must be billed with a valid CPT/HCPCS code. Providers can resubmit these claims with
the T1015 code properly included on the claim.
The IHCP allows only one encounter per IHCP member, per provider, per day, unless the diagnosis
code differs. When the IHCP determines the number of allowable encounters for that specific claim, it
multiplies that number by the facility-specific PPS rate to calculate the amount paid on the claim.
Providers can submit valid encounters with differing diagnosis codes for a member that exceed the
allowed one encounter per day to HP for manual processing.
Providers can submit claims electronically using the 837P transaction. When a provider submits claims
for valid encounters submitted using the 837P transaction, those claims must contain the T1015 and
the CPT/HCPCS codes for the services rendered.
For services provided at these place of service locations that are not valid encounters with the
appropriate provider, such as injections performed by a nurse without a corresponding visit to satisfy
the valid encounter definition, providers should instead reflect the services in the facility’s cost report
submitted to Myers and Stauffer, LC.
Hospital Services
The IHCP reimburses claims submitted with place of service 20-26 at the current reimbursement rate
for each specific CPT/HCPCS code. It is not necessary for providers to include the T1015 encounter
code on claims with place of service 20-26. The IHCP considers these services non-FQHC/RHC
services provided by the valid provider but in a setting other than an RHC/FQHC setting.
Dental Services
Providers should continue to bill dental claims for services provided at an FQHC or RHC on a dental
claim form using Current Dental Terminology (CDT) codes. Do not include the T1015 encounter code
on the dental claim form. Myers and Stauffer, LC makes settlements and reconciles dental claims to
the provider-specific PPS rate through annual reconciliations. The reconciliations continue until the
IndianaAIM system is adapted to the PPS methodology.
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Care Select
Claims submitted for Care Select members with a date of service prior to January 01, 2011, require
PMP authorization if the service provided to the member was not provided by the PMP. See the billing
information at the beginning of this section for information about submitting the paper CMS-1500
claim form. Services provided to a Care Select member with a date of service prior to January 01,
2011, such as immunizations, at a location other than the PMP’s office require the Memorandum of
Collaboration (MOC) and authorization information. If the visit does not satisfy the criteria for an
encounter with a valid provider, the claim is denied. Providers can use the denial information to track
these services and reflect them in the facilities cost report. Self-referral services provided at the FQHC
or RHC do not require PMP authorization information when appropriately billed. These must,
however, satisfy the criteria for valid encounters and include the T1015 encounter code when
submitting the claim for processing.
Third-Party Liability Considerations
All TPL, patient liability, and copayments continue to apply as appropriate. Allowable EPSDT and
pregnancy services provided during the encounter visit and appropriately billed continue to bypass
TPL. Providers need to apply previous TPL payments and spend-down to the total amount due. The
IHCP excludes all Medicare crossover claims from the PPS logic, as well as the crossover
reimbursement methodology, and continues to pay coinsurance and deductible amounts.
Risk-Based Managed Care
Providers should continue to use CPT codes to bill claims for members in RBMC. Providers must
submit the claims to the applicable managed care entity. Do not include the T1015 encounter code on
these claims. Myers and Stauffer, LC reconciles all managed care claims to the provider-specific PPS
rate and makes annual settlements at that time. Providers may submit requests for supplemental
payment to Myers and Stauffer, LC. The MCEs must also provide data related to annual
reconciliations to Myers and Stauffer, LC.
Medicare Processed Claims Submitted to the IHCP by the Provider
Providers can submit claims electronically using the 837I or the 837P transaction. Claims submitted
using the 837P transaction must contain the T1015 and the CPT codes for the services rendered. Per
the Family and Social Services Administration (FSSA) Emergency Rule LSA #02-121, all paper UB-04
claim form or electronic 837I transaction crossover claims must contain additional information on the
claim form. The rule changed how the IHCP reimburses providers for crossover claims. The IHCP
uses the information in the required fields on the paper UB-04 claim form or electronic 837I
transaction to process claims. Fields 39 through 41 on the paper UB-04 claim form must contain value
code A1 to reflect the Medicare deductible amount and value code A2 to reflect the Medicare
coinsurance amount.
To ensure correct reimbursement, the paper UB-04 claim form or the electronic 837I transaction must
show Medicare as the previous payer. Additionally, the paper UB-04 claim form or electronic 837I
transaction must contain the Medicare paid amount (actual dollars received from Medicare). Providers
should continue to report TPL payments on the paper UB-04 claim form or the electronic 837I
transaction.
Providers can use the professional format to submit claims processed by Medicare, which did not cross
over to the IHCP. These are claims allowed by Medicare that failed to cross over as well as Medicaredenied claims.
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Providers should refer to the 837 companion guides for specific information about electronic claims
transaction requirements to be used with the 837 implementation guides. For the links to the
appropriate websites and documents, go to indianamedicaid.com.
Providers that submit claims on paper when the claims do not automatically cross over from Medicare
to the IHCP must submit FQHC and RHC encounter service claims on the paper CMS-1500 claim
form. Submit the paper claims using CPT or HCPCS codes for FQHCs, provider-based RHCs, or
independent RHCs along with the T1015 for services billed. If Medicare denied the claim, providers
must attach the Medicare Remittance Notice (MRN) and make sure that the MRN is clearly marked as
a Medicare MRN. If you are submitting an electronically generated MRN, you must print it in
landscape format so that all information is properly and clearly labeled. Providers can submit claims
electronically using the 837I or 837P transaction. Claims submitted using the 837P transaction must
contain the T1015 and the CPTs for the services rendered.
Provider Enrollment Considerations
All physicians associated with the clinic must have an individual IHCP provider number (LPI).
Providers must also report their NPI number to IHCP. The provider numbers must be linked to the
FQHC or RHC. The clinic must also notify the Provider Enrollment Unit in writing when a provider is
no longer associated with the FQHC or RHC so the clinic provider profile is current. If the CMS
notifies an FQHC or RHC that the FQHC or RHC status has been terminated, the provider must also
send a copy of the termination to the ISDH, which then forwards it to the Provider Enrollment Unit.
The provider must contact HP to request an application to enroll as a medical clinic until FQHC or
RHC status is reinstated. Failure to do this will result in disenrollment as a provider and loss of any
managed care members assigned to PMPs linked to that location. Physician assistants cannot obtain an
IHCP rendering provider NPI number. Providers must use the supervising practitioner’s NPI number to
submit claims for services rendered by these practitioners.
Service Definition
The IHCP defines a visit as a face-to-face encounter between a clinic patient and a physician or other
provider. The IHCP considers multiple services a provider performs during the same visit for the same
or related diagnosis to be a single encounter, even though the provider can consider them separate
encounters if billed independently. For example, if a patient receives a dental exam and an amalgam
during the same visit, the IHCP considers it a single encounter.
The IHCP considers multiple visits, which occur within the same 24-hour period, to be a single
encounter if they are for the same diagnosis. The IHCP considers multiple visits to be multiple
encounters if the diagnosis is different. For example, if the patient has an office visit in the morning
and returns later the same day with the same or related diagnosis, the IHCP considers the two instances
as a single encounter. However, if a patient has an office visit in the morning and returns later the same
day for treatment of a fracture, two different encounters have occurred.
Providers can bill only one unit of service on a single detail line of the paper or electronic claim form.
When two valid providers see the same patient in the same day, such as a medical provider and a
mental health provider, the principal diagnoses should not be the same. Providers should break down
consecutive service dates and bill each day on a separate line. When a provider has more than one visit
per day for the same member for the same provider and the diagnoses are different, the IHCP requires
a manual review.
Therefore, providers should submit proper documentation along with the claim to substantiate the need
for additional visits. This documentation includes, but is not limited to, the following:
•
Visits performed at separate times of the day that indicate the times and the reasons for each visit
on the face of the claim or on a claim attachment
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•
Visits provided by different providers on the same day that indicate the type of provider that
rendered each visit and denote which practitioner treated which diagnosis
•
Documentation in writing from the medical record that supports the medical reasons for the
additional visit
- This documentation includes presenting symptoms or reasons for the visit, onset of symptoms,
and treatment rendered.
•
Documentation that the diagnosis for each encounter is different
The IHCP also reimburses for services and supplies incidental to such services as would otherwise be
covered if furnished by a physician or as an incident to a physician’s services. Services such as
drawing blood, collecting urine specimens, performing laboratory tests, taking X-rays, filling and
dispensing prescriptions, or providing optician services do not constitute encounters. Providers can
include these services in the encounter reimbursement when performed in conjunction with the office
visit to a valid provider. The IHCP does not reimburse for these services through claim submission if
performed without a visit with a valid provider.
FQHCs and RHCs can provide preventive services and HealthWatch services.
HealthWatch/EPSDT Services
The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program, referred to as
HealthWatch/EPSDT in Indiana, is a preventive healthcare program designed to improve the overall
health of IHCP eligible members from birth to 21 years old (subject to the limitations of each benefit
package). Special emphasis is given to early detection and treatment of health issues as these efforts
can reduce the risk of more costly treatment or hospitalizations, which can result when detection is
delayed.
Because HealthWatch/EPSDT services include more components than a simple well-child office visit,
reimbursement rates for HealthWatch/EPSDT screens are higher than the rates paid for well-child
exams. To offer HealthWatch/EPSDT services, the provider must be licensed to perform an unclothed
physical exam, as well as other screening components of the HealthWatch/EPSDT examination.
Medicaid-enrolled providers must furnish and document all components of the EPSDT visit to bill for
the higher rate of reimbursement for EPSDT screens. To review a complete list of EPSDT
requirements, see the HealthWatch/EPSDT Provider Manual for screening and referral details.
Examination Procedure and Diagnosis Codes
Providers are required to use specific examination codes, classified as initial or established, based on
the age of the member. The primary diagnosis code (V20.2) must be indicated with the diagnosis
cross-reference code of 1 in box 24 E of the medical claim form if sending on paper, or 837P
transaction if submitting electronically, for the procedure code billed. The procedure codes are shown
in Table 8.89.
Enhanced reimbursement for the initial patient exam is limited to the first HealthWatch/EPSDT screen
performed by a screening provider during the participant’s lifetime. If additional claims are received
for initial screening from the same provider, reimbursement is allowed at the resource-based relative
value scale (RBRVS) rate on file for the billed CPT code, not the higher EPSDT rate.
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Initial and established EPSDT exams are reimbursed when submitted with V20.2 as the primary
diagnosis, and are subject to the 30 office visits per year limitation without prior authorization (PA).
Claims submitted with charges other than the designated amounts for screening exams are paid at the
HealthWatch/EPSDT rate or the charged amount, whichever is lower. Examinations that do not
contain the screening components or that are not well child visits by this definition can be billed using
the appropriate CPT code for those visits.
Claims submitted using any patient exam procedure codes listed in Table 8.89 are billed in conjunction
with the V20.2 diagnosis code as the primary diagnosis code to identify that all EPSDT screening
components have been provided. For services provided to EPSDT eligible members that do not qualify
as full screening examinations, use the appropriate office visit codes for the services rendered.
Appropriate documentation of the services provided or referred must be included in the patient’s
medical records.
Specific Billing Procedures
The following billing procedures must be followed to permit correct and prompt reimbursement. Every
claim for a HealthWatch/EPSDT visit must be coded with the following:
•
The appropriate patient examination code (99381-99385, and 99391-99395) must be included on
the first detail line of the medical claim form if sending on paper or 837P transaction if submitting
electronically
•
The preventive health diagnosis code, V20.2, must be used as the primary diagnosis.
•
When patient exams are billed in conjunction with the V20.2 diagnosis code as the primary
diagnosis code, the screen components must have been provided.
•
Physicians are strongly encouraged to include all applicable diagnosis codes (up to four) and
procedure codes on the medical claim form if sending on paper, or on the 837P transaction if
submitting electronically, for each HealthWatch/EPSDT visit.
The appropriate EPSDT documentation must be kept in the patient’s record and the appropriate
Current Procedural Terminology (CPT) codes and V20.2 (for the initial or established patient exam)
must be billed. A copy of the HealthWatch manual is available on the Manuals page on
Table 8.89 – CPT Codes for EPSDT Visits
Age
Initial Patient Exam
Established Patient Exam
Less than 1 year
99381
99391
1 to 4 years
99382
99392
5 to 11 years
99383
99393
12 to 17 years
99384
99394
18 to 20 years
99385
99395
When a member presents to a provider for a sick visit, and his or her records indicate the need for an
updated EPSDT visit, physicians can include services for both visits and bill two visit codes for
reimbursement of both services on the same day. Providers must maintain a complete problem-focused
visit exam for the presenting problem and a complete preventive visit documenting the EPSDT
components of the screening exam within the member’s health records.
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Table 8.90 – CPT Code for EPSDT and Sick Visit
Visits
Sick visit plus
EPSDT
(two visit codes)
CPT Code
Preventive visit
code and 9920399215 with
modifier 25
ICD-9 Coding
V20.2 must be used as the primary
diagnosis for the appropriate
preventive visit and multiple
diagnoses for presenting problem.
Additional
Reimbursement
Sick visits depend on
complexity and
doctor/patient
relationship
(new/established)
EPSDT is a required component of care for Hoosier Healthwise and Care Select members. If the
member is in a Hoosier Healthwise RBMC network, the member’s MCE can provide information.
Information on Care Select members can be obtained through the member’s CMO.
Histrelin Implant (Supprelin LA)
Description of Service
Supprelin LA implant is approved by the FDA for the treatment of central precocious puberty (CPP).
Children with CPP have an early onset of secondary sexual characteristics before age 8 in females and
age 9 in males. They also show significantly advanced bone age that can result in diminished adult
height attainment.
The work-up for precocious puberty should include both physical and laboratory diagnostic
confirmatory steps before treatment are initiated. Physical diagnostic documentation should include the
following:
•
A record of growth, Tanner stages, and height and weight percentiles
•
External genitalia changes
•
Abdominal, pelvic, neurologic examinations
•
Signs of androgenization
•
Other conditions such as McCune-Albright and hypothyroidism
Laboratory diagnostic studies include:
•
Bone age X-rays
•
Head MRI, ultrasonography of abdomen and pelvis
•
FSH, LH, hCG assays
•
Thyroid hydoxyprogesterone
•
Inhibin levels
•
GnRH testing
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Reimbursement Requirements
Supprelin LA is considered medically necessary when all the following criteria are met:
•
The diagnosis of CPP is made before the age of 8 years in girls and 9 years in males.
•
The diagnosis of CPP is documented in clinical records (history, physical findings, and laboratory
analysis).
•
A pediatric endocrinologist has been consulted and is in agreement with the diagnosis and
treatment plan.
•
Documented inability to tolerate leuprolide acetate (Lupron Depot Ped) intramuscularly (not due to
pain) once every four weeks due to recurrent sterile fluid collections at the sites of injections.
•
Documentation that subcutaneous injections of aqueous leuprolide, given once or twice daily (total
dose 60 mg/kg/24 hr) or intranasal administration of the GnRH agonist nafarelin (Synarel) 800 mg
bid would not be tolerated or complied with.
Prior Authorization Requirements
This service does not require PA.
Billing Requirements
Supprelin LA implant is designed to deliver approximately 65 mcg of histrelin per day over 12 months.
The recommended dose of histrelin is one 50 mg implant inserted subcutaneously for 12 months. The
implant must be removed 12 months after insertion. At the time the implant is removed, another
implant may be inserted to continue therapy. Table 8.91 lists the HCPCS code for Supprelin LA.
Table 8.91 – HCPCS Coding for Histrelin Supprelin LA Implant
HCPCS
Code
J9226
Definition
Histrelin implant (Supprelin LA), 50 mg
Supprelin LA will only be reimbursed when billed with the following ICD-9-CM diagnosis code listed
in Table 8.92.
Table 8.92 – ICD-9-CM Code Available for Reimbursement of Histrelin Supprelin LA Implant
ICD-9-CM
Code
259.1
Definition
Precocious sexual development and puberty, not elsewhere classified
For members enrolled in the Hoosier Healthwise RBMC program, the HIP, HIP-ESP Plan, or any other
plan, providers must contact the member’s MCE or plan administrator for more specific guidelines
regarding their policies and PA procedures. IHCP members enrolled in Care Select receive the same
benefit coverage and are subject to the same limitations as members enrolled in traditional Medicaid
FFS program. See IHCP Provider Manual Chapter 1 for detailed information about the FFS, Care
Select, and RBMC delivery systems.
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Hearing Aids
If a provider voluntarily provides a loaner hearing aid for a 30-day trial period, the loaner hearing aid
for that 30-day trial period does not need PA. Purchase of a hearing aid becomes effective with the
authorization of the PA request.
Hearing Aid Purchase
The IHCP provides reimbursement for the purchase, repair, or replacement of hearing aids under the
following conditions:
•
PA is required for the purchase of hearing aids.
•
When a member is fitted with a hearing aid by an audiologist or a registered hearing aid specialist,
the specialist must complete and submit a medical clearance and audiometric test form with the PA
request form. Providers must perform professional audiology services associated with dispensing a
hearing aid in accordance with the appropriate provisions of 405 IAC 5-19-13, Hearing aids,
purchase.
•
Hearing aids purchased by the IHCP become the property of the OMPP.
•
The IHCP does not cover hearing aids for members with a unilateral pure tone average (500, 1,000,
2,000, or 3,000 hertz) equal to or less than 30 decibels.
•
The IHCP authorizes binaural aids and Contralateral Routing Of Signals (CROS) type aids only
when providers can document significant, objective benefit to the member.
•
The IHCP covers programmable hearing aids when the member meets certain criteria.
•
The IHCP does not reimburse for canal hearing aids.
•
Prior to date of service July 1, 2011, reimbursement of the hearing aid included dispensing fees,
which were not separately billable.
Hearing Aid Reimbursement
Effective July 1, 2011, manually priced hearing aid procedure codes will be reimbursed at 75% of the
manufacturer suggested retail price (MSRP) Providers will be required to submit documentation of the
MSRP for hearing aid codes listed in Table 8.93. Claims for the codes listed in Table 8.93 for dates of
service prior to May 18, 2012, also require the manufacturer’s cost invoice to be submitted with the
claim.
Table 8.93 – Manually Priced Hearing Aids
Procedure Code
Description
V5080
Glasses, bone conduction
V5095
Semi-implantable middle ear hearing prosthesis
V5100
Hearing aid, bilateral, body worn
V5120
Binaural, body
V5170
Hearing aid, CROS, in the ear
V5180
Hearing aid, CROS, behind the ear
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Procedure Code
Description
V5210
Hearing aid, BICROS, in the ear
V5220
Hearing aid, BICROS, behind the ear
V5246
Hearing aid, digitally programmable analog, monaural, ITE (in the
ear)
V5247
Hearing aid, digitally programmable analog, monaural, BTE
(behind the ear)
V5252
Hearing aid, digitally programmable, binaural, ITE
V5253
Hearing aid, digitally programmable, binaural, BTE
V5299
Hearing service, miscellaneous
Hearing Aid Dispensing Fee
Effective July 1, 2011, the IHCP has also established reimbursement rates for hearing aid dispensing
fees. This is a one-time dispensing fee every five years. The dispensing fee codes in the following table
may be billed only in conjunction with hearing aid codes that have an established Medicaid rate. The
dispensing fee codes may not be billed with hearing aid codes that are manually priced. The dispensing
fee code should be billed with the date the hearing aid is delivered. The dispensing fee includes all
services related to the initial fitting and adjustment of the hearing aid, orientation of the patient, and
instructions on hearing aid use. The procedure codes for billing hearing aid dispensing fees are listed in
Table 8.94. Prior authorization is not required for these dispensing fee codes. Prior authorization is
required if dispensing fee is medically necessary more than once every five years.
If providers bill a dispensing fee earlier, they will receive a denial with explanation of benefits (EOB)
6364 – Dispensing fees for hearing aids are limited to one every five years.
Table 8.94 – Procedure Codes for Hearing Aid Dispensing Fee
Procedure Code
Description
V5241
Dispensing fee, monaural hearing aid, any type
V5160
Dispensing fee, binaural
Maintenance and Repair
The IHCP reimburses for the maintenance and repair of hearing aids as defined in 405 IAC 5-19-14,
under the following conditions:
•
The IHCP does not require PA for repairs for hearing aids and ear molds; however, the IHCP does
not make reimbursement for such repairs more frequently than once in a 12-month calendar year,
per hearing aid, per member. Providers can obtain PA for repairs more frequently for members
under 21 years of age if the provider documents circumstances justifying the need.
•
The IHCP does not require PA for batteries, sound hooks, tubing, and cords. Providers must use the
appropriate HCPCS code and indicate the number of packages in the quantity field of the CMS1500 claim form.
Note: The IHCP designates one unit of code V5266 to represent four batteries;
therefore, when submitting claims to the IHCP for reimbursement, providers
are to report one unit of V5266 for each package of four batteries supplied.
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•
The IHCP does not pay for repair of hearing aids still under warranty.
•
The IHCP does not cover routine servicing of functional hearing aids.
•
The IHCP makes no payment for repair or replacement of hearing aids necessitated by member
misuse or abuse, whether intentional or unintentional.
Replacement
The IHCP reimburses for the replacement of hearing aids as defined in 405 IAC 5-19-15 and under the
following conditions:
•
The IHCP reimburses for the replacement of hearing aids, subject to the conditions listed in the
maintenance and repair section.
•
Requests for replacement of hearing aids must document all the following:
- Change in the member’s hearing status
- Purchase date of current hearing aid
- Condition of current hearing aid
•
The IHCP does not replace hearing aids before five years from the purchase date of a previously
purchased hearing aid. Providers can prior authorize replacements more frequently for members
under 21 years old, if the provider documents circumstances justifying the medical necessity (see
405 IAC 5-22-7 for more information).
Audiology Services
Audiology services are subject to the following restrictions:
•
The physician must certify in writing the need for audiology assessment or evaluation.
•
The audiology service must be rendered by a licensed audiologist or a person registered for his or
her clinical fellowship year that is supervised by a licensed audiologist.
•
When an audiologist or a registered hearing aid specialist fits a member with a hearing
amplification device, the provider must complete a medical clearance and audiometric test form in
accordance with the instructions given herein and submitted with the PA request form. Providers
must ensure that the form is complete and includes the proper signatures, where indicated.
•
The IHCP limits audiological assessments to one assessment every three years per member. If more
frequent audiological assessments are necessary, providers must obtain PA.
•
Provisions of audiological services are subject to the following criteria:
- Audiologists should enroll in the IHCP and receive direct reimbursement for services rendered.
- The contractor reviews all requests for PA on a case-by-case basis.
- The involved professionals must complete the member history.
- The referring physician must complete Part 2 of the Medical Clearance and Audiometric Test
Form no earlier than six months before providing the hearing aid. An otolaryngologist must
examine children 14 years old and younger. A licensed physician can examine older members if
an otolaryngologist is not available.
- The audiologist must conduct all testing in a sound-free enclosure. If a member is
institutionalized and his or her physical or medical condition precludes testing in a sound-free
enclosure, the ordering physician must verify medical confinement in the initial order for
audiological testing. A licensed audiologist, clinical fellowship year audiologist, or
otolaryngologist must conduct the audiological assessment. The IHCP does not reimburse for
testing conducted by other professionals and cosigned by an audiologist or otolaryngologist. If
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the audiological evaluation reveals one or more of the following conditions, the member must
be referred to an otolaryngologist for further evaluation:
 Speech discrimination testing must indicate a score of less than 60% in either ear.
 Pure tone testing must indicate an air bone gap of 15 decibels or more for two adjacent
frequencies in the same ear with a speech discrimination score of less than 60%.
- The audiologist or registered hearing aid specialist must complete the hearing aid evaluation.
Before the IHCP grants PA, providers must document the results of the hearing aid evaluation
on the PA request and must indicate that the member can derive significant benefit from
amplification.
- A registered hearing aid specialist must sign the hearing aid contract portion of the audiometric
test form.
For audiology assessments rendered more frequently than every three years, providers must obtain
prior authorization and assess on a case-by-case basis, based on documented otologic disease.
Note: For audiology procedures, providers cannot fragment and bill separately.
The IHCP considers hearing tests, such as whispered voice and tuning fork,
to be part of the general otolaryngology services and may not be reported
separately.
Basic comprehensive audiometry includes pure tone, air and bone threshold, and discrimination. The
IHCP reimburses for all other audiometric testing procedures on an individual basis, based on the
medical necessity of the test procedure.
The following audiology services do not require PA:
•
Screening tests indicating the need for additional medical examination; however, screenings are not
reimbursed separately
•
Initial hearing assessments
•
Determinations of suitability of amplification and recommendations about a hearing aid
•
Determinations of functional benefit gained by use of a hearing aid
The facility’s established per diem rate includes audiology services provided by a NF, large private
ICF/IID, or small ICF/IID.
Augmentative Communication Devices
An Alternative or Augmentative Communication (AAC) device is a device or system that compensates
for the loss or impairment of speech function due to a congenital condition, an acquired disability, or a
progressive neurological disease. The term includes only equipment used for communication, such as
electronic devices.
Reimbursement
The IHCP reimburses for a communication device if a medical doctor or a doctor of osteopathy orders
the device in writing.
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The IHCP requires PA for a communication device. Requesting practitioners must include medical
necessity documentation on or attached to the PA request form that is submitted. As part of the PA
request, providers must submit a speech pathologist’s clinical evaluation, substantiating the medical
necessity for the communication device.
Authorization
The IHCP grants authorization of reimbursement for a communication device only when the provider
sends the following:
•
Documentation to substantiate that the member demonstrates sufficient mental and physical ability
to benefit from the use of the system
•
Documentation to substantiate that, in the absence of a communication device, people outside the
member’s communication environment cannot effectively understand the member
•
Documentation to substantiate that the provider reasonably expects that the member’s medical
condition will necessitate use of the device for at least two years
•
Documentation that identifies all communication devices that would meet the member’s
communication needs, taking into account the physical and cognitive strengths and weaknesses of
the member and the member’s communication environment
- The documentation should note the recommended least expensive communication device.
•
Documentation that the intended use of a computer or computerized device is to compensate for the
member’s loss or impairment of communication function (in cases where the provider requests
authorization for a computer or computerized device)
Trial Period
The IHCP does not require a trial period for AAC devices, but the speech-language pathologist who
conducts the AAC evaluation may recommend a trial period.
The IHCP approves PA for rental of an AAC device for a trial use period when the speech and
language pathologist prepares a request that includes the following information:
•
Duration of the trial period
•
Examination of the AAC device during the trial period, including all the necessary components,
such as mounting device, software, and switches or access control mechanism
•
Identification of the AAC services provider that will assist the member during the trial period
•
Identification of the AAC services provider that will assess the trial period
•
Evaluation criteria specific to the member, used to determine the success or failure of the trial
period
•
Extension of trial periods and provision of different AAC devices when requested by the speech
and language pathologist responsible for evaluating the trial use period
Rental versus Purchase
The IHCP contractor determines whether to rent or purchase an approved AAC device, based on the
least expensive option to meet the member’s needs. The IHCP denies no AAC device to an eligible
member solely because it is not available for rental.
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Repair and Replacement
The IHCP does not authorize replacement of an augmentative communication device more often than
once every five years per member, unless a documented change in the member’s medical needs arises
and is significant enough to warrant a different type of equipment.
Rehabilitation Engineering
Subject to PA, the IHCP covers rehabilitation engineering service necessary to mount or make
adjustments to a communication device. The IHCP also covers speech therapy services as medically
necessary to aid the member in the effective use of a communication device, subject to 405 IAC 5-19
and 405 IAC 5-22.
Pneumatic Artificial Voicing Systems
For a pneumatic artificial voice system or artificial larynx, the IHCP reimburses subject to PA. The
IHCP grants PA only when the provider sends the following:
•
Documentation to substantiate the member demonstrates sufficient mental and physical ability to
benefit from the use of the system
•
Documentation to substantiate the member demonstrates sufficient articulation and language skills
to benefit from the use of the system
Purchase
When a provider supplies a pneumatic artificial voice system or an artificial larynx to a member on an
inpatient basis, the attendant costs fall under the established per diem rate for the hospital or LTC
facility. The provider should not bill for attendant costs separately.
Home and Community-Based Services Waiver Programs
The IHCP reimburses Home and Community-Based Services (HCBS) waiver providers for covered
services they provide to waiver members using a standard, statewide rate-setting methodology. The
OMPP establishes waiver service rates and rate capitations.
All waiver providers, including home health agencies, bill waiver services on the CMS-1500 or 837P.
Note: Providers should verify member eligibility on the first and 15th of the month,
because member eligibility in managed care is effective on the first and 15th
calendar days of the month. If a member is enrolled in Hoosier Healthwise,
contact that member’s MCE immediately to disenroll from managed care.
MCE contact information is included in Chapter 1: General Information of
this manual. If the member is identified as a Care Select member, contact the
CMO to which the member is assigned to disenroll from Care Select.
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Supportive documentation is required when billing for waiver services. The documentation
requirements are defined in the waiver service definition specific to the waiver service provided. The
documentation must include the following:
•
Complete date of service, including month, day, and year.
•
Time entry for service provided, including the time in and time out, noting a.m. and p.m., as
appropriate, unless the provider chooses to use 24-hour time notations. Providers should ensure
consistent notation of time – standard notation or 24-hour notation.
•
Number of units of service delivered on that date.
•
Signature of any staff member providing the service or making entries into the documentation.
Signature must include a minimum of the first initial and last name, and must include the staff
member’s certification or title.
To receive appropriate reimbursement, the provider must bill only the waiver services and procedure
codes authorized on the approved Notice of Action (NOA) and listed on the member’s prior
authorization file. Providers must ensure the documentation of the service rendered and the procedure
code billed are in accordance with the service definition and parameters as published in the approved
waiver.
In an institutional setting (for example, hospitalized or incarcerated), the only HCBS waiver service for
which a provider can render and receive reimbursement is case management. The IHCP prohibits
reimbursement for other services including, but not limited to, respite, residential habilitation and
support (RHS), and behavior management while the member is institutionalized.
For service providers that use electronic signatures for documentation, a specific policy must be in
place specifying how electronic signatures will be established, controlled, and verified.
For citations specific to documents transmitted to the State, see the Electronic Digital Signatures Act
(IC 5-24) and the Uniform Electronic Transactions Act (IC 26-2-8). In addition, the State Board of
Accounts has promulgated a rule with additional regulations, which can be found at 20 IAC 3.
Attendant Care Services, Respite Home Health Aide Services,
and Medicaid Prior Authorization for Home Health Aide
Services
In collaboration with the Indiana Association for Home & Hospice Care, the purpose of the side-byside comparison in Table 8.95 is to assist case managers and providers in determining the appropriate
services needed for waiver clients. The chart outlines allowed activities for waiver services, including
attendant, respite home health aide, and home health aide services through the Medicaid prior
authorization process.
The following questions can be used to assist in deciding whether a member requires attendant care
service through HCBS waiver services or home health aide services through the Medicaid prior
authorization process:
•
Is the client’s health condition medically complex?
•
Is the client’s health condition medically unstable?
•
Would the client benefit from having the nurse oversight function as required by Medicaid prior
authorization for home health aide personnel?
•
Does the client require a total bed bath?
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•
Does the client’s health condition require the reading of and recording of the temperature, pulse,
and respiration?
•
Does the client require assistance with specialized feeding, such as an individual who has difficulty
swallowing, refusing to eat, or does not eat enough?
•
Is this service needed so that the client’s primary caregiver can work, attend school, or sleep?
If the answer is “yes” to any of these questions, the needs of the member would appear to be greater
than what is allowed through the attendant care service definition. Therefore, the approval should be
requested for home health aide or nursing services utilizing the appropriate funding source.
Table 8.95 – Side-by-Side Comparison of Attendant Care/Home Health Aide
Activity
Attendant Care
Respite Home
Health Aide
Medicaid PA Home
Health Aide
Bathing
Assistance with bathing; partial
bathing; sponge bathing; tub or
shower
X
X
X
Oral hygiene
X
X
X
Hair care, including clipping
hair and shampoo
X
X
X
Shaving
X
X
X
Hand/foot/nail/intact skin care
X
X
X
Application of cosmetics
X
X
X
Dressing or undressing
X
X
X
Communication/documentation/observation
Communication includes: ability
to read, write, and communicate
in a clear and accurate manner
that is easily understood
X
X
X
Documentation includes: name
of worker (including
professional title); date, time,
location of service delivered;
amount and type of services
delivered; description of services
rendered; and any identified
issues or concerns noted.
X
X
X
Observation includes:
recognizes emergencies and
knowledge of emergency
procedures; services are
delivered in accordance to the
approved plan of care
X
X
X
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Activity
Attendant Care
Respite Home
Health Aide
Medicaid PA Home
Health Aide
Escorting
Escorts individuals to
community activities that are
therapeutic in nature or that
assist with developing and
maintaining natural supports
X
Medication management
Assistance through providing
reminders or cues to take
medication, the opening of
preset medication containers,
and providing assistance in the
handling or ingesting of
noncontrolled substance
medications, including eye
drops, herbs, supplements, and
over-the-counter medications;
and to an individual who is
unable to accomplish the task
due to an impairment and who is
competent and has directed the
services; or incompetent and has
the services directed by a
competent individual who may
consent to healthcare for the
impaired individual
X
X
X
Mobility
Assistance with proper body
mechanics
X
X
X
Assistance with transfers
X
X
X
Assistance with ambulation
X
X
X
Assistance with use of assistive
devices
X
X
X
X
X
Nutrition
Assistance with nutrition; meal
planning; preparation; feeding;
cleanup
X
Other
Provides assistance with
correspondence and bill paying
X
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Activity
Attendant Care
Respite Home
Health Aide
Medicaid PA Home
Health Aide
The physical, emotional, and
developmental needs of and
ways to work with the
populations served by the
agency, including the need for
respect for the patient, privacy,
and property
X
X
X
Hands-on activity
X
X
X
Normal range of motion and
positioning
X
X
X
Any other task the home health
agency may choose to have the
home health aide perform
X
Requires supervision of a
registered nurse
X
X
Safety
Assistance/identify and
eliminate safety hazards
X
X
X
Waste disposal and household
tasks
X
X
X
Maintaining a clean, safe, and
healthy environment
X
X
X
Basic infection control
procedures and universal
precaution
X
X
X
Toileting
Assistance with bedpan, bedside
commode, toilet
X
X
X
Assistance with incontinent or
involuntary care
X
X
X
Assistance with emptying urine
collection and colostomy bags
X
X
X
Training and evaluations
Training and evaluation
X
X
X
Injections
With the exception of vaccines available through the Vaccines for Children (VFC) Program, the IHCP
calculates the maximum allowable amount for reimbursement for physician office-administered
injectable drugs, using HCPCS J codes and CPT immunization codes, on the basis of the most costeffective, current, reimbursement for an appropriate NDC, identified as the benchmark NDC. The
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maximum allowable reimbursement is equal to Wholesale Acquisition Cost (WAC) plus 5%
(WAC+5%) of the benchmark NDC or, if no WAC data is available, CMS’ reimbursement, which is
currently Average Sales Price (ASP) plus 6% (ASP+6%). The maximum allowable cost corresponds to
the dose in the narrative description of the HCPCS or CPT code. When the provider specifies no dose
in the narrative, the reimbursement rate is set by the contractor responsible for updating the rates based
on what corresponds to a typical dose for the particular code. The IHCP notifies providers through
bulletins or banner pages about reimbursement rates for codes that have no dose or are doseunspecified.
For injectable drugs, vaccines that are not part of the VFC program, and vaccines typically part of the
VFC program but supplied out of private stock, providers may separately bill an appropriate CPT
administration code, 96372 – 96373, in addition to the HCPCS J-code or CPT drug code. If an E/M
code is billed with the same date of service as an office-administered drug, the provider should not bill
a drug administration code separately. Reimbursement for administration is included in the E/M code
allowed amount. Separate reimbursement is allowed when the administration of the drug is the only
service billed by the practitioner. In addition, if more than one injection is given on the same date of
service and no E/M code is billed, providers may bill a separate administration fee for each injection
using the appropriate codes.
The IHCP reviews pricing for physician office-administered injectable drugs quarterly and updates
pricing according to WAC data in the drug database file received from First DataBank. If no WAC
data is available, Medicare’s reimbursement, currently ASP+6%, is used.
The IHCP limits joint injections to four injections per joint site, per provider, per month. Claims
submitted for more than three injections per joint site in a one-month period must have supporting
documentation attached to indicate the medical necessity of the fourth injection per joint site.
Additionally, providers billing for more than four joint injections per provider in a one-month period
must have supporting documentation to indicate that the injections involve different joint sites and that
no more than four injections were administered to a single joint.
The IHCP limits Vitamin B12 injections to one per 30 days per member.
Billing Nonspecific CPT or HCPCS Codes for Injections
When a provider cannot use an existing CPT or HCPCS code to bill for new injectable drugs that the
IHCP covers because the IHCP has not assigned a specific code, the provider should use an
appropriate nonspecific CPT or HCPCS code such as J3490 – Unclassified drugs or 90749 – Unlisted
vaccine/toxoid to bill. Providers can use a nonspecific CPT or HCPCS code only when no code is
available with a narrative that accurately describes the drug being administered or the drug’s route of
administration.
The IHCP manually prices drugs billed with a nonspecific CPT or HCPCS code, and providers must
submit them with an attachment. For all CMS-1500 claims or 837P transactions billed with a
nonspecific code, providers must write the NDC qualifier, NDC, NDC unit of measure, and number of
units administered on the claim itself; otherwise, the IHCP must deny the claim. The IHCP reimburses
for nonspecific codes at the WAC+5% – or ASP+6% if no WAC data is available – of the NDC
indicated on the claim form, multiplied by the number of units administered. For electronic 837
transactions, providers can indicate the NDC for the drug dispensed in the NDC field. The NDC
quantity and unit of measure must also be provided.
The Federal Deficit Reduction Act of 2005 requires that NDCs are submitted on the CMS-1500 in the
shaded area of field 24a. Because the State may pay up to the 20% Medicare B copayment for dualeligible individuals, the NDC is required on Medicare crossover claims for all applicable procedure
codes.
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Remittance Advice
The Remittance Advice (RA) will not display the NDC submitted on the claim. The following edits
will be activated as a part of claims processing:
•
Edit 0217 – NDC number is missing.
•
Edit 0218 – NDC number is not in a valid format.
•
Edit 0219 – Quantity dispensed or quantity billed information is missing.
•
Edit 4003 – Less than effective drugs are not covered under Indiana Health Coverage Programs.
Note: Additional information on how drugs are determined to be less than effective
is located on the CMS website.
A list of noncovered less than effective drugs (DESI) is located on the CMS website.
•
Edit 4004 – This NDC is not on file. Please verify that the NDC was filed correctly.
•
Edit 4007 – Noncovered NDC due to CMS Termination – Claims with an NDC that has been
terminated by the CMS will not be reimbursable.
•
Edit 4300 – Invalid NDC to procedure code combination.
•
Edit 0810 – NDC Unit Qualifier (unit of measure) is missing.
•
Edit 1016 – Nonparticipating Manufacturer – Claims with an NDC from a nonrebating
manufacturer will be denied and are not reimbursable.
Note: CMS maintains a list of rebating labelers on the CMS website. Providers can
also contact their wholesaler or drug supplier to determine if products
supplied are from CMS rebating labelers.
Procedure Codes
Procedure codes that require the submission of the product NDC and NDC quantity, along with the
procedure code and procedure code billing units, are listed on indianamedicaid.com. This list is
reviewed and updated on an annual basis, or as determined by the OMPP. The procedure codes are
listed in the Procedures Codes that Require a National Drug Code (NDC) document located at
About the NDC
Medication listed under Section 510 of the U.S. Federal Food, Drug, and Cosmetic Act is assigned a
unique 11-digit, three-segment number. This number, known as the NDC, identifies the labeler or
vendor, product, and package size. The first segment, known as the labeler code, is assigned by the
Food and Drug Administration (FDA). A labeler is any firm that manufactures, repacks, or distributes
a drug product. The second segment, known as the product code, identifies a specific drug, strength,
and dosage form of that drug. The third segment, known as the package code, identifies the package
size.
For purposes of meeting the new billing requirement, NDCs must be configured in what is referred to
as a “5-4-2” format; the first segment must include five digits, the second segment must include four
digits, the third segment must include two digits. If an NDC segment is missing a number on the
product label, the appropriate number of zeros must be added at the beginning of the segment. For
example, 12345-1234-12 is a correctly configured NDC. Because a zero can be a valid digit in the
NDC, this can lead to confusion when trying to reformat the NDC back to its FDA standard. Example:
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12345-0678-09 (11 digits) could appear as 12345-678-09 or 12345-0678-9 on the label, depending on
the labeler’s configuration. To ensure proper payment of claims, the NDC must be zero-padded as
appropriate.
The procedure code billing units, as well as the NDC quantity, are required. To report the NDC on the
CMS-1500 claim form, enter the following information into the shaded portion of fields 24A to 24H:
•
Enter the NDC qualifier of N4
•
Enter the NDC 11-digit numeric code
•
Enter the drug description
•
Enter the NDC Unit qualifier
- F2 – International Unit
- GR – Gram
- ML – Milliliter
- UN – Unit
•
Enter the NDC Quantity (Administered Amount) in the format 9999.99
NDC Quantity
The procedure code billing units and NDC quantity do not always have a one-to-one relationship. The
NDC quantity is based on the strength of the drug administered per unit, and the designated strength of
the procedure code. The NDC quantity billed must reflect the procedure code quantity billed on the
claim.
Compounds – Professional Claim Types
When billing any compound drugs that require an NDC, providers must bill the appropriate NDC for
each procedure code. Providers receive payment for all valid NDCs included in the compound drugs.
When billing NDCs that have one procedure code but that involve multiple NDCs, providers no longer
need to use the KP and KQ modifiers. Providers bill the claim with the appropriate NDC for the drug
they are dispensing on separate detail lines. For example, if a provider administers 150 mg of Synagis,
most likely a 50 mg vial plus a 100 mg vial would be used. These two vials have different NDCs but
one procedure code; therefore, the item would be billed with two detail lines for the same procedure
code and the corresponding NDCs. This process will be the same for crossover and Medicare
Replacement plan claims.
Botulinum Toxin Coverage and Billing Procedures
Currently, the FDA has approved four types of botulinum toxin injections: Botox (J0585), Dysport
(J0586), Myobloc (J0587), and Xeomin (J0588). Providers should be aware that the potency units of
these products are not interchangeable with each other and, therefore, units of biological activity of one
product cannot be compared to or converted into units of other botulinum toxin products.
Due to the short life of the botulinum toxin products, providers may bill the units injected in a single
treatment and the units discarded and not used for another patient. The amount of the agent actually
administered and the amount discarded should be documented in the patient’s medical chart. If a vial is
split between two or more members, the provider must bill the amount used for each member and then
bill the unused amount as wastage on the claim for the last member injected.
Providers should bill botulinum toxin injections using the appropriate HCPCS codes.
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Table 8.96 – HCPCS Codes for Botulinum Toxin Injections
HCPCS Code
Code Description
J0585
Injection, onabotulinumtoxin A, 1 unit (Botox)
J0586
Injection, abobotulinumtoxin A, 5 units (Dysport)
J0587
Injection, rimabotulinumtoxin B, 100 units (Myobloc)
J0588
Injection, incobotulinumtoxin A, 1 unit (Xeomin)
IHCP reimbursement for botulinum toxin injections must include one of the following CPT codes
available for billing chemodenervation, listed in Table 8.97.
Table 8.97 – CPT Codes for Chemodenervation for use with Botox and Myobloc Injections
CPT Code
Definition
42699
Unlisted procedure, salivary glands or ducts
43201
Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance
43236
Upper gastrointestinal endoscopy including esophagus, stomach, and either the
duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any
substance
46505
Chemodenervation of internal anal sphincter
52287
Cystourethroscopy, with injection(s) for chemodenervation of the bladder
53899
Unlisted procedure, urinary system
64612
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve unilateral
(eg, for blepharospasm, hemifacial spasm)
64613
Chemodenervation of muscle(s); neck muscles (eg for spasmodic torticollis,
spasmodic dysphonia)
64614
Chemodenervation of muscle(s); extremity and/or trunk muscle(s)
(eg, for dystonia, cerebral palsy, multiple sclerosis)
64650
Chemodenervation of eccrine glands; both axillae
64653
Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day
67345
Chemodenervation of extraocular muscle
95873
Electrical stimulation for guidance in conjunction with chemodenervation (List
separately in addition to code for primary procedure)
95874
Needle electromygraphy for guidance in conjunction with chemodenervation (List
separately in addition to code for primary procedure)
To ensure that the injections are medically necessary, the IHCP reimbursement for botulinum toxin
injections is limited to specific diagnosis codes. Table 8.98 shows the ICD-9-CM codes that are
available for reimbursement of botulinum toxin injections.
Table 8.98 – ICD-9-CM Diagnosis Codes for Botox and Myobloc Injections
Diagnosis Codes
333.6
333.71
333.79
333.81
333.82
333.83
333.84
333.89
334.1
340
341.0
341.1
341.22
341.8
341.9
342
342.10
342.11
342.12
343.0
343.1
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Diagnosis Codes
343.2
343.3
343.4
343.8
343.9
344.00
344.01
344.02
344.03
344.04
344.09
344.1
344.2
344.30
344.31
344.32
344.40
344.41
344.42
351.8
374.03
374.13
378.00
378.01
378.02
378.03
378.04
378.05
378.06
378.07
378.08
378.10
378.11
378.12
378.13
378.14
378.15
378.16
378.17
378.18
378.20
378.21
378.22
378.23
378.24
378.30
378.31
378.32
378.33
378.34
378.35
378.40
378.41
378.42
378.43
378.44
378.45
378.50
378.51
378.52
378.53
378.54
378.55
378.56
378.60
378.61
378.62
378.63
378.71
378.72
378.73
378.81
378.82
378.83
378.84
378.85
378.86
378.87
378.9
478.75
527.7
530.0
565.0
596.54
596.55
705.21
723.5
754.1
These diagnosis codes reflect medically necessary diagnoses for these injections. The IHCP also limits
reimbursement of these injections to one treatment session every three months, per member, unless an
additional injection is medically necessary. The medical record must contain documentation of the
medical necessity for additional treatment sessions provided within a three-month period.
Vaccines for Children Program
The IHCP encourages providers to bill drugs on the Indiana Medicaid Drug Claim Form instead of
billing unlisted codes on a CMS-1500 or 837P. See instructions for completing the Indiana Medicaid
Drug Claim Form on indianamedicaid.com.
The section in this chapter titled Vaccines for Children provides information about billing procedures
and reimbursement for vaccines available through the VFC Program.
Laboratory Services
The IHCP defines a laboratory as any facility that performs laboratory testing on specimens derived
from humans to provide information for the diagnosis, prevention, and treatment of disease, or for
information about impairment or assessment of health. Providers must order all laboratory services in
writing and include a condition-related diagnosis that necessitates the laboratory services.
Providers should use the pathology and laboratory guidelines noted in the CPT and HCPCS codes
when billing laboratory services. To receive reimbursement from the IHCP for laboratory services
falling under Clinical Laboratory Improvement Amendment (CLIA) regulations, the provider must
have a valid copy of the CLIA certificate on file with the contractor and must bill only lab codes
allowed by the certificate. The section in Chapter 4: Provider Enrollment, Eligibility, and
Responsibilities of this manual titled Provider Eligibility gives further information about CLIA, or the
provider can contact the ISDH at (317) 233-7502. Provider types subject to CLIA rules include those
in Table 8.99.
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Table 8.99 – CLIA Provider Types
CLIA Code
Description
01
Hospitals, type/specialty 010–012
04
Rehabilitation facilities
05
Home health agencies
06
Hospices
08
Clinics, type/specialty 080–085
11
Mental health, type/specialty 110–111
13
Public health agencies
14
Podiatrists
15
Chiropractors
28
Laboratories, type/specialty 280–281
30
End-stage renal disease clinics
31
Physicians, all types/specialties
See the CMS CLIA Overview page at cms.hhs.gov for information about the procedures that are
eligible for reimbursement under specific CLIA certificates. For more information, go to the CMS
CLIA Overview page and select Categorization of Tests.
Clinical Diagnostic Laboratory Procedures
When billing for clinical diagnostic tests, providers must indicate the appropriate CPT or HCPCS code
on the claim form. Laboratories performing services must bill the IHCP directly unless otherwise
specified by the CMS. If the provider administers the procedure more than one time in the same day,
the provider should bill it as only one line item, with an indication of the number of units of service
given that day.
The IHCP reimburses for clinical diagnostic laboratory procedures, performed in a physician’s office,
by an independent laboratory, or by a hospital laboratory for outpatients, on the basis of the following:
•
The lower of the submitted charge or the Medicare Lab Fee Schedule
•
The lower of the submitted charge or the RBRVS
For procedures on the Medicare Fee Schedule that do not have Relative Value Units (RVUs), the IHCP
reimburses based on the Medicare Clinical Laboratory Fee Schedule or manual pricing methodology, if
a rate has not yet been established by Medicare. On the Medicare Fee Schedule, some procedures do
not have RVUs because the procedure meets one of the following criteria:
•
Associated with special restrictions
•
Carrier-priced
•
Excluded from the definition of physician services
•
Excluded from the Medicare Fee Schedule
•
Noncovered by Medicare
•
Not valid for Medicare
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For laboratory procedures not covered by the Medicare Fee Schedule as not meeting the definition of
physician-provided services, the IHCP reimburses from the Medicare Clinical Laboratory Fee
Schedule. The IHCP reimburses through manual pricing until Medicare assigns a rate for codes for
which Medicare has not yet established a specific rate in the Medicare Fee Schedule or in the Medicare
Clinical Laboratory Fee Schedule. Blood or blood products, blood testing, and tests involving
physician interpretation are exceptions.
Clinical diagnostic laboratory services include all laboratory tests listed in codes 80048 through 89356,
as well as some G, P, and Q codes listed in the HCPCS Level II Code book.
When providers submit codes from Table 8.100 on the same claim form with codes corresponding to
blood or blood products, the codes are not subject to pricing by the Medicare fee schedule. If providers
submit the codes without charges for blood or blood products, the IHCP classifies the services as
clinical diagnostic lab tests, subject to pricing by the Medicare fee schedule.
Table 8.100 – CPT Codes – Blood or Blood Products
CPT Code
Description
86021
Antibody identification; leukocyte antibodies
86022
Antibody identification; platelet antibodies
86880
Antihuman globulin test (Coombs test); direct, each antiserum
86885
Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell
86886
Antihuman globulin test (Coombs test); indirect, each antibody titer
86900
Blood typing; ABO
86901
Blood typing; Rh (D)
86904
Blood typing; antigen screening for compatible unit using patient serum, per unit screened
86905
Blood typing; RBC antigens, other than ABO or Rh (D), each
86906
Blood typing; Rh phenotyping, complete
86910
Blood typing, for paternity testing, per individual; ABO, Rh and MN
86911
Blood typing, for paternity testing, per individual; each additional antigen system
86970
Pretreatment of RBCs for use in RBC antibody detection, identification, and/or
compatibility testing; incubation with chemical agents or drugs, each
86971
compatibility testing; incubation with enzymes, each
86972
compatibility testing; by density gradient separation
86975
Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each
86976
Pretreatment of serum for use in RBC antibody identification; by dilution
86977
Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors,
each
86978
Pretreatment of serum for use in RBC antibody identification; by differential red cell
absorption using patient RBCs or RBCs of known phenotype each absorption
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Professional and Technical Components
Some clinical diagnostic laboratory procedures encompass professional and technical components of
service. A physician typically performs the professional component of the lab procedure. The IHCP
reimburses the physician for the professional component because the physician bills the appropriate
CPT lab code along with modifier 26, professional component. When billing only the technical
component, providers should append modifier TC, technical component, with the appropriate CPT lab
code. When billing for professional and technical components of service, providers should use no
modifiers. Providers should bill the appropriate lab code only. Look in the Federal Register under
Relative Value Units and Related Information to see a list of lab codes billed using these modifiers.
Hospital Outpatient Defined
The IHCP defines hospital outpatient as a member who the hospital has not admitted as an inpatient
but is registered in hospital records as an outpatient and receives services directly from the hospital. If
personnel not employed by the hospital take a tissue sample, blood sample, or specimen and send it to
the hospital for tests, the IHCP classifies the tests as nonpatient (rather than outpatient) hospital
services, because the patient did not directly receive services from the hospital.
Independent Diagnostic Testing Facility
An independent diagnostic testing facility (IDTF) is a diagnostic testing facility (entity) that is
independent of a physician’s office or hospital (that is, it is not owned by a hospital, individual
physician, or physician group). An IDTF furnishes diagnostic tests and does not use test results to
directly treat patients. IDTFs are distinguished from facilities that provide similar services by their
ownership structure and the types of services they perform. IDTFs must be enrolled in Medicare before
enrolling in the IHCP.
Example:
A radiologist-owned or hospital-owned office that bills for
professional interpretations and rarely bills for purchased interpretations or
technical components only of diagnostic tests is not an IDTF.
An IDTF must employ one or more supervisory physicians who are proficient in the performance and
interpretation of each type of diagnostic procedure performed by the IDTF. A physician group practice
cannot be considered a supervisory physician. In accordance with 42 CFR410.33 (b)(2), Medicare
IDTFs have discretion in determining the qualifications required of a supervisory physician if the
physician is not certified in a medical specialty.
Billing
IDTF services are billed on a CMS-1500 Professional claim form or the HIPAA 837P transaction with
place-of-service code 81 – Independent laboratory.
Specimen Collection
The IHCP allows a minimal fee for separate charges made by physicians, independent laboratories, or
hospital laboratories for drawing or collecting specimens. The IHCP covers these services only when
the provider draws a blood sample through venipuncture or collects a urine sample by catheterization.
Providers must itemize specimen collection fees when billing for them. The IHCP allows only one
charge per day for each patient for venipuncture. The IHCP allows a charge for catheterization for each
patient encounter and does not limit this service per day.
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Handling Conveyance
The IHCP allows a fee for physicians, chiropractors, and podiatrists for handling and conveying a
specimen to a laboratory (405 IAC 5-18-2(c)). The IHCP reimburses providers for no more than two
conveyance fees (CPT procedure codes 99000 and 99001) per member, per provider, on the same date
of service. Providers can charge this only if the physician has an expense involved in conveyance.
Lab Panels
Organ or disease-oriented panels were developed to allow for coding of a group of tests. Providers are
expected to bill the lab panel when all the tests listed within each panel are performed on the same date
of service. When one or more of the tests within the panel are not performed on the same date of
service, providers may bill each test individually. Providers may not bill for a panel and all the
individual tests listed within that panel on the same day. However, tests performed in addition to those
listed on the panel on the same date of service may be reported separately in addition to the panel code.
Providers must follow CPT coding guidelines when reporting multiple panels. For example, providers
cannot report 80048 with 80053 on the same date of service because all the same lab codes in 80048
are components of 80053.
Interpretation of Clinical Laboratory Services
The CMS has identified certain procedures as clinical lab tests that frequently require a laboratory
physician to interpret. The physician can bill these codes with the 26 modifier. The IHCP covers
consultative pathology services for clinical laboratory tests if the claim meets the following conditions:
•
The patient’s attending physician requested the service in writing.
•
The service relates to a test that lies outside the clinically significant normal or expected range in
view of the condition of the patient.
•
The service results in a written narrative report in the patient’s medical record.
•
The service requires the exercise of medical judgment by the consulting physician.
Hospice providers should note that they must not include costs for services, such as laboratory and Xrays, with the attending physician’s billed charges. The daily hospice care rates that the IHCP pays
include these costs, and they are expressly the responsibility of the hospice provider.
Breast Cancer Testing
HER2 Laboratory Testing
Providers should use the codes in Table 8.101 to bill HER2 protein over expression tests, HercepTest®,
as an aid in assessment of patients who use trastuzumab, HERCEPTIN ®.
Table 8.101 – CPT Codes for HER2 Test
CPT Code
Description
88342
Immunohistochemistry (including tissue immunoperoxidase), each antibody
88365
In situ hybridization (eg, FISH), each probe
HER-2/neu Gene Detection Test, such as Oncor’s INFORM ®, is an adjunct to existing clinical and
pathological information and an aid to stratify breast cancer patients with a primary, invasive, or
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localized breast cancer, who are lymph node negative, for risk of recurrence or disease-related death.
Providers use this test as a prognostic indicator and should use the codes in Table 8.102 to bill it.
Table 8.102 – CPT Codes for HER-2/neu Gene Detection Test
CPT Code
Description
88271
Molecular cytogenetics; chromosomal in situ hybridization, analyze 3-5 cells
(eg, for derivatives and markers)
88274
Molecular cytogenetics; interphase in situ hybridization, analyze 25–99 cells.
(Either code 88274 or 88275 should be billed.)
88275
Molecular cytogenetics; interphase in situ hybridization, analyze 100–300
cells. (Either code 88274 or 88275 should be billed.)
88291
Cytogenetics and molecular cytogenetics, interpretation and report
Billing Requirements and Prior Authorization Criteria for Genetic Testing
for Breast and Ovarian Cancer
Breast and Ovarian Cancer – BRCA 1 and BRCA 2
The IHCP reimburses for genetic testing for breast and ovarian cancer (BRCA) 1 and BRCA 2 genetic
testing when medically necessary, with prior authorization (PA) billed with the appropriate HCPCS
codes shown in Table 8.103.
Effective December 1, 2012, the IHCP will reimburse the codes shown in Table 8.103 at 90% of billed
charges. This pricing will apply retroactively to dates of service on or after April 1, 2012. Providers
may resubmit claims for retroactive dates of service for reprocessing.
Consistent with coding guidelines, providers may be reimbursed once per lifetime, per member, for
only one of the procedure codes in the following code pairs:
•
CPT code 81211 or 81214
•
CPT code 81211 or 81216
If both codes in the code pair are billed, one of the codes will deny for explanation of benefits (EOB)
6376 − 81214 or 81216 will not pay if 81211 has ever been paid. If the IHCP has provided
reimbursement for CPT code 81211, 81214 or 81216, the IHCP will not reimburse 81212, 81213,
81215, or 81217 for that member because 81211, 81214 and 81216 represents complete BRCA 1 and
BRCA 2 gene sequence analysis.
The IHCP gives PA for genetic testing related to breast and ovarian cancer, using the HCPCS codes
listed in Table 8.103 when medically necessary in the following circumstances. Providers must submit
documentation with the PA request and must maintain it in the member’s medical record.
•
Clinically affected individuals (invasive breast cancer or ovarian cancer at any age) meeting at least
one of the following criteria:
- One or more first-degree (mother, father, sister, or daughter) or second-degree (aunt, uncle,
grandmother, niece, or granddaughter) relatives with invasive breast cancer diagnosed before
age 50
- One or more first- or second-degree relatives with ovarian cancer
- One or more first- or second-degree relatives with male breast cancer
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• Individuals with a personal history of at least one of the following (no family history required):
- Invasive breast cancer before age 50
- Ovarian cancer at any age
- Invasive breast cancer and ovarian cancer at any age
- Male breast cancer at any age
•
Individuals with a family member (related by blood) with a known BRCA 1 or BRCA 2 mutation
•
Individuals with Ashkenazi (Eastern European) Jewish ancestry with invasive breast cancer at any
age, or meeting any of the previous criteria
The IHCP considers BRCA testing of men with breast cancer medically necessary for either of the
following indications:
•
To assess the man’s risk of recurrent breast cancer; or
•
To assess the breast cancer risk of a female member where the affected male is a first- or seconddegree blood relative of that member
- The IHCP considers BRCA 1 and BRCA 2 testing to assess the risk of breast or prostate cancer
in men without breast cancer to be not medically necessary.
Table 8.103 – HCPCS Codes to Report Genetic Testing for Breast and Ovarian Cancer
Diagnoses Only
Code
Description
81211
BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene
analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (i.e.,
exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del
7.1 kb
81212
analysis; 185delAG, 5385insC, 6174delT variants
81213
analysis; uncommon duplication/deletion variants
81214
BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full
sequence analysis and common duplication/deletion variants (i.e., exon 13 del 3.835kb, exon
13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
81215
BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; known
familial variant
81216
BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full
sequence analysis
81217
BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known
familial variant
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Lead Testing
For lead testing in the office setting, the coverage and reimbursement rate for code 83655 includes
tests administered using filter paper and handheld testing devices. Providers should bill using the
following procedure codes and modifier combinations listed in Table 8.104.
Table 8.104 – New Codes for Lead Testing
Procedure Code
Description
83655
Lead
83655 U1
Lead, using filter paper
83655 U2
Lead, handheld testing device
Medical and Surgical Supplies
Medical and surgical supplies (medical supplies) are items that are disposable, nonreusable items,
which must be replaced on a frequent basis. The IHCP covers some medical supplies but not all.
Providers use medical supplies primarily and customarily to serve a medical purpose, and medical
supplies are generally not useful to a person in the absence of an illness or an injury. To the extent the
IHCP covers a medical supply item – it is a reimbursable service only when medically necessary. A
physician or a dentist must prescribe all medical supplies and must document the need for such items.
Covered medical supplies include, but are not limited to, antiseptics and solutions, bandages and
dressing supplies, gauze pads, catheters, incontinence supplies, irrigation supplies, diabetic supplies,
ostomy supplies, and respiratory and tracheotomy supplies.
The IHCP requires providers to submit claims for medical supplies on the paper CMS-1500 claim form
or 837P transaction using HCPCS codes. Providers should send all claims for medical supplies to HP
using HCPCS procedure codes. The IHCP denies all claims submitted on the pharmacy claim form,
using NDCs, Health Related Item (HRI) codes, Universal Package Codes (UPCs), or Product
Identification Numbers (PINs).
Reimbursement for medical supplies is equal to the lower of the provider’s submitted charges (usual
and customary) or the Medicaid calculated allowable for the item. The Medicaid calculated allowable
for an item is the statewide fee schedule amount. Providers must include their usual and customary
charge for each medical supply item when submitting claims for reimbursement. Providers should not
use the Medicaid calculated allowable for their billed charge unless the Medicaid calculated allowable
is equal to the amount charged by the provider to the general public.
Limitations on Coverage
When providers include medical supplies in LTC facility reimbursement (nursing facilities, group
homes, ICFs/IID) or otherwise include them as part of reimbursement for a medical or surgical
procedure, LTC providers must always include them as part of their NF per diem. Under no
circumstances should a pharmacy, LTC facility, or any other provider separately bill such supplies to
the program. This requirement includes all covered medical supplies that are included in the LTC
provider’s per diem rate, even if the LTC facility does not include the cost of medical supplies in its
cost report.
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The IHCP does not reimburse for medical supplies provided in quantities greater than a one-month
supply for each calendar month, except when the manufacturer packages those supplies only in larger
quantities. Medical supplies must be for a specific medical purpose, not incidental or general-purpose
usage.
All covered sterile water products, with the exception of those required for compounded prescriptions,
are included in the nursing home per diem and are, therefore, not separately reimbursable.
Covered sterile water products are billable with an NDC on the pharmacy claim form, which can be
located under the Pharmacy Services quick link at indianamedicaid.com.
Manually Priced Supplies
For medical supplies billed with a nonspecific HCPCS code with a description such as unspecified,
unclassified, or miscellaneous, the IHCP bases reimbursement on manual pricing. Payment for
manually priced HCPCS codes, related to medical supplies, is specific to the item being billed.
Effective July 1, 2011, manually priced HCPCS codes are reimbursed at 75% of the manufacturer’s
suggested retail price (MSRP). A provider is required to submit documentation of the MSRP for
medical supplies codes that do not have established rates when submitting the claim for adjudication.
For dates of service prior to May 18, 2012, providers are also required to submit a manufacturer’s cost
invoice with their claims for manually priced medical supplies procedure codes.
The HCPCS code must be present on all invoices submitted for manual pricing.
Providers must not bill more than their usual and customary charge for any item. All nonspecific
HCPCS codes may be subject to retrospective review.
Medicare Part B Crossover Claims
Crossover claims filed with the IHCP must comply with IHCP billing rules. Therefore, providers must
bill services on the appropriate claim form. There is no filing limit for paid Medicare crossover claims.
Note: Providers should bill outpatient professional charges on the CMS-1500 or
837P. Always submit ambulatory surgery center charges on a UB-04 or
837I.
FQHCs, hospital-based ambulance services, and independent RHCs submit claims to the Medicare
intermediary on the UB-04 or 837I, but they must submit claims to the IHCP on the CMS-1500 or
837P.
Providers must submit LTC facility Medicare charges for parenteral and enteral services and therapies
to the IHCP on the UB-04 claim form or 837I transaction.
See the UB-04 Billing Instructions section of this chapter for instructions on completing a UB-04
crossover claim form. The CMS-1500 form must contain the combined total of the Medicare
coinsurance, deductible, and psych reduction when applicable, in the left side of field 22, under the
heading Code. Providers must submit the Medicare paid amount (actual dollar amount received from
Medicare) in field 22 on the right side, under the heading Original Ref No. Additionally, in field 29,
providers must enter only a total payment amount received from a TPL, if applicable. Do not include
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the Medicare paid amount or contract adjustment in field 29. The IHCP requires the Medicare
Remittance Notice only for claims containing a zero paid amount by Medicare.
Note: Providers should submit Medicare denials through the normal claims
process, because the IHCP does not consider the denials as crossover
claims.
Medicare and Medicaid Reimbursement
Providers must be Medicare providers and accept assignment for a claim for dually eligible members
to cross over. Detailed information about Medicare-Medicaid related reimbursement appears in
Chapter 5: Third Party Liability of this manual.
Atypical providers must ensure that the Medicare provider number, per service location, by individual
provider and billing provider, is on file with the HP Provider Enrollment Unit. Chapter 4: Provider
Enrollment, Eligibility, and Responsibilities of this manual provides further information about provider
enrollment.
Mental Health Services
Providers furnishing mental health services to members enrolled in Care Select must follow existing
PA guidelines. Some mental health services are no longer carved out and providers must submit
RBMC member claims to the member’s MCE for payment. Services requiring PA furnished to
members enrolled in RBMC must be prior-authorized by the MCE in accordance with the MCE
guidelines. See the Hoosier Healthwise page on indianamedicaid.com.
As stated in 405 IAC 5-20-8, the IHCP allows direct reimbursement for outpatient mental health
services provided by licensed physicians, psychiatric hospitals, psychiatric wings of acute care
hospitals, outpatient mental health facilities, and psychologists endorsed as health services providers in
psychology (HSPP). Outpatient mental health services rendered by or under supervision of a physician
or HSPP are subject to the limitations in 405 IAC 5-25 and are subject to the following limitations.
Subject to PA by the OMPP or its designee, the IHCP reimburses physician- or HSPP-directed
outpatient mental health services for group, family, and individual psychotherapy when services are
provided by one of the following mid-level practitioners:
•
Advanced practice nurse under IC 25-23-1-1(b), who is a licensed, registered nurse with a master’s
degree in nursing, with a major in psychiatric or mental health nursing from an accredited school of
nursing
•
Licensed psychologist
•
Licensed independent practice school psychologist
•
Licensed clinical social worker (LCSW)
•
Licensed marriage and family therapist (LMFT)
•
Licensed mental health counselor (LMHC)
•
A person holding a master’s degree in social work, marital and family therapy, or mental health
counseling
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These mid-level practitioners may not be separately enrolled as individual providers to receive direct
reimbursement. Mid-level practitioners can be employed by an outpatient mental health facility, clinic,
or physician, or HSPP enrolled in the IHCP. The IHCP reimburses for covered services rendered. The
employer or supervising psychiatrist bills for the services.
The IHCP reimburses for services provided by mid-level practitioners in an outpatient mental health
facility when an HSPP supervises services. Mid-level practitioners who render services must bill using
the rendering NPI of the supervising practitioner and the billing NPI of the outpatient mental health
clinic or facility. An HSPP may certify the diagnosis or supervise the plan of treatment.
Outpatient Mental Health
The physician or HSPP is responsible for certifying the diagnosis and supervising the plan of treatment
as stated in 405 IAC 5-20-8(3). The physician or HSPP must be available for emergencies and must see
the patient or review the information obtained by the mid-level practitioner within seven days of the
intake process. The physician or HSPP must again see the patient or review the documentation to
certify the treatment plan and specific treatment modalities at intervals not to exceed 90 days during a
course of treatment. The physician must document all reviews in writing. A cosignature is not
sufficient.
The IHCP requires written evidence of physician or HSPP involvement and personal evaluation to
document the member’s acute medical needs. If practicing independently, a physician or an HSPP
must order therapy in writing.
The IHCP requires PA for mental health services provided in an outpatient or office setting that exceed
20 units per member, per provider, per rolling 12-month period. Providers must attach a current plan of
treatment and progress notes explaining the necessity and effectiveness of therapy to the PA form and
available for audit purposes, according to 405 IAC 5-20-13.
The IHCP requires PA for all units of neuropsychology and psychological testing. This applies to the
following CPT codes:
•
96101 – Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual
abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the
psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time
interpreting these test results and preparing the report
•
96110 – Developmental screening, with interpretation and report, per standardized instrument form
•
96111 – Developmental testing, (includes assessment of motor, language, social, adaptive, and/or
cognitive functioning by standardized developmental instruments) with interpretation and report
•
96118 – Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler
Memory Scales and Wisconsin Car Sorting Test), per hour of the psychologist’s or physician’s
time, both face-to-face time administering tests to the patient and time interpreting these test results
and preparing the report
According to 405 IAC 5-20-8(6), a physician or HSPP must provide these services. The IHCP provides
reimbursement for psychological and neuropsychological testing (96102 and 96119) when rendered by
a mid-level practitioner under the direct supervision of a physician or health service provider in
psychology (HSPP), as outlined in 405 IAC 5-20-8. These services require prior authorization (PA).
The IHCP does not reimburse CPT code 96101 when billed for the same test or services performed
under psychological testing code 96102.
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Similarly, CPT code 96118 is not reimbursed when billed for the same test or services performed
under neuropsychological testing code 96119.
Note: When requesting PA, the provider must have a list of the tests or services to
differentiate procedure code 96101 from 96102, and also procedure code
96118 from 96119.
According to 405 IAC 5-20-8 (14), reimbursement is available for one unit of psychiatric diagnostic
interview examinations, CPT code 90791 or 90792, per member, per provider, per rolling 12-month
period. All additional units of psychiatric diagnostic interviews require prior authorization; with the
exception that, two units are allowed every rolling 12-month period when the recipient is separately
evaluated by both the physician or HSPP and a mid-level practitioner.
The following HCPCS codes in combination are subject to 20 units per member, per provider, per
rolling 12-month period:
•
90791–90792
•
90832–90840
•
90845–90853
•
90899
•
96151–96153
The IHCP does not cover the following services:
•
Biofeedback
•
Broken or missed appointments
•
Day care
•
Hypnosis
•
Partial hospitalization, except as set forth in 405 IAC 5-21.5
CPT codes 90833, 90836, and 90838 for psychotherapy with medical evaluation and management.
Therefore, the IHCP does not reimburse clinical social workers, clinical psychologists, or any midlevel practitioners (excluding nurse practitioners and clinical nurse specialists) for these codes.
For all outpatient services rendered, providers must identify and itemize services rendered on the CMS1500. The medical record documentation must identify the services and the length of time of each
therapy session. Providers must make this information available for audit purposes. Providers should
use the rendering NPI of the supervising practitioner (physician or HSPP) to bill psychiatric and
clinical nurse specialist services. Providers must use these modifiers with the appropriate procedure
code, which are as follows:
•
AH – Services provided by a clinical psychologist
•
AJ – Services provided by a clinical social worker
•
HE in conjunction with SA – Services provided by a nurse practitioner or clinical nurse specialist
•
HE – Services provided by any other mid-level practitioner as addressed in the 405 IAC 5-20-8 (10)
•
HW –Funded by State mental health agency (MRO services)
•
SA – NP/CNS in a nonmental health arena
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For claims that providers bill for mid-level practitioner services and bill with the modifiers noted –
except modifiers SA and HW, which are informational and do not affect reimbursement – the IHCP
reimburses at 75% of the IHCP-allowed amount for the procedure code identified. HSPPs do not need
to use the modifier, and the IHCP reimburses them at 100% of the RBRVS fee. Place the modifiers in
field 24D of the CMS-1500 claim form.
CMHCs must continue to use the HW modifier to denote MRO services in addition to the modifiers
listed previously that identify the qualifications of the individual rendering the service. Further, there
are specific modifiers needed for submission of MRO claims. Place the modifiers in field 24D of the
CMS-1500 claim form. Additional information about MRO services is published in the MRO Provider
Manual on the Manuals page of indianamedicaid.com.
Bridge Appointments
Effective December 1, 2011, the IHCP covers bridge appointments for Care Select and Traditional
Medicaid Fee-for-Service (FFS) members, for dates of service on or after December 1, 2011.
Bridge appointments are follow-up appointments after inpatient hospitalization for behavioral health
issues, when no outpatient appointment is available within seven days of discharge. The goal of the
bridge appointment is to provide proper discharge planning while establishing a connection between
the member and the outpatient treatment provider.
During the bridge appointment, the provider should ensure at minimum that:
•
The member understands the medication treatment regimen as prescribed.
•
The member has ongoing outpatient care.
•
The family understands the discharge instructions for the member.
•
Barriers to continuing care are addressed.
•
Any additional questions from the member or family are answered.
Reimbursement
The following conditions must be met for bridge appointments to be reimbursed:
•
Appointments must be conducted face-to-face in an outpatient setting on the day of discharge from
an inpatient setting.
•
Appointments must be a minimum of 15 minutes long.
•
The member must have one or more identified barriers to continuing care, such as:
- Special needs
- Divorce or custody issues
- Work conflicts
- Childcare problems
- Inability to schedule within seven days
- History of noncompliance
- Complex discharge plans
•
The member must have one of the diagnosis codes listed in the following table. Bridge
appointments may be appropriate for members with psychiatric diagnoses not listed; however,
documentation must be maintained in the member’s chart, indicating the reason the bridge
appointment service was necessary.
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Table 8.105 – Bridge Appointment Diagnosis Codes
Diagnosis Code
Description
295.XX – 295.9X
Schizophrenic Disorders
296.0X – 296.9X
Episodic Mood Disorders
297.0 – 297.9
Delusional Disorders
298.0 – 298.9
Depressive Type Psychosis
299.0X – 299.9X
Pervasive Developmental Disorders
300.3
Obsessive Compulsive Disorder
300.4
Dysthymic Disorder
309.0 – 309.9
Adjustment Reaction with Adjustment
Disorder with Depressed Mood
311
Depressive Disorder Not Elsewhere
Classified
312.0X – 312.9
Disturbance of Conduct Not Elsewhere
Classified
313.0 – 313.9
Disturbance of Emotions Specific to
Childhood and Adolescence
314.0X – 314.9
Hyperkinetic Syndrome of Childhood
The appointment must be conducted by a qualified mental health provider, defined as:
•
A licensed psychologist
•
A licensed independent practice school psychologist
•
A licensed clinical social worker (LCSW)
•
A licensed marital and family therapist (LMFT)
•
A licensed mental health counselor (LMHC)
•
counseling
•
An advanced practice nurse (APN) who is a licensed, registered nurse holding a master’s degree in
nursing, with a major in psychiatric or mental health nursing from an accredited school of nursing
Billing requirements
The IHCP limits reimbursement of bridge appointments to one unit per member, per hospitalization.
As previously noted, bridge appointments must be conducted face-to-face for a minimum of 15
minutes.
Providers must bill bridge appointments on a CMS-1500 form using CPT code 99401 – Preventive
Medicine Counseling and/or Risk Factor Reduction Intervention(s) provided to an Individual, along
with the HK modifier, to indicate bridge appointment service.
Note: Fractional or multiple units may not be billed. Only one unit may be billed
per hospitalization.
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Package C
The IHCP reimburses for 30 visits per member, per rolling calendar year for Package C members. The
IHCP may cover an additional 20 visits with PA for a maximum of 50 visits per year.
Medicaid Rehabilitation Option Services
MRO Services are clinical behavioral health services provided to consumers and families of consumers
living in the community who need aid intermittently for emotional disturbances or mental illness and
addiction. Services may be provided in individual or group settings, and in the community. The IHCP
provides reimbursement for the following MRO, outpatient mental health services:
•
Adult Intensive Resiliency Services (AIRS)
•
Addiction Counseling
•
Behavioral Health Counseling and Therapy
•
Behavioral Health Level of Need Redetermination
•
Case Management Services
•
Child and Adolescent Rehabilitative Services (CAIRS)
•
Crisis Intervention
•
Intensive Alcohol or Drug (substance-related disorder) Outpatient Treatment (IOT)
•
Medication Training and Support
•
Peer Recovery
•
Psychiatric Assessment and Intervention
•
Skills Training and Development
As stated in 405 IAC 5-21.5, the IHCP reimburses for community mental health services for members
with mental illness when the provider for those services is an enrolled mental health center that meets
applicable federal, state, and local laws concerning the operation of CMHCs. Community Medicaid
Rehabilitation Services include outpatient mental healthcare for the seriously mentally ill or seriously
emotionally disturbed, partial hospitalization services, and case management services. Outpatient
mental health services may include clinical attention in the member’s home, workplace, mental health
facility, emergency department, or wherever needed. A qualified mental health professional, as
outlined in 405 IAC 5-21.5-1(c) must render these services.
Acute Partial Hospitalization
The service code for partial hospitalization is S0201 – Partial Hospitalization Services, less than 24
hours, per diem is used for dates of service (DOS) on or before August 30, 2013.
Services for partial hospitalization on and after September 1, 2013, must be billed using H0035 –
Mental health, partial hospitalization, treatment, less than 24 hours.
Definition of Partial Hospitalization Service
Partial hospital (PH) programs are highly intensive, time-limited medical services intended to provide
a transition from inpatient psychiatric hospitalization to community-based care or, in some cases,
substitute for an inpatient admission.
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Admission criteria for a PH program are essentially the same as for the inpatient level of care, except
that the patient does not require 24-hour nursing supervision. Patients must have the ability to reliably
maintain safety when outside the facility. Patients with clear intent to seriously harm themselves or
others are not candidates for partial hospitalization.
The program is highly individualized, with treatment goals that are measureable, functional, time
framed, medically necessary, and directly related to the reason for admission.
To qualify for partial hospitalization services, members must have a diagnosed or suspected mental
health illness and one of the following:
•
Short-term deficit in daily functioning
•
High probability of serious deterioration of the patient’s general medical or mental health
Target Population for Partial Hospitalization
The target population for partial hospitalization is members with psychiatric disturbances that meet the
criteria for acute inpatient admission, but who can maintain safety in a reliable, independent housing
situation. PH is not covered for persons currently residing in group homes or other residential care
settings.
Authorization Process
Providers must contact the member’s health plan at the time of PH admission to request authorization
for services.
•
Services are authorized for up to five days, depending on the patient’s condition.
- If less than four days per week of active treatment is provided, individual services (for example:
therapy) provided must be billed instead of PH.
•
Reauthorization criteria is applied to stays that exceed five days.
Programming Standards
PH has the following program standards:
•
Services must be ordered and authorized by a psychiatrist.
•
A face-to-face evaluation and assignment of mental illness diagnosis must take place within 24
hours following admission to the program.
•
PH programs must include four to six hours of active treatment per day and must be provided at
least four days a week
- If less than four to six hours (or four days per week) of active treatment is to be provided, the
individual services provided (for example, therapy) must be billed instead of partial
hospitalization.
•
The program has a high degree of structure and scheduling, and does not mix patients in partial
hospitalization with consumers receiving outpatient behavioral health services.
•
Some overlap with activities and services with psychiatric inpatients may be acceptable if the
services are provided in the least restrictive setting and not in a locked unit.
•
A psychiatrist must actively participate in the case review and monitoring of care.
•
The treatment team must include licensed mental health providers with direct supervisory oversight
by a physician, psychiatrist, or health services provider in psychology (HSPP).
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•
Evidence of active oversight and monitoring of progress by the physician, psychiatrist, or HSPP
must appear in each individual patient record.
•
At least one psychotherapy service must be delivered daily (individual, family, or group
psychotherapy) by a licensed mental health provider.
•
For children, there must be evidence of active therapy, including but not limited to occupational
therapy and coordination with school.
•
PH is not an MRO service.
Treatment Plan
The individual treatment plan must identify the following:
•
The coordinated services to be provided around the individual needs of the patient
•
The behaviors and/or symptoms that resulted in admission and treatments for those behaviors or
symptoms
•
The functional changes necessary for transition to a lower intensity of service, and the means
through which progress will be evaluated
•
The criteria for discharge and the planned transition to community services
The treatment plan must receive regular review by the physician, psychiatrist, or HSPP.
Exclusions
The following are excluded from partial hospitalization service:
•
Persons who represent an active risk to themselves or others
•
Persons who cannot engage in active psychotherapies and commit to change
•
Persons in concurrent treatment for addiction and not in recovery
•
Persons who by virtue of age or medical condition cannot actively participate in group therapies
Prior Authorization Criteria
This service is offered as an alternative to inpatient admission. All partial hospitalization services
require prior authorization and review by the health plan for medical necessity. Contact the member’s
health plan to request specific details or to request authorization of services.
Reauthorization Criteria
Continued stay requires at least one of the following criteria be met:
•
Clinical evidence indicates the persistence of problems that caused the admission, to the degree that
would necessitate continued treatment in the partial hospitalization program.
•
Current treatment plan must include documentation of diagnosis, discharge planning,
individualized goals of the treatment, and treatment modalities needed and provided.
•
Patient’s progress confirms that the presenting or newly defined problems will respond to the
current treatment plan.
•
Daily progress notes, written and signed by the provider, document the treatment received and the
patient’s response.
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•
Severe reaction to the medication or need for further monitoring and adjustment of dosage in a
controlled setting. This should be documented daily in the progress notes by a physician.
•
Clinical evidence that disposition planning, progressive decreases in time spent in the partial
hospital program, and attempts to discontinue the partial hospital treatment program have resulted
in, or would result in, exacerbation of the psychiatric illness to the degree that would necessitate
inpatient hospitalization.
Level of Need
Any Child & Adolescent Needs and Strengths Assessment (CANS) or Adult Needs and Strengths
Assessment (ANSA) level of need can qualify for partial hospitalization services.
Applicable Service Codes
The service code for partial hospitalization is S0201 – Partial Hospitalization Services, less than 24
hours, per diem for DOS on or before August 30, 2013.
Services for partial hospitalization on and after September 1, 2013, must be billed using H0035 –
Mental health, partial hospitalization, treatment, less than 24 hours,
Provider Qualifications
Subject to prior authorization by the office or its designee, Medicaid reimburses the physician or
HSPP-directed outpatient mental health services for group, family, and individual outpatient
psychotherapy when the services are provided by one of the following practitioners:
•
A licensed psychologist
•
A licensed independent practice school psychologist
•
A licensed clinical social worker (LCSW)
•
A licensed marital and family therapist (LMFT)
•
A licensed mental health counselor (LMHC)
•
counseling
- Partial hospitalization services provided by the person will not be reimbursed by Medicaid.
•
An advanced practice nurse who is a licensed, registered nurse with a master’s degree in nursing
with a major in psychiatric or mental health nursing from an accredited school of nursing
Limitations and Restrictions
•
Prior authorization is required.
•
Providers are subject to postpayment review to ensure that the minimum requirement of four to six
hours of active therapy is provided.
•
One unit (H0035) is allowed per date of service.
•
Inpatient services are not reimbursable on the same date as H0035.
•
Physician services and prescription drugs are reimbursed separately from H0035.
•
Service must be provided at least four days per week.
Acute Partial Hospitalization and Third-Party Liability
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Providers inquired about the need to bill third-party insurance before submitting claims to Medicaid.
Acute partial hospitalization is not a Medicaid Rehabilitation Option Service, and the IHCP requires
third-party insurance, including commercial carriers and Medicare, be billed before submitting the
claim to Medicaid. For more information about the process for billing claims when a member has
coverage through another insurer or policy, see Chapter 6: Prior Authorization of this manual.
Coverage of Mental Health Codes for Children’s Health Insurance Program
As a result of Senate Enrolled Act 102, the IHCP now reimburses for mental health services, including
Psychiatric Residential Treatment Facility (PRTF) and MRO services under Children’s Health
Insurance Plan (CHIP), or Package C. Providers can check the Fee Schedule on indianamedicaid.com
to see if PA is required.
Table 8.106 shows codes for covered services rendered and billed under CHIP. The same limits and
restrictions that apply to these codes under Medicaid apply to these codes covered under CHIP
(Package C).
Table 8.106 – Codes for Covered Services under CHIP
Code/Modifier
Description
H0004 HW
Behavioral health counseling and therapy
H0004 HW HR
Behavioral health counseling and therapy, family/couple
with client
H0004 HW HS
Behavioral health counseling and therapy, family/couple
without the client present
H0031 HW
Mental health assessment, by nonphysician
H2011 HW
Crisis intervention service, per 15 minutes
H2014 HW
Skills training and development, per 15 minutes
T1016 HW
Case management, each 15 minutes
97535
Self-care/home management training (eg, activities of daily
living (ADL) and compensatory training, meal preparation,
safety procedures, and instructions in use of assistive
technology devices/adaptive equipment) direct one-on-one
contact, each 15 minutes
97537
Community/work reintegration training (eg, shopping,
transportation, money management, avocational activities
and/or work environment/modification analysis, work task
analysis, use of assistive technology device/adaptive
equipment), direct one-on-one contact, each 15 minutes
T2048
Behavioral health; long-term care residential (nonacute care
in a residential treatment program where stay is typically
longer than 30 days), with room and board, per diem
T2048 U1
longer than 30 days); medical leave days are limited to four
(PRTF)
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Code/Modifier
Description
T2048 U2
longer than 30 days); therapeutic leave days are limited to
14 (PRTF)
90785
Interactive complexity (List separately in addition to the
90791
Psychiatric diagnostic evaluation
90792
Psychiatric diagnostic evaluation with medical services
90832
Psychotherapy, 30 minutes with patient and/or family
member
90833
member when performed with an evaluation and
management service (List separately in addition to the code
for primary procedure)
90834
member
90836
90837
member
90838
90839
Psychotherapy for crisis; first 60 minutes
90840
Psychotherapy for crisis; each additional 30 minutes (List
separately in addition to code for primary service)
90845
Psychoanalysis
90846
Family psychotherapy (without the patient present)
90847
Family psychotherapy (conjoint psychotherapy) (with
patient present)
90849
Multiple-family group psychotherapy
90853
Group psychotherapy (other than of a multiple-family
group)
90870
Electroconvulsive therapy (includes necessary monitoring)
90899
Unlisted psychiatric service or procedure
96101
Psychological testing (includes psychodiagnostic
assessment of emotionality, intellectual abilities,
personality and psychopathology, eg, MMPI, Rorschach,
WAIS), per hour of the psychologist’s or physician’s time,
both face-to-face time administering tests to the patient and
time interpreting these test results and preparing the report
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Code/Modifier
Description
96105
Assessment of aphasia (includes assessment of expressive
and receptive speech and language function, language
comprehension, speech production ability, reading,
spelling, writing, eg, by Boston Diagnostic Aphasia
Examination) with interpretation and report, per hour
96110
Developmental screening, with interpretation and report,
per standardized instrument form
96111
Developmental testing, (includes assessment of motor,
language, social, adaptive, and/or cognitive functioning by
standardized developmental instruments) with interpretation
and report
96116
Neurobehavioral status exam (clinical assessment of
thinking, reasoning, and judgment, eg, acquired knowledge,
attention, language, memory, planning and problem
solving, and visual spatial abilities), per hour of the
psychologist’s or physician’s time, both face-to-face time
with the patient and time interpreting test results and
preparing the report
96118
Neuropsychological testing (eg, Halstead-Reitan
Neuropsychological Battery, Wechsler Memory Scales and
Wisconsin Card Sorting Test), per hour of the
psychologist’s or physician’s time, both face-to-face time
administering tests to the patient and time interpreting these
test results and preparing the report
96150
Health and behavior assessment (eg, health-focused clinical
interview, behavioral observations, psycho physiological
monitoring, health-oriented questionnaires), each 15
minutes face-to-face with the patient; initial assessment
96151
Health and behavior assessment (eg, health-focused clinical
interview, behavioral observations, psycho physiological
monitoring, health-oriented questionnaires), each 15
minutes face-to-face with the patient; re-assessment
96152
Health and behavior intervention, each 15 minutes face-toface; individual
96153
Health and behavior intervention, each 15 minutes, face-toface; group (2 or more patients)
96154
Health and behavior intervention, each 15 minutes, face-toface; family (with the patient present)
96155
Health and behavior intervention, each 15 minutes, face-toface; family (without the patient present)
Psychiatric Residential Treatment Facilities
Coverage Provisions
The IHCP reimburses for medically necessary services provided to children younger than 21 years old
in a PRTF. The IHCP also reimburses for children younger than 22 years old who began receiving
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PRTF services immediately before their 21st birthday. All services require prior authorization by
the appropriate MCE or CMO.
Effective January 1, 2013, clinical providers have the option to request PA for a member’s admission
to a PRTF via telephone. The clinician or provider must maintain the same documentation in the chart
that would be required if submitting the request via mail or fax. Once PA is created in IndianaAIM, the
request will remain in a “pending” status until the required documentation has been submitted via mail
or fax. Submission is required within 14 business days of admission. See Chapter 6: Prior
Authorization of this manual for complete information on required forms and documentation.
Note:
The PRTF Model Attestation Letter Addendum has been updated to include
State Survey Provider ID so that the ISDH and the OMPP can track
facilities. The ISDH issues a State Survey Provider ID after reviewing the
PRTF Attestation Form. Because the State Survey Provider ID is used for
internal purposes, the provider should disregard this field. Additional
information can be found in Chapter 4: Provider Enrollment, Eligibility, and
Responsibilities of this manual.
Risk-based Managed Care
The IHCP carves out PRTF services from the risk-based MCEs’ financial responsibility. However,
MCEs must provide care coordination services and associated services related to PRTF services. These
services are subject to the PA and reimbursement policies of the member’s managed care plan.
Providers should verify the member’s eligibility at initial admission on the first and 15th of the month
to determine the member’s current managed care eligibility.
Care Select
PRTF services do not require certification from the primary medical provider (PMP). The appropriate
CMO provides PA for PRTF placement, and providers bill claims to the IHCP. Services rendered
outside the PRTF may be subject to PMP certification and PA requirements. Providers should verify
the member’s eligibility before rendering services and also verify on the first and 15th of each month to
confirm the member’s current care management eligibility.
Leave Days
The days of care that can be billed to the IHCP for a member admitted to a PRTF must be expressed in
units of full days. A day consists of 24 hours beginning at midnight and ending 24 hours later at
midnight. For IHCP billing purposes, PRTFs are expected to follow the midnight-to-midnight
method when reporting days of care for members, even if the health facility uses a different
definition of a day for statistical or other purposes.
Although it is not mandatory for facilities to reserve beds, Medicaid reimburses for reserving beds for
recipients at one-half the regular customary per diem rate, provided that criteria set forth is met for
medical and therapeutic leave. These services are available to Medicaid members younger than 21
years old. In no instance will the IHCP reimburse a PRTF for reserving beds for Medicaid
members when the facility has an occupancy rate of less than 90%. The occupancy rate must be
determined by dividing the total number of residents in licensed beds (excluding residential beds) in
the psychiatric treatment facility taken from the midnight census as of the day that a Medicaid recipient
takes a leave of absence, by the total number of licensed PRTF beds (excluding residential beds) in the
PRTF.
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Medical Leave Days
For members younger than 21 years old, the IHCP reimburses for medical leave days in a PRTF at
one-half the regular customary per diem rate when the provider meets all the following conditions:
•
The physician orders hospitalization for treatment of an acute condition that cannot be treated in the
PRTF.
•
The total length of time allowed for payment of a reserved bed in a PRTF for a single hospital stay
is four consecutive days. If the member requires hospitalization longer than four consecutive days,
the PRTF must discharge the member.
•
The PRTF must maintain a physician’s order for the hospitalization in the member’s file.
•
The facility has an occupancy rate of at least 90%. In no instance does the IHCP reimburse a PRTF
for reserving beds for Medicaid members when the facility has an occupancy rate of less than 90%.
Documentation is subject to retrospective review.
Therapeutic Leave Days
For members younger than 21 years old, the IHCP reimburses for therapeutic leave days in a PRTF at
one-half the regular customary per diem rate when the provider meets all the following conditions:
•
A leave of absence must be for therapeutic reasons as prescribed by the attending physician and as
indicated in the member’s plan of care.
•
In a PRTF, the total length of time allotted for therapeutic leaves in any calendar year is 14 days per
member. If the member is absent from the PRTF for more than 14 days per year, the IHCP makes
no further reimbursement in that year for reserving a bed for therapeutic leave for that member.
Therapeutic leave days do not have to be consecutive.
•
The facility must maintain a physician’s order for therapeutic leave in the member’s file.
•
The facility must have an occupancy rate of at least 90%. In no instance does the IHCP reimburse a
PRTF for reserving beds for Medicaid members when the facility has an occupancy rate of less
than 90%. Documentation is subject to retrospective review.
Providers must submit claims for PRTF services on the CMS-1500 claim form or the 837P electronic
transaction. PRTF services are reimbursed on a per diem basis. PRTF providers may bill a single date
of service per detail, with consecutive dates of service per individual CMS-1500 claim form. The
PRTF per diem does not include pharmaceutical supplies and physician services. The per diem rate
includes the cost of all IHCP-covered psychiatric services provided to members residing in a PRTF, as
well as the cost for IHCP-covered services not related to the member’s psychiatric condition if such
services are performed at the PRTF. The IHCP makes separate reimbursement available only in
instances where IHCP-covered services, not related to the member’s psychiatric condition, are
unavailable at the PRTF and are performed at a location other than the PRTF. The PRTF per diem does
not include pharmaceutical supplies and physician services, and the IHCP pays for them separately
from the PRTF per diem rate. These services are subject to provisions set forth in 405 IAC 5-24 and
405 IAC 5-25, respectively.
Providers should use the following codes when billing for these services included in the PRTF per
diem:
•
T2048 – For per diem services (behavioral health, long-term care residential, or nonacute care in a
residential treatment facility where the stay is typically longer than 30 days).
•
T2048 U1 – For medical leave (behavioral health, long-term care residential, nonacute care in a
residential treatment facility where the stay is typically longer than 30 days). Medical leave days
are limited to four.
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•
T2048 U2 – For therapeutic leave (behavioral health, long-term care residential, nonacute care in a
residential treatment facility where the stay is typically longer than 30 days). Therapeutic leave
days are limited to 14.
Risk-based Managed Care
Most behavioral health services are carved into the RBMC program. Services rendered by providers
enrolled in the IHCP with the following provider specialties are the responsibility of the MCE:
•
011 – Freestanding Psychiatric Hospital
•
110 – Outpatient Mental Health Clinic
•
111 – Community Mental Health Center
•
112 – Psychologist
•
113 – Certified Psychologist
•
114 – Health Services Providers in Psychology
•
115 – Certified Clinical Social Worker
•
116 – Certified Social Worker
•
117 – Psychiatric Nurse
•
339 – Psychiatrist
The carved-in behavioral health services rendered by the mental health provider specialties previously
listed should be billed directly to the applicable behavioral health organization (BHO) subcontracted
by the MCE. Behavioral health services rendered by nonmental health provider specialties should be
billed to the applicable MCE.
The following mental health services remain carved out of the RBMC program and are paid by HP on
the fee-for-service methodology:
•
PRTF services rendered by a provider enrolled in the IHCP program with a specialty of 034. The
MCEs retain responsibility for services outside the PRTF, including transportation, pharmacy, and
other related healthcare services. MCEs are also responsible for care coordination of members
receiving PRTF services.
- Effective January 1, 2011, Hoosier Healthwise members receiving PRTF services are
disenrolled from RBMC and moved to fee-for-service while in the PRTF. To facilitate
appropriate claims payment, a level of care is established for members receiving PRTF services.
PRTF providers need to contact ADVANTAGE Health Solutions SM at 1-800-269-5720 when
they have an RBMC member who is going to be admitted, so ADVANTAGE can assign a level
of care. Once the level of care is assigned, the member will be disenrolled from RBMC.
- When the member is discharged from the PRTF, he or she is reenrolled immediately into the
most applicable Medicaid program.
•
All claims for mental health medications, when billed by a pharmacy, are processed by the State’s
Pharmacy Benefit Manager, Catamaran.
•
MRO services rendered by provider specialty 111 – Community Mental Health Center to
individuals, families, or groups living in the community who need aid intermittently for emotional
disturbances or mental illness. MRO services include outpatient mental health services.
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Before January 1, 2011, as with other carved-out services, the MCE remains responsible for services
that may be related to the PRTF or MRO services outside the PRTF services rendered, including but
not limited to care coordination, transportation, and pharmacy services.
The following services remain excluded from the Hoosier Healthwise program, and members are
disenrolled from managed care when they qualify for such services:
•
Services in an ICF/IID
•
Inpatient services in a state psychiatric hospital that are not Medicaid services, but are provided
under the State’s 590 program
Screening and Brief Intervention Services
The IHCP reimburses providers for screening and brief intervention (SBI) services. SBI identifies and
intervenes with individuals at risk for substance abuse-related problems or injuries. SBI services use
established systems, such as trauma centers, emergency rooms, community clinics, and school clinics,
to screen patients who are at risk for substance abuse and, if necessary, provide the patients with brief
interventions or referrals to appropriate treatment.
The IHCP reimburses providers when they bill procedure codes 99408 or 99409. The descriptions for
the procedure codes are listed in Table 8.107.
Table 8.107 – Screening and Brief Intervention Service Procedure Codes
Code
Description
99408
Alcohol and/or substance (other than tobacco) abuse structured screening
(eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30
minutes
99409
Alcohol and/or substance (other than tobacco) abuse structured screening
(eg, AUDIT, DAST), and brief intervention (SBI) services; greater than
30 minutes
The CPT codes were developed by the American Medical Association (AMA) to make it possible for
the healthcare system to “efficiently report screening services for drug and alcohol abuse.” Providers
can bill procedure code 99408 or 99409 only after an individual has been screened for alcohol or drug
abuse by a healthcare professional.
SBI services currently do not require prior authorization. Procedure codes 99408 and 99409 are limited
to one structured screening and brief intervention per individual, every three years, when billed by the
same provider. This screening and intervention visit does not count toward the number of annual office
visits allowed per year for an individual.
Mid-Level Practitioner Services
The proper billing procedures for billing nurse practitioner and physician assistant services are as
follows:
•
Nurse practitioners – The IHCP reimburses independently practicing nurse practitioners at 75% of
the rate on file. The nurse practitioner must enter his or her rendering NPI number in field 24J of
the CMS-1500. The billing NPI must be entered in field 33a on the CMS-1500 claim form.
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•
Nurse practitioners not individually enrolled in the IHCP, and clinical nurse specialists employed
by physicians in a physician-directed group or clinic, bill services with the SA modifier and the
physician rendering NPI in fields 24J of the CMS-1500. The billing NPI must be entered in field
33a on the CMS-1500 claim form. The IHCP reimburses these providers at 100% of the Medicaidallowed amount.
•
Nurse practitioners with an individual LPI and NPI who are employed by a physician, should bill
using their rendering NPI in field 24J of the CMS-1500. The NPI must be entered in field 33a on
the CMS-1500 claim form. The IHCP reimburses these providers at 100% of the Medicaid-allowed
amount.
•
Providers cannot bill separately for nurse practitioner services in outpatient hospital settings and
should include these services in the hospital outpatient reimbursement rate.
•
Physician assistants – Providers should bill physician assistant services with the HN, bachelor’s
degree or HO, master’s degree modifier applicable to the level of education of the physician
assistant. The physician’s rendering NPI must be entered in field 24J of the CMS-1500. The
physician’s billing NPI must be entered in field 33a on the CMS-1500 claim form. The IHCP
reimburses these providers at 100% of the Medicaid-allowed amount. Physician assistants are not
separately enrolled in the IHCP. However, when a physician assistant provides assistant surgeon
services, the provider should use modifier AS instead of the HN or HO modifier. Reimbursement
for the assistant at surgery is 20% of the rate on file.
Providers should place modifiers in field 24D, under the modifier heading on the CMS-1500 claim
form.
Smoking Cessation Treatment Services
Eligible Providers and Practitioners
Practitioners eligible to provide smoking cessation treatment services, but not currently enrolled as
IHCP providers, should contact HP Provider Enrollment at 1-877-707-5750 to request a provider
enrollment application. Eligible practitioners, such as pharmacists who work for or own IHCP-enrolled
pharmacies, bill for treatment services rendered through the enrolled entity where services are
provided. Physician assistants, registered nurses, and psychologists who are not HSPPs bill for
counseling services rendered through the enrolled entity through which services are provided.
Treatment services must be prescribed by a licensed practitioner within the scope of license under
Indiana law. The IHCP reimburses for smoking cessation treatment services rendered by the following
licensed practitioners participating in the IHCP:
•
Nurse practitioner
•
Pharmacist
•
Physician
•
Physician’s assistant
•
Psychologist
•
Registered nurse
•
Dentist
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The following practitioners cannot obtain an IHCP rendering NPI number and must bill under the
supervising practitioner’s NPI number:
•
Physician assistant
•
Psychologist
•
Registered nurse
Reimbursement
The IHCP makes reimbursement for smoking cessation available for one 12-week course of treatment
per member per calendar year. Treatment may include prescription of any combination of smoking
cessation products and counseling. Providers can prescribe one or more modalities of treatment.
Providers must include counseling in any combination of treatment.
Note: For information about reimbursement of smoking cessation products refer to
Chapter 9: IHCP Pharmacy Services Benefit of this manual.
Providers must order smoking cessation treatment services for the IHCP to reimburse for the services.
Practitioners ordering smoking cessation services should maintain documentation about the order in
the same manner used for other covered services.
The IHCP does not require PA for reimbursement for smoking cessation products or counseling.
Providers of smoking cessation treatment services must obtain PMP certification for Hoosier
Healthwise and Care Select enrollees.
Counseling
When providers and practitioners furnish a service to the general public at no charge, including
smoking cessation counseling services, they cannot receive IHCP reimbursement for that service. The
IHCP Program Department closely monitors adherence to this program limitation.
Ordering and rendering practitioners must maintain sufficient documentation of respective functions to
substantiate the medical necessity of the service rendered and to substantiate the provision of the
service itself; this requirement is consistent with existing IHCP policies and regulations.
For services rendered prior to November 1, 2011, providers or practitioners of counseling services
must bill only on the CMS-1500 or 837P using procedure code S9075 – Smoking cessation treatment,
with a primary diagnosis code of 305.1 – Tobacco use disorder.
For dates of service on or after November 1, 2011, providers must bill using procedure code 99407 U6
– Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes; per 15
minutes with a primary diagnosis code of 305.1. Providers must bill the modifier U6 to denote “per 15
minutes.”
Note: Providers and practitioners must bill the usual and customary charge for the
units of service rendered, and the IHCP calculates the final reimbursement
amount.
One unit of 99407 U6 is 15 minutes of service. Providers should not round up to the nearest 15
minutes.
Providers must perform counseling for a minimum of 30 minutes (two units) and a maximum of 150
minutes (10 units) within the 12 weeks. Providers must bill counseling in 15-minute increments.
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Newborn Services
Newborn Blood Screening
Indiana law requires newborn blood screening tests for at least eight conditions for every infant before
discharge from the hospital. IC 16-41-17-2(d) identifies religious belief exception from this
requirement.
The newborn screening test screens for the following:
•
Galactosemia
•
Hemoglobinopathies, including sickle cell anemia
•
Homocystinuria
•
Hypothyroidism
•
Maple syrup urine disease
•
Phenylketonuria (PKU)
•
Congenital adrenal hyperplasia
•
Biotinidase deficiency
•
Medium Chain Acyl-Coenzyme A Dehydrogenase (MCAD) deficiency
•
34 other amino acid defects, fatty acid oxidation defects and/or organic acidemias
•
Cystic Fibrosis (CF)
•
Congenital heart disease (CCHD), effective January 1, 2012.
The hospital collects all blood samples on a filter paper card that must also contain information to
identify the infant, the physician, the time of birth, the time of first feeding, and the time of the blood
draw. The hospital sends the blood sample to the Indiana University (IU) Newborn Screening
Laboratory.
The IU Laboratory has a contract with the Indiana State Department of Health (ISDH) to perform
laboratory analysis for newborn screening. Providers using laboratories other than the IU Laboratory to
perform newborn screening analysis must discontinue the practice. To ensure that the IU Laboratory
performs all newborn screening, the ISDH must coordinate all newborn screening.
Primary care providers can access newborn screening results online through the Indiana Newborn
Screening Tracking & Education Program (INSTEP). For registration instructions, please send an email to Bob Bowman, director of Genomics and Newborn Screening (BobBowman@isdh.IN.gov).
Other healthcare professionals who are not primary care providers can obtain newborn screening
results by contacting the IU Newborn Screening Laboratory. A fax must be sent on office letterhead
with the patient’s name, date of birth (DOB), patient’s mother’s name, and birthing facility to (317)
491-6679. Healthcare professionals with any questions may call 1-800-245-9137. Parents or other
individuals requesting newborn screening results can contact the ISDH Genomics and Newborn
Screening Program by calling 1-888-815-0006.
If the IU Laboratory has obtained a valid test and the results are normal, the IHCP requires no further
testing. If the laboratory needs to rescreen due to invalid or abnormal results, the provider must contact
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the ISDH to work out the best method of accomplishing the rescreening. Because hospitals are more
frequently releasing newborns before the 48 hours needed to obtain valid newborn screen results, an
increasing number of newborns require a second screen. Providers ask families to bring the newborn
back to the birth hospital as an outpatient, or the hospital requests a nurse make a follow-up visit to
obtain the sample for newborn screening. In either case, the possibility arises that the hospital could
bill separately for newborn screening that is already included in the DRG that the IHCP pays for the
newborn hospitalization.
The IHCP does not require HealthWatch/EPSDT providers to report newborn screening on the CMS1500 or 837P. The IHCP does not permit hospitals to bill separately for newborn screening. The IHCP
pays the newborn hospitalization under the DRG that includes the newborn screening. Newborns
should be screened at the birth hospital or the hospital of closest proximity. To avoid being charged by
the IU Laboratory for a second screen, a hospital screening a newborn who was born in another
Indiana hospital must indicate the name of the birth hospital on the filter paper card. If the newborn’s
name or birth date has been changed, the hospital must include the original name and date of birth in
the information sent to the IU Laboratory to facilitate a match and avoid a charge by the lab.
Note: A child born to a woman eligible for pregnancy and urgent care only is
categorically eligible at birth for full IHCP coverage, at least for the month
of birth. The child’s claims must have the child’s RID.
Newborn Hearing Screening
Indiana legislation mandates that every infant must be given a physiologic hearing screening
examination at the earliest feasible time for the detection of hearing impairments. The IHCP includes
the cost of this screening in the IHCP DRG reimbursement rate that includes the newborn’s
hospitalization. The IHCP does not allow hospitals to bill separately for initial newborn screening.
Newborns must be screened at the birth hospital before the infant is discharged. Newborns requiring
further evaluation should be referred to First Steps. See the First Steps page on the FSSA website at
in.gov/fssa for contact information.
Providers that deliver newborns not hospitalized at birth, at locations other than in the hospital, may
use the appropriate CPT codes to bill for the newborn hearing screening. Use CPT code 92585 for
auditory evoked potentials for evoked response audiometry and testing of the central nervous system,
or evoked auditory brainstem responses (ABR). Use CPT code 92587 for evoked otoacoustic
emissions (OAE); limited, single stimulus level, either transient or distortion products, or OAE.
For any follow-up diagnostic testing resulting from detection of possible audiological impairment via
the newborn screening process, providers should bill the same way they bill other audiological testing.
Providers should obtain PA if applicable.
Presumptive Eligibility – Package P
Presumptive Eligibility (PE) provides coverage to low-income pregnant women through a simplified
application process. Presumptive Eligibility covers most pregnancy-related outpatient services while
the Medicaid application process is completed. Coverage begins on the date a qualified provider (QP)
determines the woman presumptively eligible using the process outlined in the Qualified Provider
Presumptive Eligibility Manual. The woman’s Medicaid eligibility determination is subsequently
completed by the Division of Family Resources (DFR). A patient’s failure to cooperate with the DFR
to complete the Medicaid application process results in termination of PE benefits.
PE does not cover hospice, long-term care, inpatient care, labor and delivery services, abortion
services, postpartum services, sterilization, and services unrelated to the pregnancy or birth outcome.
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These services, if determined to be pregnancy-related, may be covered if the woman is later
determined eligible for Hoosier Healthwise benefits.
Presumptive Eligibility Requirements
To be eligible for presumptive eligibility, a pregnant woman must:
•
Be pregnant, as verified by a professionally administered pregnancy test
•
Not be a current Medicaid member
•
Be an Indiana resident
•
Be a U.S. citizen or a qualified noncitizen (defined in the Qualified Provider Presumptive
Eligibility Manual)
•
Not be currently incarcerated
•
Have gross family income less than 200% of the federal poverty level
Qualified Provider
Only a QP or designee can make a determination of pregnancy for PE. A QP is a provider that meets
the following criteria:
1. Enrolled as a provider in the IHCP
2. Capable of verifying pregnancy via a professionally administered pregnancy test (homeadministered tests do not meet this requirement)
3. Must attend a QP training session provided by the FSSA or designee
4. Currently provide outpatient hospital, rural health clinic, or clinic services
5. Must have access to a printer, fax machine, and Web interChange
Providers must allow PE applicants to use an office telephone to facilitate the PE and Hoosier
Healthwise enrollment process.
Billing Procedures
Submit Presumptive Eligibility claims to the appropriate MCE as selected by the patient or HP for feefor-service claims. Covered PE services are similar to Package B services, except for the following
limited diagnosis listing. More information about billing for Obstetrical Services and Package B is
found in this chapter. Contact information for the MCEs can be found in Chapter 1: General
Information of this manual. Qualified providers follow general billing directions for completing the
CMS-1500 claim form.
Table 8.108 – Diagnosis Codes for PE (Effective on or after March 1, 2011)
Diagnosis Code
Description
63300
Abdominal pregnancy without intrauterine
pregnancy
63301
Abdominal pregnancy with intrauterine
pregnancy
63310
Tubal pregnancy without intrauterine pregnancy
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Diagnosis Code
Description
63311
Tubal pregnancy with intrauterine pregnancy
63320
Ovarian pregnancy without intrauterine
pregnancy
63321
Ovarian pregnancy with intrauterine pregnancy
63380
Other ectopic pregnancy without intrauterine
pregnancy
63381
Other ectopic pregnancy with intrauterine
pregnancy
63390
Unspecified ectopic pregnancy without
intrauterine pregnancy
63391
Unspecified ectopic pregnancy with intrauterine
pregnancy
640
Hemorrhage in early pregnancy
6400
Threatened abortion
64003
Threatened abortion-antepartum
6408
Other specified hemorrhage in early pregnancy
64083
Other specified hemorrhage in early pregnancy
antepartum condition or complication
6409
Unspecified hemorrhage in early pregnancy
64093
Unspecified hemorrhage in early pregnancy,
antepartum condition or complication
641
Antepartum hemorrhage and placenta previa
6410
Placenta previa without hemorrhage
64103
Placenta previa without hemorrhage, antepartum
condition, or complication
64113
Placenta previa hemorrhage, antepartum
64120
Premature separation of placenta, unspecified
64123
Premature separation of placenta, antepartum
6413
Antepartum hemorrhage associated with
coagulation defects
64133
Antepartum hemorrhage associated with
coagulation defects, antepartum
6418
Other antepartum hemorrhage
64183
Other antepartum hemorrhage, antepartum
6419
Unspecified antepartum hemorrhage
64193
Unspecified antepartum hemorrhage
64200
Unspecified benign essential hypertension
complicating pregnancy, childbirth, and the
puerperium
64203
Essential hypertension, antepartum
64210
Renal hypertension, unspecified
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Diagnosis Code
Description
64213
Renal hypertension, antepartum
64220
Other pre-existing hypertension complicating
pregnancy, unspecified
64223
Other pre-existing hypertension complicating
pregnancy, childbirth, and the puerperium,
antepartum
64230
Transient hypertension of pregnancy,
unspecified
64233
Transient hypertension, antepartum
64240
Mild or unspecified pre-eclampsia
64243
Mild or unspecified pre-eclampsia, antepartum
64250
Severe pre-eclampsia, unspecified
64253
Severe pre-eclampsia, antepartum
64260
Eclampsia, unspecified
64263
Eclampsia, antepartum
64270
Pre-eclampsia or eclampsia superimposed on
pre-existing hypertension, unspecified
64273
Pre-eclampsia or eclampsia on pre-existing
hypertension, antepartum
64290
Unspecified hypertension complicating
pregnancy, unspecified as to episode of care or
not applicable
64293
Unspecified hypertension complicating
pregnancy, childbirth, or the puerperium,
antepartum
643
Excessive vomiting in pregnancy
6430
Mild hyperemesis gravidarum
64303
Mild hyperemesis gravidarum, antepartum
6431
Hyperemesis gravidarum with metabolic
disturbance
64313
Hyperemesis gravidarum with metabolic
disturbance, antepartum
6432
Late vomiting pregnancy
64323
Late vomiting pregnancy, antepartum
6438
Other vomiting complicating pregnancy
64383
Other vomiting complicating pregnancy,
antepartum
6439
Unspecified vomiting of pregnancy
64393
Unspecified vomiting of pregnancy, antepartum
644
Early or threatened labor
6440
Threatened premature labor
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Diagnosis Code
Description
64403
Threatened premature labor, antepartum
6441
Other threatened labor
64413
Other threatened labor, antepartum
645
Late pregnancy
6451
Prolonged pregnancy, delivered
64513
Post-term pregnancy, antepartum
64520
Prolonged pregnancy, unspecified
64523
Prolonged pregnancy, antepartum complication
6453
Prolonged pregnancy, antepartum,
646
Other complication of pregnancy
6460
Papyraceous fetus
64603
Papyraceous fetus, antepartum
6461
Edema or excessive weight gain in pregnancy,
without mention of hypertension
64613
Edema or excessive weight gain in pregnancy
without mention of hypertension, antepartum
64620
Unspecified renal disease in pregnancy, without
mention of hypertension – unspecified as to
episode of care or not applicable
64623
Unspecified renal disease in pregnancy, without
mention of hypertension, antepartum
6463
Recurrent pregnancy loss
64633
Recurrent pregnancy loss, antepartum
6464
Peripheral neuritis in pregnancy
64643
Peripheral Neuritis in pregnancy, antepartum
6465
Asymptomatic bacteriuria in pregnancy
64653
Asymptomatic bacteriuria in pregnancy,
antepartum
64660
Infections of genitourinary tract in pregnancy,
unspecified
64663
Infections of genitourinary tract, antepartum
6467
Liver disorder in pregnancy
64673
Liver disorder, antepartum
6468
Other specified complication of pregnancy
64683
Other specified complication of pregnancy,
antepartum
6469
Unspecified complication of pregnancy
64693
Unspecified complication of pregnancy,
antepartum
64700
Syphilis in pregnancy, unspecified
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Diagnosis Code
Description
64703
Syphilis, antepartum
64710
Gonorrhea in pregnancy, unspecified
64713
Gonorrhea, antepartum
64720
Other venereal disease in pregnancy, unspecified
64723
Other venereal disease, antepartum
64730
Tuberculosis in pregnancy, unspecified
64733
Tuberculosis, antepartum
64740
Malaria in pregnancy, unspecified
64743
Malaria, antepartum
64750
Rubella in pregnancy, unspecified
64753
Rubella, antepartum
64760
Other viral diseases in pregnancy, unspecified
64763
Other viral diseases, antepartum
64780
Other specified infections and parasitic disease
in pregnancy, unspecified
64783
Other specified infectious and parasitic diseases,
antepartum
64790
Unspecified infection or infestation in pregnancy
64793
Unspecified infection of infestation, antepartum
64800
Diabetes mellitus in pregnancy, unspecified
64803
Diabetes, antepartum
64810
Thyroid dysfunction in pregnancy, unspecified
64813
Thyroid dysfunction, antepartum
64820
Anemia in pregnancy, unspecified
64823
Anemia, antepartum
64830
Drug dependence in pregnancy, unspecified
64833
Drug dependence, antepartum
64840
Mental disorder in pregnancy, unspecified
64843
Mental disorder, antepartum
64850
Congenital cardiovascular disorders in
64853
Congenital cardiovascular disorders, antepartum
64860
Other congenital cardiovascular disorders in
64863
Other cardiovascular diseases, antepartum
64870
Bone and joint disorders of back, pelvis, and
lower limbs in pregnancy, unspecified
64873
Bone disorder, antepartum
6488
Abnormal glucose tolerance in pregnancy
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Diagnosis Code
Description
64880
Abnormal glucose tolerance in pregnancy,
unspecified
64883
Abnormal glucose, antepartum
64890
Other current conditions in pregnancy,
unspecified
64893
Other current conditions, antepartum
64900
Tobacco use disorder complicating pregnancy,
childbirth, or the puerperium, unspecified as to
64903
Tobacco use disorder complicating pregnancy,
childbirth, or the puerperium, antepartum
condition or complication
64910
Obesity complicating pregnancy, childbirth, or
the puerperium, unspecified as to episode of care
or not applicable
64913
Obesity complicating pregnancy, childbirth, or
the puerperium, antepartum condition or
complication
64920
Bariatric surgery status complicating pregnancy,
64923
Bariatric surgery status complicating pregnancy,
64930
Coagulation defects complicating pregnancy,
64933
Coagulation defects complicating pregnancy,
64940
Epilepsy complicating pregnancy, childbirth, or
the puerperium, unspecified as to episode of care
or not applicable
64943
Epilepsy complicating pregnancy, childbirth, or
the puerperium, antepartum condition or
complication
64950
Spotting complicating pregnancy, unspecified as
to episode of care or not applicable
64953
Spotting complicating pregnancy, antepartum
64960
Uterine size date discrepancy, unspecified as to
64963
Uterine size date discrepancy, antepartum
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Diagnosis Code
Description
64970
Cervical shortening, unspecified as to episode of
care or not applicable
64973
Cervical shortening, antepartum condition or
complication
65103
Twin pregnancy, antepartum
65113
Triplet pregnancy, antepartum
65123
Quadruplet pregnancy, antepartum
65133
Twin pregnancy with fetal loss and retention of
one fetus, antepartum
65143
Triplet pregnancy with fetal loss and retention of
one or more fetus(es), antepartum
65153
Quadruplet pregnancy with fetal loss and
retention of one or more fetus(es), antepartum
65163
Other multiple pregnancy with fetal loss and
retention of one or more fetus(es), antepartum
65173
Multiple gestation following (elective) fetal
reduction antepartum
65183
Other specified multiple gestation, antepartum
65193
Unspecified multiple gestation, antepartum
65203
Unstable lie, antepartum
65213
Breech or other malpresentation successfully
converted to cephalic presentation, antepartum
65223
Breech presentation without mention of version,
antepartum
65233
Transverse or oblique presentation, antepartum
65243
Face or brow presentation, antepartum
65253
High head or term, antepartum
65263
Multiple gestation with malpresentation of one
fetus or more, antepartum
65273
Prolapsed arm, antepartum
65283
Other specified malposition or malpresentation,
antepartum
65293
Unspecified malposition or malpresentation,
antepartum
65303
Major abnormality of bony pelvis, not further
specified, antepartum
65313
Generally contracted pelvis, antepartum
65323
Inlet contraction of pelvis, antepartum
65333
Outlet contraction of pelvis, antepartum
65343
Fetopelvic disproportion, antepartum
65353
Unusually large fetus causing disproportion,
antepartum
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Diagnosis Code
Description
65363
Hydrocephalic fetus causing disproportion,
antepartum
65373
Other fetal abnormality causing disproportion,
antepartum
65383
Disproportion of other origin, antepartum
65393
Unspecified disproportion, antepartum
65403
Congenital abnormalities of uterus, antepartum
65413
Tumors of body of uterus, antepartum
65423
Previous cesarean delivery, antepartum
65433
Retroverted and incarcerated gravid uterus,
antepartum
65443
Other abnormalities in shape or position of
gravid uterus and of neighboring structures,
antepartum
65453
Cervical incompetence, antepartum
65463
Other congenital or acquired abnormality of
cervix, antepartum
65473
Congenital or acquired abnormality of vagina,
antepartum
65483
Congenital or acquired abnormality of vulva,
antepartum
65493
Other and unspecified, antepartum
655
Known or suspected fetal abnormality affecting
management of mother
65503
Central nervous system malformation in fetus,
antepartum
65513
Chromosomal abnormality in fetus, antepartum
65523
Hereditary disease in family possibly affecting
fetus, antepartum
65533
Suspected damage to fetus from viral disease in
the mother, antepartum
65543
Suspected damage to fetus from other disease in
the mother, antepartum
65553
Suspected damage to fetus from drug,
antepartum
65563
Suspected damage to fetus from radiation,
antepartum
65573
Decreased fetal movements, antepartum
65583
Other known or suspected fetal abnormality, not
elsewhere classified, antepartum
65593
Unspecified, antepartum
65603
Fetal-maternal hemorrhage, antepartum
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Diagnosis Code
Description
65613
Rhesus isoimmunization, antepartum
65623
Isoimmunization from other and unspecified
blood group incompatibility, antepartum
65633
Fetal distress, antepartum
65653
Poor fetal growth, antepartum
65663
Excess fetal growth, antepartum
65673
Other placenta condition, antepartum
65683
Other specified fetal and placenta problems,
antepartum
65693
Unspecified fetal and placenta problem,
antepartum
65703
Polyhydramnios, antepartum
65803
Oligohydramnios, antepartum
65843
Infection of amniotic cavity, antepartum
65883
Other, antepartum
65893
Unspecified, antepartum
65943
Grand multiparity, antepartum
65953
Elderly primigravida, antepartum
65963
Elderly multigravida maternal, antepartum
65973
Abnormality in fetal heart rate or rhythm,
antepartum
66303
Prolapse of cord, antepartum
66313
Cord around neck, with compression, antepartum
66323
Other and unspecified cord entanglement, with
compression, antepartum
66333
Other and unspecified cord-entanglement,
without mention of compression, antepartum
66343
Short cord, antepartum
66353
Vasa previa, antepartum
66363
Vascular lesions of core, antepartum
66383
Other umbilical cord complications, antepartum
66393
Unspecified umbilical cord complication,
antepartum
66503
Rupture of uterus before onset of labor,
antepartum
66583
Other specified obstetrical trauma, antepartum
66593
Unspecified obstetrical trauma, antepartum
67103
Varicose veins of legs, antepartum
67113
Varicose veins of vulva and perineum,
antepartum
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Diagnosis Code
Description
67123
Superficial thrombophlebitis, antepartum
67133
Deep phlebothrombosis, antepartum, antepartum
67153
Other phlebitis and thrombosis, antepartum
67183
Other venous complications, antepartum
67193
Unspecified venous complications, antepartum
67303
Obstetrical air embolism, antepartum
67313
Amniotic fluid embolism, antepartum
67323
Obstetrical blood-clot embolism, antepartum
67333
Obstetrical pyemic and septic embolism,
antepartum
67383
Other pulmonary embolism, antepartum
67403
Cerebrovascular disorders in the puerperium,
antepartum
67503
Infections of nipple, antepartum
67513
Abscess of breast, antepartum
67523
Nonpurulent mastitis, antepartum
67583
Other specified infections of the breast and
nipple, antepartum
67593
Unspecified infection of the breast and nipple,
antepartum
67603
Retracted nipple, antepartum
67613
Cracked nipple, antepartum
67623
Engorgement of breasts, antepartum
67633
Other and unspecified disorder of breast,
antepartum
67643
Failure of lactation, antepartum
67653
Suppressed lactation, antepartum
67663
Galactorrhea, antepartum
67683
Other disorders of lactation, antepartum
67693
Unspecified disorder of lactation, antepartum
7600
Maternal hypertensive disorders unspecified as
to episode of care or not applicable
7601
Maternal renal and urinary tract diseases
7602
Maternal infections
7603
Other chronic maternal circulatory and
respiratory diseases
7604
Maternal nutritional disorders
7605
Maternal injury
V189
Genetic disease carrier
V22
Normal pregnancy
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Diagnosis Code
Description
V220
Supervision of normal first pregnancy
V221
Supervision of other normal pregnancy
V222
Pregnancy state, incidental
V23
Supervision high risk pregnancy
V230
Pregnancy with history of infertility
V231
Pregnancy with history of trophoblastic disease
V232
Pregnancy with history of abortion
V233
Grand multiparity
V234
Pregnancy with other poor obstetric history
V2341
Pregnancy with history of pre-term labor
V2342
Pregnancy with history of ectopic pregnancy
V2349
Pregnancy with other poor obstetric history
V235
Pregnancy with other poor reproductive history
V237
Insufficient prenatal care
V238
Other high-risk pregnancy
V2381
Elderly primigravida
V2382
Elderly multigravida
V2384
Young multigravida
V2385
Pregnancy resulting from assisted reproductive
technology
V2386
Pregnancy with history of in utero procedure
during previous pregnancy
V2389
Other high-risk pregnancy
V239
Unspecified high-risk pregnancy
V2631
Testing of female genetic disease carrier status
V2632
Other genetic testing of female
V2633
Genetic counseling
V28
Encounter for antenatal screening of mother
V280
Screening for chromosomal anomalies by
amniocentesis
V281
Screening for raised alpha-fetoprotein levels in
amniotic fluid
V282
Other screening based on amniocentesis
V283
Encounter for routine screening for
malformation using ultrasonics
V284
Screening for fetal growth retardation using
ultrasonics
V285
Screen for isoimmunization
V286
Screening for Streptococcus B
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Diagnosis Code
Description
V2889
Other specified antenatal screening
V289
Unspecified antenatal screening
V7242
Pregnancy examination or test, positive result
V9100
Twin gestation, unspecified number of placenta,
unspecified number of amniotic sacs
V9101
Twin gestation, monochorionic/monoamniotic
(one placenta, one amniotic sac)
V9102
Twin gestation, monochorionic/diamniotic (one
placenta, two amniotic sacs)
V9103
Twin gestation, dichorionic/diamniotic (two
placentae, two amniotic sacs)
V9109
Twin gestation, unable to determine number of
placenta and number of amniotic sacs
V9110
Triplet gestation, unspecified number of placenta
and unspecified number of amniotic sacs
V9111
Triplet gestation, with two or more
monochorionic fetuses
V9112
Triplet gestation, with two or more
monoamniotic fetuses
V9119
Triplet gestation, unable to determine number of
placenta and number of amniotic sacs
V9120
Quadruplet gestation, unspecified number of
placenta and unspecified number of amniotic
sacs
V9121
Quadruplet gestation, with two or more
monochorionic fetuses
V9122
Quadruplet gestation, with two or more
moamniotic fetuses
V9129
Quadruplet gestation, unable to determine
number of placenta and number of amniotic sacs
V9190
Other specified multiple gestation, unspecified
number of placenta and unspecified number of
amniotic sacs
V9191
Other specified multiple gestation, with two or
more monochorionic fetuses
V9192
Other specified multiple gestation, with two or
more monoamniotic fetuses
V9199
Other specified multiple gestation, unable to
determine number of placenta and number of
amniotic sacs
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Obstetrical Services
Policies for the following pregnancy-related services are presented in this subsection:
•
Antepartum care policy
•
Other outpatient office visits
•
Normal pregnancy
•
High-risk pregnancy
•
Pregnancy services billing procedures
•
Hoosier Healthwise Package B – Pregnancy and Urgent Care Only
Antepartum Care Policy
To encourage comprehensive, timely, and appropriate antepartum care, providers must indicate the
date of last menstrual period (LMP) in field 14 on the CMS-1500 (or Last Menstrual Period Date,
Data Element 1251 on the 837P), enter the appropriate diagnosis codes in field 21 of the CMS-1500,
and refer to the date of LMP in field 24E on the CMS-1500 for these pregnancy-related services.
The IHCP reimburses up to 14 visits for normal antepartum care, one visit more than the 13 visits
recommended by the American College of Obstetricians and Gynecologists (ACOG). The IHCP
reimburses providers for the following number of visits in a normal pregnancy:
•
Three visits in trimester one
•
Three visits in trimester two
•
Eight visits in trimester three
Billing for Antepartum Visits
Providers should bill antepartum care for pregnant members separately from the delivery and
postpartum visits using the following procedure codes:
•
99201 – 99215, for the first antepartum visit to accommodate the greater amount of work involved.
•
59425 – Antepartum care only – for visits two through six
•
59426 – Antepartum care only – for the seventh and all subsequent visits
When submitting claims, providers should:
•
List each antepartum visit individually on the CMS-1500 or 837P,
•
Submit claims after each individual visit or at the end of the respective trimester,
•
Bill the required antepartum tests and screenings for each trimester along with the trimester visits,
•
Bill antepartum visits in the same trimester within 30 days of the end of the trimester
•
To identify antepartum visits in each trimester, providers must bill one of the modifiers in Table
8.109 in conjunction with CPT procedure code 59425, 59426, or 99201-99215 (if used for the first
antepartum visit) with each specific date of service. The modifier should be placed, following the
CPT code, in field 24D on the CMS-1500 claim form. Table 8.110 lists modifiers for antepartum
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visits. If providers report an E/M code for the first visit, they must bill using the appropriate
trimester modifier and expected date of delivery.
•
CPT procedure codes 59425 and 59426 are not subject to NCCI Column I/II editing when billed
with modifiers U1, U2, or U3 and billed on the same date of service as the listed laboratory
procedure codes.
Table 8.109 – Antepartum Billing
Procedure Code
99201-99215
Billing Instructions
Bill appropriate E/M code for
the first antepartum visit (to
accommodate the greater
amount of work involved
with each visit.)
Bill antepartum care only
code for visits two through
six
59425
Bill antepartum care only
code for visits seven and all
subsequent visits, with
procedure code 59426 at each
visit
59426
Modifier
Description
U1
Trimester one – 0 through 14
weeks, 0 days
U2
Trimester two – 14 weeks, one day
through 28 weeks, 0 days
U3
Trimester three – 28 weeks, one
day, through delivery
U1
weeks, 0 days
U2
U3
U1
weeks, 0 days
U2
U3
Table 8.110 – Modifiers – Antepartum Visits
Modifier
Description
U1
Trimester one – 0 through 14 weeks, 0 days
U2
Trimester two – 14 weeks, one day through 28 weeks, 0 days
U3
Trimester three – 28 weeks, one day, through delivery
Note: The IHCP allows up to eight antepartum visits during the third trimester for
a normal pregnancy, and providers can bill these visits along with delivery
and postpartum services on the same CMS-1500 claim form or 837P
transaction.
Antepartum Tests and Screenings Schedule
In addition to the schedule for antepartum visits, the OMPP has developed a schedule of tests and
screenings highly recommended for pregnant members in each respective trimester. Providers should
render other tests and screenings, such as those defined as optional, only when the person providing the
service determines that the procedure is necessary. Providers can bill the tests and screenings with the
appropriate antepartum care visit code on the same CMS-1500 or 837P transaction.
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The trimester schedules in Table 8.111 are uniform with standards established by the American
Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics
(AAP).
Note: For dates of service on or after August 1, 2012, providers will no longer be
allowed to bill separately for each component of the total obstetrical panel
when all the tests listed in the panel are performed on the same date of
service. If the total panel of tests and screenings is performed on the same
date of service, providers must bill the total obstetrical panel using the
bundled laboratory procedure code 80055.
Table 8.111 – Antepartum Tests and Screenings Schedule
CPT Code
Procedure
Trimester One (three total visits)
59425*
First trimester visits = three
59426*
59015
Chorionic Villa Sampling (CVS), optional for women older
than 35
81000 (includes microscopy for
suspected urinary tract infection),
or 81002 (without microscopy),
or 81001 (Urinalysis, automated
with microscopy), or 81003
(Urinalysis, automated without
microscopy)
Urinalysis by dipstick, performed each visit; the use of the
automated urinalysis is to be based on medical necessity as
determined by the physician
86644
Cytomegalovirus (CMV) antibody titer
86694
Herpes simplex test
86701
HIV test (optional)
86777
Toxoplasma antibody titer
88150, 88152-88155
Cervical cytology (Pap smear)
80055
Total obstetrical panel includes:
•
CBC with complete differential
•
Hepatitis B surface antigen
•
Rubella antibody titer
•
Syphilis test
•
Antibody screen, RBC
•
Blood typing (ABO)
• Blood typing (RhD)
80055 must be used if all tests on the obstetrical panel are performed on the same day. The following
are included in that panel:
85025
87340
Hepatitis B surface antigen (HBsAg)
86762
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CPT Code
Procedure
86592
Syphilis test, non treponemal antibody: qualitative (e.g., VDRL,
RPR, ART)
86850
86900
Blood typing (ABO)
86901
Blood typing (RhD)
*Use the appropriate CPT code for the number of antepartum visits:
59425
Antepartum care only
59426
Antepartum care only
CPT Code
Procedure
Trimester Two (three total visits)
59425*
Second trimester visits = three
59426*
59000
Amniocentesis, optional for women older than 35
microscopy)
automated urinalysis is be based on medical necessity as
82105
Serum alpha-fetoprotein
82947
Diabetic screening
82951
Glucose tolerance test
86644
86694
Herpes simplex test
86777
80055
•
•
•
•
Syphilis test
•
•
Blood typing (ABO)
85025
87340
86762
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CPT Code
Procedure
86592
Syphilis test, non treponemal antibody; qualitative (e.g., VDRL,
RPR, ART)
86850
86900
Blood typing (ABO)
86901
Blood typing (RhD)
59425
Antepartum care only; one to six visits
59426
Antepartum care only; seven or more visits
Trimester Three (eight total visits)
59425*
Third trimester visit = eight
59426*
microscopy)
automated urinalysis is to be based on medical necessity as
85025
CBC with differential
86592
Syphilis test, repeat test for patients who tested positive in first
trimester
86850
Antibody test, repeat for patients who tested negative in first
trimester
86644
86694
Herpes simplex test
86777
80055
•
•
•
•
Syphilis test
•
•
Blood typing (ABO)
85025
87340
86762
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CPT Code
Procedure
86592
Syphilis test, non treponemal antibody; qualitative (e.g., VDRL,
RPR, ART)
86850
86900
Blood typing (ABO)
86901
Blood typing (RhD)
59425
Antepartum care only; one to six visits
59426
Antepartum care only; seven or more visits
Placental Alpha Microglobulin-1 (PAMG-1) Test
Effective January 1, 2012, the IHCP provides coverage for CPT code 84112 – Placental alpha
microglobulin-1 [PAMG-1], cervicovaginal secretion, qualitative. Coverage is retroactive to dates of
service on or after January 1, 2011.
Reimbursement and Billing Requirements
The IHCP reimburses for the PAMG-1 test when it is considered medically necessary to confirm the
diagnosis of premature rupture of membranes (PROM) or preterm premature rupture of membranes
(PPROM). This test may be performed in a hospital setting (either inpatient or outpatient), or in a
nonhospital setting (for example, a physician’s office or clinic). PA is not required for this testing;
however, the use of the PAMG-1 test is closely monitored for appropriateness of use.
For reimbursement, providers should bill CPT code 84112 with the appropriate trimester modifier, as
listed in the following table.
Table 8.112 – Billing Information for PAMG-1 – Effective for Dates of Service on or after
January 1, 2011
CPT Code
84112
Modifiers
Description
Placental alpha microglobulin-1 (PAMG-1), cervicovaginal
secretion, qualitative
Units
1 unit per test
Description
U1
Trimester one – 0 through 14 weeks, 0 days
U2
Trimester two – 14 weeks, one day through 28 weeks, 0 days
U3
Trimester three – 28 weeks, one day through delivery
Salivary Estriol Test for Preterm Labor Risk Assessment
Effective for dates of service on and after October 1, 2012, the IHCP eliminated reimbursement for
HCPCS code S3652 – Saliva test, hormone level. This test is obsolete and considered investigational
for the assessment of preterm labor risk and is no longer covered. The IHCP covers other tests that can
determine preterm labor.
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Sonography
The IHCP reimburses for sonography performed during pregnancy when warranted by one or more of
the following conditions:
•
Early diagnosis of ectopic or molar pregnancy
•
Placental localization associated with abnormal bleeding
•
Fetal postmaturity syndrome
•
Suspected congenital anomaly
•
Polyhydramnios or oligohydramnios
•
Guide for amniocentesis
•
Fetal age determination if necessitated by the following:
- Discrepancy in size versus fetal age
- Lack of fetal growth or suspected fetal death
The IHCP reimburses for sonography for fetal age determination before nonelective abortions when
the age of the fetus cannot be determined by the patient’s history and physical examination in the case
of fetal demise or for missed abortion. The information may also be essential for the selection of the
abortion method when the member is considering a procedure and the conditions meet the
requirements of IC 16-34-1-8 for an elective abortion.
Echography
The IHCP does not reimburse for routine echographies. A diagnosis of normal pregnancy does not
explain the reason for the echography. Documentation in the patient’s medical record must substantiate
the medical need for the echography. Echographies performed to detect fetal malformations or
intrauterine growth retardation should list an ICD-9-CM code from the V22 series as the primary
diagnosis and an ICD-9-CM diagnosis code from the V28 series, antenatal screening, as the secondary
diagnosis. Pregnancy-related echographies billed without a secondary diagnosis to support medical
necessity of the echography are subject to recoupment. The secondary codes are as follows:
•
V28.0 – Screening for chromosomal anomalies by amniocentesis
•
V28.1 – Screening for raised alpha-fetoprotein levels in amniotic fluid
•
V28.2 – Other antenatal screening based on amniocentesis
•
V28.3 – Screening for malformation using ultrasonics
•
V28.4 – Screening for fetal growth retardation using ultrasonics
•
V28.5 – Antenatal screening for isoimmunization
•
V28.6 – Antenatal screening for streptococcus b
•
V28.8 – Other specified antenatal screening
•
V28.9 – Unspecified antenatal screening
First Trimester Fetal Nuchal Translucency Ultrasound
The first-trimester fetal nuchal translucency ultrasound does not require prior authorization. However,
the first-trimester fetal nuchal translucency ultrasound must be performed in conjunction with maternal
serum-free beta human chorionic gonadotropin (hCG) and pregnancy-associated plasma protein A for
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the detection of chromosomal defects. The IHCP does not cover first-trimester fetal nuchal
translucency testing when performed alone for the detection of chromosomal defects, as it is
considered investigational. For optimal test results, the first-trimester fetal nuchal translucency
ultrasound should be performed between 11 and 13 weeks of pregnancy. First-trimester fetal nuchal
translucency ultrasounds are subject to the requirements found in 405 IAC 5-27-6.
The IHCP does not provide reimbursement for routine ultrasounds or ultrasounds performed for gender
determination. The diagnosis of a normal pregnancy does not substantiate the medical necessity for an
ultrasound to be performed. Documentation must be maintained in the patient’s medical record to
support the medical need for an ultrasound.
Reimbursement is not available for CPT code 59072 – Fetal umbilical cord occlusion, including U.S.
guidance, as this procedure is designed to terminate a fetus.
Table 8.113 – First Trimester Fetal Nuchal Translucency Ultrasound CPT Procedure Codes
Code
Description
76813*
Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal
nuchal translucency measurement, transabdominal or transvaginal approach; single or
first gestation
76814*
Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal
nuchal translucency measurement, transabdominal or transvaginal approach; each
additional gestation (List separately in addition to code for primary procedure)
84163**
Pregnancy associated plasma protein-A (PAPP-A)
84702 –
84704**
Maternal serum free beta Human Chorionic Gonadotropin (hGC)
*The IHCP does not cover first trimester fetal nuchal translucency testing when performed alone
for the detection of chromosomal defects.
** The nuchal translucency sonography must be performed in conjunction with maternal serumfree beta human chorionic gonadotropin (hCG) and pregnancy-associated plasma protein A
(PAPP-A) for the detection of chromosomal defects.
For optimal test results, the First Trimester Fetal Nuchal Translucency Ultrasound should be
performed between 11 and 13 weeks of pregnancy.
Reimbursement is available for sonography services performed during pregnancy when indicated by
one or more of the following conditions:
(1) Early diagnosis of ectopic or molar pregnancy
(2) Placental localization associated with abnormal bleeding
(3) Fetal postmaturity syndrome
(4) Suspected multiple births
(5) Suspected congenital anomaly
(6) Polyhydramnios or oligohydramnios
(7) Fetal age determination if necessitated by one of the following:
(A) Discrepancy in size versus fetal age
(B) Lack of fetal growth or suspected fetal death
(8) Guide for amniocentesis
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Obstetrical Delivery and Postpartum Care Billing
Physicians should bill antepartum care separately from the delivery and postpartum care. The IHCP
follows CPT guidelines for obstetrical delivery billing.
Delivery services include admission to the hospital, the admission history and physical examination,
management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without
forceps), or cesarean delivery. Medical problems complicating labor and delivery management may
require additional resources, and physicians should identify them by using the codes in the Evaluation
and Management Services section, in addition to codes for maternity care.
The IHCP also allows up to two postpartum visits within 60 days postdelivery. The IHCP may
reimburse the physician for up to two inpatient or outpatient postpartum visits using CPT code 59430,
which is for postpartum care only.
Note: Effective July 1, 2011, codes 59410 and 59515 are no longer covered.
Effective July 1, 2011, the IHCP no longer reimburses delivery and postpartum visits bundled together
when billing using the procedure codes in Table 8.114 – End-Dated Global Delivery CPT Codes. The
IHCP requires providers to bill the delivery and postpartum care services separately using the
appropriate “delivery and postpartum only” procedure codes listed in Table 8.115.
Table 8.114 – End-dated Global Delivery CPT Codes
Global Delivery CPT
Codes
Description
59410
Vaginal delivery only (with or without episiotomy and/or forceps); including
postpartum care
59515
Cesarean delivery only; including postpartum care
59614
Vaginal delivery only, after previous cesarean delivery (with or without
episiotomy and/or forceps); including postpartum care
59622
Cesarean delivery only, following attempted vaginal delivery after previous
cesarean delivery; including postpartum care
Table 8.115 – Delivery Only and Postpartum Only CPT Codes
Global Delivery CPT
Codes
Description
59409
Vaginal delivery only (with or without episiotomy and/or forceps)
59514
Cesarean delivery only
59612
Vaginal delivery only, after previous cesarean delivery (with or without
episiotomy and/or forceps)
59620
Cesarean delivery only, following attempted vaginal delivery after previous
cesarean delivery
Postpartum CPT
Code
59430
Description
Postpartum care only (separate procedure)
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Birthing Center Professional Services
Professional services rendered at birthing centers are billed on a CMS-1500 Professional claim form or
the HIPAA 837P transaction. Services rendered by the following rendering provider types and
specialty are payable when performed at birthing centers:
•
Rendering Provider Type 09 – Advanced practice nurse with rendering provider specialty 095 –
Certified nurse mid-wife
•
Rendering Provider Type 31 – Physician
Birthing center services are to be billed with place-of-service code 25 – Birthing center.
Other Outpatient Office Visits
Providers can bill CPT procedure codes 99211–99215 or 99241-99245 for outpatient office visits
rendered to pregnant members, if the service is related to a concurrent medical condition requiring
medical care or consultative referral. Providers must identify that concurrent condition as a primary or
secondary condition by a valid ICD-9-CM diagnosis code and indicate the appropriate diagnosis
reference number (1, 2, 3, or 4) in field 24E of the CMS-1500. Additionally, providers can bill the first
prenatal visit with E/M codes 99201–99215, the appropriate trimester modifier, and the expected date
of delivery, all indicated on the claim.
For billing instructions for services rendered to IHCP Package B members, see the section titled
Hoosier Healthwise Package B – Pregnancy and Urgent Care Only in this chapter.
Normal Pregnancy
The following diagnosis codes indicate a normal, low-risk pregnancy:
•
V22.0
•
V22.1
Multiple Births
Multiple birth deliveries are subject to multiple surgery reimbursement. The current reimbursement
policy indicated in 405 IAC 5-28-1(g) for pricing multiple surgical procedures states that 100% of the
global fee is reimbursed for the most expensive procedure. The second most expensive procedure is
reimbursed at 50% of the global fee, and remaining procedures are reimbursed at 25% of the global
fee. The IHCP reimburses for only one cesarean procedure regardless of the number of babies
delivered during the cesarean section. Therefore, only one detail line with one unit of service is billed
for cesarean delivery procedure codes. The IHCP reimburses for only one delivery procedure code that
includes postpartum care. If there are multiple births during one delivery, the first delivery code can
include postpartum care; however, any subsequent deliveries are billed with a procedure code that does
not include postpartum care.
If billing for multiple births when all births are vaginal deliveries, providers bill the first birth using
procedure code 59409 – Vaginal delivery only (with or without episiotomy and/or forceps) or 59612 –
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).
The second birth and any subsequent births are billed using procedure codes 59409 or 59612 with
modifier 51 – Multiple procedures.
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When billing for one vaginal birth and one or more births by cesarean section, the cesarean birth is
billed with procedure code 59514 – Cesarean delivery only, and the vaginal birth is billed using
procedure code 59409 or 59612 with modifier 51.
When billing for two or more vaginal births and one or more births by cesarean, the cesarean births are
billed on one detail line with one unit of service using procedure code 59514 or 59515. The vaginal
births are billed as separate details using procedure code 59409 or 59612 with modifier 51.
If an assistant surgeon aids in the cesarean delivery, the service is billed using modifiers 80 and 82 to
indicate the service was performed by an assistant surgeon. The reimbursement for the assistant
surgeon’s services is 20% of the allowed amount for the cesarean delivery. Providers cannot bill the
same rendering provider number for the surgeon and assistant surgeon details when billing for a
cesarean delivery. If billing for assistant surgery services provided by a physician assistant, providers
can bill the same rendering provider number for the surgeon and physician assistant surgery details.
The detail for the physician assistant is billed with the AS modifier to indicate the service was
provided by the physician assistant. The reimbursement for the physician assistant’s services is 20% of
the allowed amount for the cesarean delivery.
High-Risk Pregnancy
Prenatal Risk Assessment
The IHCP may also consider a pregnant woman medically high-risk if the provider identifies two
relative medical conditions during a prenatal risk assessment. To document medically high-risk
pregnancies, providers must complete and submit the Notification of Pregnancy (NOP) through Web
interChange. Providers that complete and submit the NOP may claim an additional $60 reimbursement
per pregnancy.
If a normal pregnancy becomes high-risk at any time during the pregnancy, providers should use the
NOP to document the change. NOPs can be completed at any time during the pregnancy, preferably
during the initial visit, to document and monitor pregnancy conditions. See Process for Completion of
the Notification of Pregnancy section.
Psychosocially High-Risk Pregnancy
For high-risk pregnancies identified for psychosocial reasons, the IHCP limits coverage to the standard
maximum 14 antepartum care visit requirement. Psychosocially high-risk pregnancies do not
automatically qualify for additional antepartum visits unless another medical complication exists that is
listed under the ICD-9-CM codes for high-risk pregnancies. Use the ICD-9-CM diagnosis code range
V60.0 through V62.9 to indicate a high-risk pregnancy for psychosocial reasons.
Medically High-Risk Pregnancy
Some pregnant members have medical risk factors that may adversely affect the outcome of the
pregnancy if not adequately treated. These complications, identified during the prenatal assessment,
may place the member and the fetus in a high-risk pregnancy category that requires additional primary
care management. The IHCP reimburses only for treatment by physicians for medically high-risk
pregnancy care. Nonphysician providers that treat pregnant women on Medicaid must refer members
identified as having medically high-risk pregnancies only to other appropriate physicians. The IHCP
does not permit treatment or referrals to nonphysicians for high-risk pregnancy-related services.
To be considered a high-risk pregnancy, a woman must have at least two medical risk factors in her
current pregnancy or obstetrical history that places her at risk for a preterm birth or poor pregnancy
outcome.
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Medically High-Risk Diagnoses
The following list gives examples of common high-risk pregnancy conditions. This list is included for
illustrative purposes only and is not an inclusive list of all medical conditions that can complicate
pregnancy. Providers must complete and submit the NOP through Web interChange to document highrisk pregnancies. Providers that complete and submit the NOP may claim an additional $60
reimbursement per pregnancy.
For billing purposes, providers must use the ICD-9-CM diagnosis code appropriate to the patient’s
condition:
•
Abortion, second trimester, in previous pregnancy history
•
Active herpes or positive culture, third trimester in current pregnancy
•
Alloimmunization associated with fetal disease in current pregnancy
•
Anemia, less than 10gm Hgb or less than 30% Hct, in current pregnancy
•
Asthma, on medication in current pregnancy
•
Bleeding, significant after 12 weeks in current pregnancy
•
Cervix dilated or effaced in current pregnancy or previous history of cone biopsy
•
Chronic bronchitis in current pregnancy
•
Deep venous thrombosis in current pregnancy
•
Diethylstilbestrol (DES) exposure in previous pregnancy history
•
Diabetes, gestational, diet controlled in current pregnancy
•
Diabetes, insulin dependent in current pregnancy
•
Drug dependence
•
Eclampsia or severe pre-eclampsia in pregnancy history or present in current pregnancy
•
Elderly primigravida, 40 years old or older
•
Epilepsy, on anticonvulsants in current pregnancy
•
Familial genetic disorder, confirmed in current pregnancy
•
Gonorrhea, positive culture in current pregnancy
•
Grand multiparity, greater than five pregnancies with delivery
•
Heart disease, class III or IV, in current pregnancy
•
Hepatitis or chronic liver disease in current pregnancy
•
Hydatidiform mole in pregnancy history or vesicular mole in the immediate prior pregnancy
•
Hypertension, on medication in current pregnancy
•
Immediate prior pregnancy stillborn intrauterine death, neonatal, or post-neonatal death
•
Incompetent cervix in previous pregnancy history
•
Irritable uterus, more than six contractions per hour, confirmed in current pregnancy
•
Low birth-weight baby, less than 2,500 grams, or repetitive low birth-weight babies in each
pregnancy, documented
•
Major abdominal surgery in current pregnancy
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•
Major congenital anomaly in previous pregnancy history
•
Malignancy or leukemia in current pregnancy
•
Multiple gestation in current pregnancy
•
Obesity more than 20% of weight for height in current pregnancy
•
Oligohydramnios in current pregnancy
•
Organ transplantation complicating current pregnancy
•
Placenta previa, third trimester in current pregnancy
•
Pneumonia in current pregnancy
•
Polyhydramnios in current pregnancy
•
Positive serology in current pregnancy
•
Post-term pregnancy; current pregnancy has advanced beyond 41 weeks of gestation
•
Preterm labor in current pregnancy and/or previous obstetric history of preterm delivery
•
Previous cesarean delivery
•
Premature rupture of membranes (PROM), confirmed in current pregnancy
•
Psychosis or intellectual disability in current pregnancy
•
Pyelonephritis in current pregnancy
•
Renal dialysis status complicating current pregnancy
•
Respirator-dependent status complicating current pregnancy
•
Rubella exposure with rising titer in current pregnancy
•
Sickle cell anemia, other hemoglobinopathy in current pregnancy
•
Spontaneous abortions, more than two first-trimester occurrences in previous pregnancy history
•
Thyroid disease, confirmed in current pregnancy
•
Trauma requiring hospitalization in current pregnancy
•
Tuberculosis, active in current pregnancy
•
Underweight, more than 10% of weight for height in current pregnancy
•
Uterine anomaly or fibroids in current pregnancy
•
Weight loss greater than 10 pounds during pregnancy, continuing after 14 weeks
The ICD-9-CM diagnosis codes listed in Table 8.116 represent conditions that may complicate
pregnancy. These codes, when billed with prenatal office visit procedure codes 59425 and 59426,
increase the maximum fee allowed for these services by $10 per visit. Providers may complete and
submit the NOP through Web interChange for these patients and retain a copy of the form in the
patient’s record for retrospective review. Providers are encouraged to use the NOP, which provides a
$60 reimbursement per pregnancy submission.
The IHCP provides higher reimbursement for prenatal office visits only for patients who present with
medical high-risk factors.
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Table 8.116 – High-Risk Pregnancy – ICD-9-CM Diagnosis Codes
Medical Factor
Anemias, acquired and
hereditary
Code
282.0 – 282.9, 283.1X –
283.9, 284.01, 284.09,
284.1, 284.2, 284.81,
284.89, 284.9, 285.0 –
285.9, 287.X, 288X,
648.20, 648.23
Medical Factor
Code
Obesity
649.10, 649.11, 649.12, 649.13,
649.14
Bariatric surgery status
649.20, 649.21
Other (for medical high-riskpregnancy)
255.42, 259.50, 259.51, 259.52,
276.5X, 277.30, 277.31, 277.39,
278.02, V23.1, V23.4X,
V23.8X, V23.9, V60.81,
V60.89, V61.07, V61.08,
V61.23, V61.24, V61.25,
V61.42, V62.84, V85.0, V85.2X
– V85.39, V85.41-V85.45
Coagulation defects
649.34
Other specified complications
of pregnancy
646.80, 646.83
Pregnancy with history of
abortion
646.30, 646.33, V23.2
Current drug or alcohol 291.82, 304.00 – 304.93,
abuse
648.30, 648.33, V61.42
Current malignancy or
leukemia
140.0 – 174.9, 176.0 –
184.9, 188.0 – 214.3, 214.8
– 221.9, 223.0 – 233.3,
Preterm complications, history
233.30, 233.31, 233.32,
of or with current pregnancy
233.39, 233.7 – 236.3,
236.7 – 239.9
Diabetes
362.07, 648.00, 648.03,
648.80, 648.83
Preterm labor in current
pregnancy or previous
pregnancy
Epilepsy
649.40, 649.41, 649.42,
649.43, 649.44
621.34, 621.35, 624.01, 624.02,
624.09, 629.23, 648.70, 648.73,
654.00, 654.03, 654.10, 654.13,
Potential structural
654.20, 654.23, 654.50, 654.53,
complications of pregnancy or
654.60, 654.63, 657.00, 657.03,
delivery
658.00, 658.03, 664.60, 664.61,
664.64, 752.34, 752.35, 752.44,
752.45, 752.47,V13.22, V67.00
Excessive vomiting in
pregnancy
643.00, 643.03, 643.10,
643.13, 643.20, 643.23,
643.80, 643.83, 643.90,
643.93
Primigravida, less than 17 years 659.40, 659.43, 659.50, 659.60,
or more than 35 years
659.63, V23.81 – V23.84
History of a previous
286.0 – 286.4, 317, 318.X,
pregnancy resulting in a
Renal complications and
319, V19.5, V21.30 –
congenital anomaly or
infections
V21.35, V23.4
complication to infant
640.00, 640.03, 640.80, 640.83,
640.90, 640.93, 641.00, 641.03,
641.10, 641.13, 641.20, 641.23,
641.30, 641.33, 641.80, 641.83,
641.90, 641.93, 658.10, 658.13,
671.30, 671.33, 760.5
644.00, 644.03, 644.10, 644.13,
644.20, 654.50, 654.53, V13.21
580.0 – 593.9, 599.6X, 639.3,
646.20, 646.23, 646.60, 646.63
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Medical Factor
Code
Medical Factor
Code
041.02, 042, 079.5X, 090.X
– 099.X, 488.01, 488.02,
488.09, 488.11, 488.12,
Respiratory disease, history of
488.19, 567.2X – 567.8X, or acquired
616.10, 647.33, 647.53,
655.33, 795.71, V08, V01.6
480.0 – 487.0, 491.0 – 491.9,
493.0X – 493.9X, V46.1X
642.00, 642.03, 642.10,
642.13, 642.20, 642.23,
642.30, 642.33, 642.40,
642.43, 642.50, 642.53,
642.60, 642.63, 642.70,
642.73, 642.90, 642.93
Smoking, more than 10
cigarettes per day
305.11, 648.33, V15.82
345.00 – 345.91, 359.21359.29, 414.2, 415.12,
423.3, 426.82, 440.4, 449,
523.0 – 523.9, 646.13,
646.70, 646.73, 646.80,
646.83, 648.10, 648.13,
648.50, 648.53, 648.60,
648.63, 656.23, V23.82,
V23.84, V42.0 – V42.9,
V62.85
Spotting
649.50, 649.51, 649.53
651.00, 651.03, 651.10,
651.13, 651.20, 651.23,
651.30, 651.33, 651.40,
651.43, 651.50, 651.53,
651.60, 651.63, 651.70,
651.71, 651.73, 651.80,
Multiple gestation/grand 651.83, 651.90, 651.93,
multipara
659.40, 659.43, V23.3,
V91.00, V91.01, V91.02,
V91.03, V91.09, V91.10,
V91.11, V91.12, V91.19,
V91.20, V91.21, V91.22,
V91.29, V91.90, V91.91,
V91.92, V91.99
Tobacco use
649.00, 649.01, 649.02, 649.03,
649.04
Myelogibrosis
Uterine size date discrepancy
649.60, 649.61, 649.62, 649.63,
649.64
Infections affecting
pregnancy
Maternal diseases or
history affecting
pregnancy
289.83
Note: Bill each trimester on separate claims.
Additional Antepartum Visits
Members identified as medically high-risk patients may receive additional antepartum care visits,
beyond the maximum of 14 allowed for a normal pregnancy. Claims must indicate the high-risk
diagnosis, the LMP, the appropriate CPT procedure code (procedure code 59425 for visits one through
six, and procedure code 59426 for visits in excess of six), and the corresponding modifier.
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Reimbursement
The IHCP recognizes that care of pregnant women in the medical high-risk category requires greater
physician management, and therefore, the IHCP reimburses physicians practicing obstetrics an
additional $10 per prenatal visit. Additional reimbursement is available when the provider maintains
documentation through the NOP, which demonstrates a high-risk pregnancy. Ensure that this
information is easily identifiable on the medical record for audit purposes.
Pregnancy Services Billing Considerations
Providers must indicate the LMP on all claims. The IHCP does not process for payment any claims for
pregnancy-related services submitted without an LMP. Providers must enter the charged amount for
each antepartum visit and for each postpartum visit in field 24F of the CMS-1500.
Providers must indicate a pregnancy-related diagnosis code as the primary diagnosis when billing for
pregnancy-related services. The IHCP limits payment for pregnancy-related services to the following
ICD-9-CM diagnoses subject to PA restrictions and in accordance with Indiana Administrative Code.
The primary diagnosis codes are V22.0 through V25.2 and V60.0 through V62.9. Providers must
indicate the pregnancy-related diagnosis code in field 24E of the CMS-1500. Enter the pregnancy
indicator P in field 24H on the CMS-1500.
Diagnoses to identify supervision of a high-risk pregnancy for medical reasons are listed in the
Medically High-Risk Diagnoses subsection in this chapter.
Hoosier Healthwise Package B – Pregnancy and Urgent Care Only
The IHCP pays only for abortions to terminate pregnancies resulting from rape or incest, in addition to
abortions necessary to save the life of the pregnant mother.
Hoosier Healthwise Package B members are entitled to coverage of services related to pregnancy,
which includes prenatal, delivery, and postpartum services as well as conditions that may complicate
the pregnancy. Hoosier Healthwise Package B covers most conditions that can complicate pregnancies
but does not cover elective services as pregnancy-related. Additionally, Hoosier Healthwise Package B
members are eligible for family planning, transportation, and pharmacy services. As with all claims,
the IHCP reimburses services to Hoosier Healthwise Package B limited benefits in accordance with the
Indiana Administrative Code.
Note: For RBMC members, contact the appropriate MCE for additional
instructions.
Services for Hoosier Healthwise Package B must comply with the following restrictions:
•
The IHCP does not reimburse for any services other than pregnancy-related services.
•
The IHCP pays for drugs prescribed for indications directly related to the pregnancy in accordance
with IAC restrictions.
In addition to drug coverage, transportation, family planning, routine prenatal care, delivery, and
postpartum care, the IHCP reimburses providers for a condition that may complicate the pregnancy. In
other words, the IHCP covers a service provided to a pregnant woman for the treatment of a chronic or
abnormal disorder, as identified by ICD-9-CM diagnosis codes 649.00 – 649.04, 649.10 – 649.14,
649.20 – 649.21, 649.23 – 649.24, 649.30 – 649.34, 649.40 – 649.44, 649.50 – 649.51, 649.53, 649.60
– 649.64, 649.70 – 649.71, and 649.73, as well as urgent care.
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The IHCP defines a condition that may complicate the pregnancy as any condition manifesting itself
by symptoms of sufficient severity that the absence of medical attention could reasonably be expected
to result in a deterioration of the patient’s condition or a need for a higher level of care.
The IHCP does not dictate to physicians conditions that may or may not complicate a pregnancy.
Therefore, if the physician determines the illness or injury could complicate the pregnancy or have an
adverse effect on the outcome of the pregnancy, the IHCP covers the care provided for that illness or
injury. Physicians must use one of the diagnosis codes previously listed as the primary diagnosis on the
claim. If none of the diagnosis codes are appropriate for the situation, the physician should list a
pregnancy diagnosis code as the primary diagnosis code and identify the illness or injury being treated
as the secondary diagnosis code.
Following termination of the pregnancy, a pregnancy and urgent care only member is eligible solely
for transportation, family planning, and postpartum care services. The IHCP does not reimburse for
urgent care services unrelated to complications of the puerperium. This eligibility begins on the last
day of pregnancy and extends through the end of the month in which the last day of the 60-day period
ends.
When billing for urgent care services, providers must appropriately mark and code claims as
emergency. The primary diagnosis code must be pregnancy-related or the IHCP denies the claim.
Providers must indicate the pregnancy-related code in field 24E on the CMS-1500 claim form. If the
pregnancy diagnosis does not adequately address the specific reason for the visit or care, providers
must also include the visit or care diagnosis as a secondary or tertiary diagnosis on the claim form.
Providers must enter the pregnancy indicator, P, in field 24H of the CMS-1500 claim form.
If a pregnancy and urgent care only member receives a sterilization procedure following delivery, the
primary diagnosis code should be pregnancy with voluntary sterilization as a secondary diagnosis. The
member must complete consent forms, and the provider must send them with the claim.
Proton Treatment Billing
The IHCP has determined that it is appropriate for providers to report only the technical component of
proton treatment delivery using the CPT codes listed in Table 8.117. The IHCP does not reimburse
proton treatment delivery services when billed using procedure codes 77520, 77522, and 77525 with
modifiers 26 – Professional component and TC – Technical component. Providers are advised to report
the professional services using an appropriate CPT procedure code.
Table 8.117 – Proton Treatment Delivery – Technical Component Only
CPT Code
Description
77520
Proton treatment delivery; simple, without compensation
77522
Proton treatment delivery; simple, with compensation
77525
Proton treatment delivery; complex
Coverage Criteria for 17P Injections
Note: For billing information about 17P injections refer to Chapter 9: IHCP
Pharmacy Services Benefit of this manual.
The IHCP considers weekly injections of 17 alpha hydroxyprogesterone (17P) between weeks 16 and
36 of gestation medically necessary in pregnant women with a prior history of preterm delivery before
37 weeks of gestation. Use of 17P as a technique to prevent preterm labor in other pregnant women
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who do not meet the criteria listed previously and in those with other risk factors for preterm delivery,
including but not limited to multiple gestations, short cervical length, or positive tests for
cervicovaginal fetal fibronectin, continues to be considered investigational, and, therefore, remains a
noncovered therapy
Process for Completion of the Notification of Pregnancy
Recognized providers complete and submit the NOP electronically using Web interChange. Once
logged in, complete the following steps:
1. Select the Eligibility Inquiry function to verify the member’s eligibility.
2. On the Eligibility Inquiry screen, select Go To NOP to complete and submit the online form.
Providers may also complete a hard-copy NOP by selecting Print Blank NOP. Only NOPs
submitted online are reimbursable.
3. Web interChange checks for potential duplicate NOPs. If a duplicate is identified, the recognized
provider is asked to provide a reason why the new NOP is not a duplicate. The recognized provider
can choose from three reasons related to the prior pregnancy:
(1) Member abortion
(2) Member preterm delivery
(3) Member miscarriage
4. The provider can continue the process without identifying a reason; however, the duplicate NOP will
not be reimbursed.
5. The NOP can only be submitted and billed for a woman enrolled in Hoosier Healthwise risk-based
managed care.
6. The recognized provider must submit the NOP within five calendar days from the date of the risk
assessment to be reimbursed. NOPs submitted more than five days from the date of the risk
assessment are not reimbursed.
For more information on NOP, see the NOP FAQs on indianamedicaid.com.
Billing
1. Providers may receive $60 for one NOP per member, per pregnancy.
Note: Duplicate NOPs, those for the same woman and the same pregnancy, do not
qualify for the $60 reimbursement. Only one NOP per member, per
pregnancy is eligible for reimbursement. Recognized providers receive a
systematic message if the NOP appears to be a duplicate.
2. To be eligible for reimbursement, the NOP must:
- Be submitted within five calendar days of the date of service to be reimbursed. The date of
service is the date the member risk assessment is completed by the recognized provider.
- Be completed and submitted before 30 weeks of gestation.
- Bill using procedure code 99354 with modifier TH. The date of service on the NOP claim
should be the date the provider completed the risk assessment during a visit with the pregnant
woman.
NOP Billing on UB-04
Hospitals can submit claims for NOP, on the UB-04 claim form, to the appropriate managed care entity
following the following guidelines for reimbursement.
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To be eligible for reimbursement of an NOP:
1. The NOP must be submitted via Web interChange no more than five calendar days from the date the
risk assessment was completed. The NOP cannot be a duplicate of a previously submitted NOP, and
the member’s gestation must be 29 weeks or less.
2. NOP claim forms must be coded with:
- Revenue Code 960
- CPT code 99354 and modifier TH
Ophthalmological Services
The IHCP provides reimbursement for ophthalmology services, subject to the following restrictions
effective for dates of service October 1, 2011, and after:
•
One routine vision care examination and refraction for members 20 years old and younger, per
rolling calendar year
•
One routine vision care examination and refraction for members 21 years old and older, every two
years
•
The member must meet the following medical necessity guidelines in at least one eye for the
provision of eyeglasses (including replacement eyeglasses):
- A change of 0.75 diopters for patients 6 to 42 years old
- A change of 0.50 diopters prescription or change for patients more than 42 years old
- An axis change of at least 15 degrees
•
Replacement frames and lenses only when the medical necessity guidelines are met or when
necessitated by loss, theft, or damage beyond repair
Effective January 1, 2011, the IHCP revised the covered eyeglasses limitation to the following:
•
One pair of eyeglasses, for members age 20 years old and younger, per year
•
One pair of eyeglasses, for members 21 years and older, every five years
This change affects all IHCP programs, including Traditional Medicaid, Hoosier Healthwise, and Care
Select.
Date of Service Definition
All claims must reflect a date of service. The date of service is the date the specific services were
actually supplied, dispensed, or rendered to the patient. For example, when rendering services for
space maintainers or dentures, the date of service must reflect the date the appliance or denture is
delivered to the patient. This requirement is applicable to all IHCP-covered services.
Vision Coding and the Vision Services Code Set
Providers must use the appropriate CPT codes or HCPCS codes when submitting claims for vision
services to the IHCP. Optometrists and opticians are subject to the vision services code set, and the
IHCP reimburses only for services listed on the code set. IHCP provider code sets are available on
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The IHCP considers the following services bundled and not separately billable to the IHCP or the
patient:
•
Eyeglass cases
•
Fitting of eyeglasses
•
Neutralization of lenses
•
Verification of prescription
•
Fitting for contact lenses
Coverage for Ophthalmologic Uses of HCPCS Code J3300
The IHCP provides coverage for ophthalmologic use of HCPCS code J3300 – Injection, triamcinolone
acetonide, preservative free, 1 mg. The IHCP recognizes that triamcinolone acetonide, preservative
free is distributed in single-dose vials of 40 mg and some wastage of the product may be unavoidable.
Thus, IHCP providers may bill the entire 40 mg in cases in which less than 40 mg are injected in a
single treatment session, and the balance of the product is discarded. Whenever unused triamcinolone
acetonide, preservative free is billed, both the amount of the agent actually administered and the
amount discarded are to be documented in the member’s medical record. IHCP reimbursement for
J3300 is limited to 40 mg per date of service.
Providers should note that approved indications for J3300 are limited to ophthalmologic use. A similar
code, J3301 – Injection, triamcinolone acetonide, not otherwise specified 10mg may be used for
nonophthalmologic purposes.
The IHCP reminds providers that if an E/M code is billed with the same date of service as officeadministered therapy, the administration should not be billed separately. Reimbursement for the
administration is included in the E/M code-allowed amount. Separate reimbursement is allowed when
the administration is the only service provided and billed by the practitioner.
Vision Procedures Limited to One Unit
IHCP providers may bill only one unit, per member, per day for the procedures listed in Table 8.118.
Claims that have more than one unit per day for these codes automatically cut back and pay for one
unit. Providers that have been reimbursed for more than one unit may be subject to postpayment
review and possible recoupment.
Table 8.118 – Eye Exams and Other Ophthalmological Services
CPT
Code
Definition
92002
Ophthalmological services: medical examination and evaluation with initiation of diagnostic
and treatment program; intermediate, new patient
92004
Ophthalmological services: medical examination and evaluation with initiation of diagnostic
and treatment program; comprehensive, new patient, 1 or more visits
92012
Ophthalmological services: medical examination and evaluation, with initiation or
continuation of diagnostic and treatment program; intermediate, established patient
92014
Ophthalmological services: medical examination and evaluation, with initiation or
continuation of diagnostic and treatment program; comprehensive, established patient, 1 or
more visits
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CPT
Code
Definition
92018
Ophthalmological examination and evaluation, under general anesthesia, with or without
manipulation of globe for passive range of motion or other manipulation to facilitate
diagnostic examination; complete
92019
Ophthalmological examination and evaluation, under general anesthesia, with or without
manipulation of globe for passive range of motion or other manipulation to facilitate
diagnostic examination; limited
92020
Gonioscopy (separate procedure)
92060
Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or
paretic muscle with diplopia) with interpretation and report (separate procedure)
92065
Orthoptic and/or pleoptic training, with continuing medical direction and evaluation
92081
Visual field examination, unilateral or bilateral, with interpretation and report; limited
examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated
test, such as Octopus 3 or 7 equivalent)
92082
Visual field examination, unilateral or bilateral, with interpretation and report; intermediate
examination (eg, at least two isopters on Goldmann perimeter, or semiquantitative,
automated suprathreshold screening program, Humphrey suprathreshold automatic
diagnostic test, Octopus program 33)
92083
Visual field examination, unilateral or bilateral, with interpretation and report; extended
examination (eg, Goldmann visual fields with at least 3 isopters plotted and static
determination within the central 30 degrees, or quantitative, automated threshold perimetry,
Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 302, 24-2, or 30/60-2)
92100
Serial tonometry (separate procedure) with multiple measurements of intraocular pressure
over an extended time period with interpretation and report, same day (eg, diurnal curve or
medical treatment of acute elevation of intraocular pressure)
92140
Provocative tests for glaucoma, with interpretation and report, without tonography
92250
Fundus photography with interpretation and report
92260
Ophthalmodynanometry
92265
Needle oculoelectromyography, 1 or more extraocular muscles, 1or both eyes, with
interpretation and report
92270
Electro-oculography with interpretation and report
92275
Electroretinography with interpretation and report
92284
Dark adaptation examination with interpretation and report
92285
External ocular photography with interpretation and report for documentation of medical
progress (eg, close-up photography, slit lamp photography, goniophotography, stereophotography)
92286
Anterior segment imaging with interpretation and report; with specular microscopy and
endothelial cell analysis
92287
Anterior segment imaging with interpretation and report; with fluorescein angiography
92311
Prescription of optical and physical characteristics of and fitting of contact lens, with medical
supervision of adaptation; corneal lens for aphakia, 1 eye
92312
supervision of adaptation; corneal lens for aphakia, both eyes
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CPT
Code
Definition
92313
supervision of adaptation; corneoscleral lens
92314
Prescription of optical and physical characteristics of contact lens, with medical supervision
of adaptation and direction of fitting by independent technician; corneal lens, both eyes
except for aphakia
92315
of adaptation and direction of fitting by independent technician; corneal lens for aphakia, 1
eye
92316
of adaptation and direction of fitting by independent technician; corneal lens for aphakia,
both eyes
92317
of adaptation and direction of fitting by independent technician; corneoscleral lens
Eye Examinations
Providers should use the CPT code that best describes the examination to report eye examinations.
Table 8.119 lists CPT codes for eye examinations including counseling and coordination::
The eye examination includes the following services, and providers should not bill separately for these:
•
Biocular measurement
•
External eye examination
•
Gross visual field testing including color vision, depth perception, or stereopsis
•
Routine ophthalmoscopy
•
Tonometry
•
Visual acuity determination
Providers may code examinations in which counseling and coordination of care are the dominant
services with the appropriate E/M code using the time factor associated with the code. Documentation
in the patient’s record must include the total time of the encounter and a synopsis of the counseling
topics and coordination of care efforts.
Table 8.119 – Eye Examination
CPT Codes
99201 – 99215
99241 – 99245
99251 – 99255
92002 – 92014
Effective January 1, 2012, the IHCP reimburses provider specialty 180 – Optometrists for CPT code
95930 – Visual evoked potential (VEP) testing central nervous system, checkerboard or flash when
billed with one of the following diagnosis codes, for dates of service on or after January 1, 2012.
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Table 8.120 – ICD-9 Diagnosis Codes Billed with Code 95930
Diagnosis
Description
340
Multiple sclerosis
368.40
Visual field defect, unspecified
V17.2
Family history of neurological disease,
specifically multiple sclerosis
Providers can submit the following diagnostic services, if medically necessary, in addition to the eye
examination:
•
Dark adaptation examination
•
Determination of a refractive state
•
Extended color vision examination
•
External ocular photography and special anterior segment photography
•
Fitting of contact lens for treatment of disease, limited visual field, intermediate visual field,
extended visual field, serial tonometry, and tonography
•
Gonioscopy
•
Orthoptic or pleoptic training
•
Provocative tests for glaucoma, extended ophthalmoscopy, fluorescein angiography, indocyaninegreen angiography, fundus photography, ophthalmodynamometry, needle oculoelectromyography,
and electroretinography
•
Scanning computerized ophthalmic diagnostic imaging
•
Sensorimotor examination
Orthoptic or Pleoptic Training, Vision Training, and Therapies Coverage
Criteria
CPT code 92065 – Orthoptic and/or pleoptic training, with continuing medical direction and
evaluation covers all vision training therapies. Providers should meet the following criteria:
•
Submit services using CPT code 92065.
•
Limit 92065 to one unit or visit per day.
•
Have a physician or an optometrist order all vision therapy services.
•
The physician or optometrist must document, in the medical record, a diagnosis and treatment plan
and reevaluations of the need for continued treatment. Providers must document this information in
the member’s medical record.
•
An optometrist, a physician, or a supervised certified or trained staff can perform vision therapy
services.
•
Staff trained or certified in vision training may perform orthoptic and pleoptic training only under
the direct supervision of an optometrist or physician. Direct supervision requires the supervising
physician or optometrist must be physically available at the time and the place where the vision
therapy services are rendered.
•
Only the supervising optometrist or physician may document the treatment plan and reevaluations
in the medical record. All documentation of directly supervised vision therapy services rendered by
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opticians, orthoptists, or staff trained in vision therapy must be cosigned by the supervising
optometrist or physician in the medical record.
These services are noncovered by Medicare, and providers can bill them directly to Medicaid on a
CMS-1500 for dually eligible members. Medicare noncovered services are not covered by IHCP for
QMB Only recipients. For QMB Also recipients, please follow guidelines in Chapter 5: Third Party
Liability of the IHCP Provider Manual.
Lenses
Providers should include prescription of lenses, when required, in 92015 – Determination of refractive
state, which includes specification of lens type (monofocal, bifocal, or other), lens power, axis, prism,
absorptive factor, impact resistance, and other factors.
The IHCP does not provide coverage for the services listed in Table 8.121.
Table 8.121 – Procedure Codes Not Covered by the IHCP
Procedure Code
Description
V2702
Deluxe lens feature
V2744
Tint, photochromic, per lens
V2750
Antireflective coating, per lens
V2760
Scratch resistant coating, per lens
V2781
Progressive lens, per lens
V2782
Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per
lens
V2783
Lens, index greater than or equal to 1.66 plastic, or greater than or equal to 1.80
glass, excludes polycarbonate, per lens
V2786
Specialty occupational multifocal lens, per lens
If a member chooses to upgrade to progressive lenses, transitional lenses, anti-reflective coating, or tint
numbers other than 1 and 2, providers can bill the basic lens V code to the IHCP. Providers can bill the
upgrade portion to the member only if they gave the member appropriate advance notification of
noncoverage.
According to 405 IAC 5-23-4 (2), the IHCP may only reimburse for tints 1 and 2.
Table 8.122 – Covered Codes for Tints
Code with Modifier
Description
V2745 U1
Addition to lens; tint, any color, solid, gradient or equal, excludes
photochromatic, any lens material, per lens, plastic, rose 1 or 2, per lens
V2745 U2
Addition to lens; tint, any color, solid, gradient or equal, excludes
photochromatic, any lens material, per lens, glass, rose 1 or 2, per lens
The IHCP covers safety lenses only for corneal lacerations and other severe intractable ocular or ocular
adnexal disease.
The IHCP developed specific criteria for polycarbonate lenses to ensure that providers use the lenses
only for medically necessary conditions requiring additional ocular protection for members. HCPCS
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code V2784 – Lens, polycarbonate or equal, any index, per lens remains covered when a corrective
lens is medically necessary, and if one or more of the following criteria is met:
•
Member has carcinoma in one eye, and the healthy eye requires a corrective lens.
•
Member has only one eye that requires a corrective lens.
•
Member had eye surgery and still requires the use of a corrective lens.
•
Member has retinal detachment or is postsurgery for retinal detachment and requires a lens to
correct a refractive error of one or both eyes.
•
Member has a cataract in one eye or is postcataract surgery, and requires a lens to correct a
refractive error of one or both eyes.
•
Member has low vision or legal blindness in one eye with normal or near normal vision in the other
eye.
•
Other conditions deemed medically necessary by the optometrist or ophthalmologist exist. These
conditions must be such that one eye is affected by an intractable ocular condition, and the
polycarbonate lens is being used to protect the remaining vision of the healthy eye.
In all these situations, one or both eyes must be affected by an intractable ocular condition. The IHCP
covers the polycarbonate lens only to protect the remaining vision of the healthy eye when it is
medically necessary to correct a refractive error. Patient charts must support medical necessity. The
IHCP monitors use of these lenses in postpayment reviews.
The IHCP covers contact lenses when they are medically necessary. The IHCP does not require
documentation with the claim, but providers must maintain documentation in the patient’s medical
record for postpayment review. Examples of medically necessary contact lenses include, but are not
limited to, patients with severe facial deformity who are physically unable to wear eyeglasses or who
have severe allergy to all frame materials. The prescription of contact lens includes the specification of
optical and physical characteristics such as power, size, curvature, flexibility, and gas permeability,
and providers can bill with CPT codes 92310 through 92326, which are not part of the general
ophthalmology services. Fitting contact lenses includes instruction and training of the wearer and
incidental revision of the lenses during the training period. Providers should report follow-up of
successfully fitted extended wear lenses as part of the general ophthalmological service.
Effective December 20, 2012, for dates of service on or after November 1, 2012, CPT codes 92071 –
Fitting of contact lens for treatment of ocular surface disease and 92072 – Fitting of contact lens for
management of keratoconus, initial fitting was linked to provider specialty 180 – optometrist.
The IHCP does not reimburse for more than one unit for eye exams and other ophthalmologic
procedures. (See Table 8.123 for codes applying to eye exams and other ophthalmological services.)
IHCP providers may bill only one unit, per member, per day for the codes listed in the following table.
Claims that have more than one unit per day for these codes automatically cut back and pay for one
unit.
Table 8.123 – Eye Exams and Other Ophthalmological Services
(Limited to One Unit Per Member Per Day)
CPT Codes
92002
92004
92012
92014
92018
92019
92020
92060
92065
92081
92082
92083
92100
92140
92250
92260
92265
92270
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CPT Codes
92275
92284
92285
92286
92312
92313
92315
92316
92287
92311
Frames
The IHCP reimburses for frames including, but not limited to, plastic or metal. Providers should bill
for frames using V2020. Providers that receive payment from the IHCP for frames may not bill the
member for any additional cost above the IHCP reimbursement.
The IHCP does not cover any portion of a deluxe or fancy frame purchase, except when medically
necessary. Situations include, but are not limited to, special frames to accommodate a facial deformity
or anomaly, allergic reaction to standard frame material, or infant and child frames. Providers must
submit charges for medically necessary deluxe frames with procedure code V2025. The IHCP requires
documentation outlining the medical necessity when providers submit the claim. Providers must
submit an invoice for the frames with the claim. The IHCP reimburses at 90% of the retail price, as
indicated on the invoice. If a patient chooses to upgrade to a deluxe frame, the IHCP considers the
entire frame noncovered, and the provider may bill it to the patient if the provider gave proper advance
notice of no coverage to the member and the member signed it. In these situations, providers should
submit only the claim for the lenses to the IHCP.
The IHCP does not cover the following services:
•
Lenses with decorative designs
•
Fashion tints, gradient tints, sunglasses, and photochromatic lenses
- The IHCP does cover tint numbers 1 and 2, rose A, pink 1, soft lite, cruxite, and velvet lite,
subject to medical necessity.
•
Oversized lenses larger than 61mm, except when medical necessity is documented
The IHCP reimburses for lenses and other optical supplies, except frames, at the lower of the
provider’s usual and customary charge or the IHCP maximum rate on file.
Note: Replacement of eyeglasses beyond the indicated criteria must be medically
necessary and clearly documented in the patient’s medical record.
Replacement eyeglasses represent the beginning of a new limitation period.
Adoption of Modifiers for Replacement Eyeglasses
Repair or replacement covers the part of the eyeglasses that is broken or damaged. Patients are not
entitled to a new pair of eyeglasses if the lenses or frames can be repaired. To bill for repair of glasses,
the U8 modifier must be used.
Members younger than 21 years of age who have met the medical necessity for replacement eyeglasses
may be eligible for a new pair of eyeglasses one year from the date when the IHCP provided their
replacement eyeglasses. Members 21 years of age and older who have met the medical necessity for
replacement eyeglasses may be eligible for a new pair of eyeglasses five years from the date when the
IHCP provided their replacement eyeglasses.
If a member needs replacement eyeglasses due to loss, theft, or damage beyond repair before the
established frequency limitations, providers must use the U8 modifier to bill for the replacement lenses
or frames. Providers must include documentation in the member’s medical record to substantiate the
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need for replacement frames or lenses. Documentation that eyeglasses have been lost, stolen, or broken
beyond repair must include a signed statement by the member detailing how the eyeglasses were lost,
stolen, or broken.
If a member needs replacement eyeglasses due to a change in prescription as specified in 405 IAC 523-4(7) and before the established frequency limitations, providers must use modifier SC when billing
lenses or frames.
Use of either modifier indicates that the appropriate documentation is on file in the patient’s record to
substantiate the need to replace lenses or frames. Replacement of eyeglasses must be for medical
necessity.
Note: The IHCP requires modifiers only on claims for replacement of frames or
lenses within the one- or five-year period, based on the patient’s age at the
time of service; however, all eyeglasses dispensed must meet the minimum
prescription requirements for the initial dispensing and each subsequent
dispensing of eyeglasses.
Written Correspondence
Ophthalmology and optometric providers may not have the most current information available about
services previously rendered to the member and paid by the IHCP. This could result in reduced
reimbursement or no reimbursement for rendered services. The HP Provider Written Correspondence
Unit addresses specific questions pertaining to the IHCP. Providers may write to this unit to determine
whether particular members have exceeded their service limitations. Providers should allow 10
business days to receive an answer to a written inquiry. Benefit limits for optometry services are
available through the Eligibility Verification System (EVS). Chapter 3: Electronic Solutions of this
manual provides additional information.
When providers use the Indiana Health Coverage Programs Inquiry Form, it helps the HP Provider
Written Correspondence Unit provide the timeliest response. The IHCP may return incomplete written
inquiry forms for additional information. Clearly stating the reason for the inquiry enables analysts to
research the issue and provide a resolution. Providers should not send inquiries to resubmit claims
previously rejected.
Mail all written inquiries to the following address:
HP Provider Written Correspondence
P.O. Box 7263
Note: For RBMC members, contact the appropriate MCE.
Download copies of the Indiana Health Coverage Programs Inquiry Form from indianamedicaid.com
or request copies from the following address:
HP Forms Request
P.O. Box 7263
Note: For RBMC members, contact the appropriate MCE to obtain PA.
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Billing a Member for Services that have Exceeded Benefit Limitations
Providers may bill IHCP members for services exceeding the ophthalmology benefit limitations under
the following circumstances:
•
If the EVS informs the provider the limitation has already been met, the member is informed. If the
member still wishes to receive the service, they are asked to sign a waiver stating the service will
not be covered because benefits have been exhausted.
•
If the EVS does not show benefits have been exhausted, the provider may ask the member or their
guardian to attest in writing they have not received Medicaid-covered glasses within the past one or
five years (depending upon their age). The member is informed that if they are misrepresenting and
the provider’s claim is denied for exceeding benefit limitations, the member will be responsible for
the charges.
Prior Authorization
The IHCP does not require PA for vision care services except for the following provisions:
•
Blepharoplasty for a significant obstructive vision problem
•
Prosthetic device, except eyeglasses
•
Reconstruction or plastic surgery
Vision Services and Managed Care
Providers furnishing optical or ophthalmology services to members enrolled in Care Select must
follow existing PA guidelines for surgical services. The IHCP makes vision care and medical services
available to Care Select and Hoosier Healthwise members on a self-referral basis.
Providers must submit RBMC member claims to the members’ MCE for payment. Surgeries furnished
to patients enrolled in the RBMC must be prior authorized by the MCE in accordance with the MCE
guidelines.
Podiatric Services
Routine foot care includes the following:
•
Cutting or removal of corns, calluses, or warts, including plantar warts
•
Trimming of nails, including mycotic nails
•
Treatment of fungal, mycotic infection of the toenail is routine foot care only when the following
applies:
- Clinical evidence of infection of the toenail is present.
- Compelling medical evidence exists, documenting that the patient either has a marked limitation
of ambulation requiring active treatment of the foot or, in the case of nonambulatory patient, has
a condition that is likely to result in significant medical complications in the absence of such
treatment.
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The IHCP covers routine foot care only if a medical doctor or doctor of osteopathy has seen the patient
for treatment or evaluation of a systemic disease during the six-month period before rendering routine
foot care services. Providers must include the name and provider number of the physician in the CMS1500 in fields 17 and 17A, respectively. Providers should include the nature of the foot condition being
treated on the claim form, include the diagnosis in field 21 of the CMS-1500, and refer to the diagnosis
in field 24E of the CMS-1500.
The IHCP covers a maximum of six routine foot-care services per rolling 12-month period when the
patient has one of the following:
•
A systemic disease of sufficient severity that treatment of the disease may pose a hazard when
performed by a nonprofessional
•
Severe circulatory impairment as a result of the systemic condition or areas of desensitization in the
legs or feet
The following is a list of the ICD-9-CM diagnosis codes for systemic conditions that justify coverage
for routine foot care:
•
Diabetes mellitus, ICD-9-CM codes 250.00 through 250.91
•
Arteriosclerotic vascular disease of extremities, ICD-9-CM code 440.20 through 440.29
•
Thromboangiitis obliterans, ICD-9-CM code 443.1
•
Post-phlebitis syndrome, ICD-9-CM code 459.10 through 459.19
•
Polyneuropathy of the feet, ICD-9-CM codes 357.1 through 357.7
The IHCP does not cover routine foot-care services for Package C.
The IHCP reimburses when a podiatrist renders orthotic services covered by Medicare for all eligible
members receiving Medicare and Traditional Medicaid.
The IHCP requires PA for the following:
•
When a podiatrist prescribes or supplies corrective features built into shoes such as heels, lifts, and
wedges for members under 21 years of age.
•
When a podiatrist fits or supplies orthopedic shoes for members with severe diabetic foot disease,
subject to the restrictions and limitations outlined in 405 IAC 5-19-10.
Second Opinions
The IHCP may require providers to obtain a second or third opinion substantiating the medical
necessity or approach to the following surgical procedures:
•
Bunionectomy procedures
•
All surgical procedures involving the foot
See 405 IAC 5-8 for information on consultations and second opinions.
Office Visits
IHCP reimbursement may be allowed for podiatric office visits, subject to the following restrictions:
•
The IHCP allows for new patient office visits, using procedure codes 99201, 99202, and 99203,
one per member, per provider, within the last three years as defined by the CPT guidelines. A "new
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patient" is defined as one who has not received professional services from the provider or another
provider of the same specialty who belongs to the same group practice within the past three years.
•
The IHCP limits reimbursement to one office visit, per member, per 12 months.
•
Providers can bill a visit separately only on the initial visit. For subsequent visits, the procedure
performed on that date includes the reimbursement for the visits, and providers do not bill them
separately. However, if a second, significant problem is addressed on a subsequent visit, the
provider can report the visit code along with supporting documentation indicating why the
subsequent visit was required.
Note: The IHCP Program Integrity Department identified utilization issues related
to podiatrists inappropriately billing multiple units of CPT codes 9920199203 for new patient visits and CPT codes 99211-99213 for established
patient visits.
The IHCP Program Integrity Department advises all providers to carefully
review claims submitted to the IHCP to ensure proper billing of units for
these services. The IHCP Program Integrity Department reviews claims to
determine any inappropriate reimbursement and recoups overpayments. If a
provider identifies overpayments related to these errors, the provider should
file an adjustment or contact the IHCP Program Integrity Department to
arrange for repayment.
Surgical Services
The IHCP may reimburse for the following surgical procedures without PA:
•
Surgical cleansing of the skin
•
Drainage of skin abscesses
•
Drainage or injections of a joint or bursa
•
Trimming of skin lesions
The IHCP allows reimbursement for surgical procedures other than those previously mentioned,
performed within the scope of the podiatrist’s license, subject to PA, as specified in 405 IAC 5-26. For
podiatric surgical procedures, including diagnostic surgical procedures, providers cannot fragment and
bill separately. Generally, providers include such procedures in the major procedure. Procedures in this
category include, but are not limited to, the following:
•
Arthroscopy or arthrotomy procedures in the same area as a major joint procedure unless the claim
documents a second incision was made
•
Local anesthesia administered to perform the surgical or diagnostic procedure
•
Scope procedures used for the surgical procedure approach
Laboratory and X-ray Services
The IHCP may allow a podiatrist to be reimbursed for laboratory or X-ray services only if the services
are rendered by or under the personal supervision of the podiatrist. For services ordered by a podiatrist,
but performed by a laboratory or X-ray facility, the laboratory or X-ray facility bills the IHCP directly.
The IHCP may reimburse the podiatrist for collection of a specimen sent to the laboratory. The IHCP
does not reimburse for comparative foot X-rays, unless prior authorized.
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The IHCP reimburses for the following lab and X-ray services billed by a podiatrist:
•
Cultures for foot infections and mycotic fungal nails for diagnostic purposes
•
Medically necessary presurgical testing
•
Sensitivity studies for treatment of infection processes
Prior Authorization
The IHCP requires PA for the following:
•
Corrective features built into shoes, such as heels, lifts, and wedges, for members under 21 years of
age
•
Orthopedic shoes for members with severe diabetic foot disease, subject to the restrictions and
limitations outlined in 405 IAC 5-19-10
•
Comparative foot X-rays
Doppler Evaluations
The IHCP provides coverage for ultrasonic measurement of blood flow (Doppler evaluation) providing
prior authorization has been obtained for the proposed medical procedure and is subject to the
following limitations:
•
There is a preoperative diagnosis of diabetes mellitus, peripheral vascular disease, or
peripheral neuropathy.
•
The measurement is for preoperative podiatric evaluation.
•
The measurement cannot be used for routine screening.
•
The measurement cannot be used as an evaluation of routine foot care procedures, including
such services as removal or trimming of corns, calluses, and nails.
•
The preoperative Doppler evaluation is limited to one per year.
Radiology Services
Providers furnishing radiology services to members enrolled in Care Select must follow existing PA
guidelines. The IHCP makes radiology services available to Care Select and Hoosier Healthwise
patients on a self-referral basis. Providers submit RBMC member claims to the member’s MCE for
payment. Services that require PA furnished to members enrolled in RBMC must be prior authorized
by the MCE in accordance with the MCE guidelines.
Some radiological procedures encompass professional and technical components of the service. A
physician typically performs the professional component of the procedure.
The IHCP reimburses radiology inpatient and outpatient facilities, freestanding clinics, and surgical
centers for services provided to members subject to the following limitations:
•
The IHCP requires PA for any radiological services that exceed the use parameters set out in this
section.
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•
For a radiological service, a physician or other practitioner authorized to do so under state law must
order it in writing.
•
The radiological service facility must bill the IHCP directly for components provided by the
facility. When two practitioners separately provide a portion of the radiology service, each
practitioner may bill the IHCP directly for the component provided. The IHCP reimburses a
physician or other practitioner for radiological services only when that physician or practitioner
directly supervised the performance of those services.
•
The IHCP reimburses a physician for the professional component by billing the appropriate CPT
code along with Modifier 26, professional component. When billing only the technical component,
providers must use Modifier TC, technical component, with the appropriate CPT code. When
billing for professional and technical components of service, providers should use no modifiers.
CPT codes for which providers should use these modifiers to bill are listed in the Federal Register
under RVUs and related information.
•
For radiology procedures, providers cannot fragment and bill separately. Such procedures may
include, but are not limited to, the following:
- The IHCP does not reimburse for CPT codes for supervision and interpretation procedures when
the same provider bills for the complete procedure CPT code.
- If two provider specialties are performing a radiology procedure, the radiologist bills for the
supervision and interpretation procedure, and the second physician bills the appropriate
injection, aspiration, or biopsy procedure.
•
The IHCP does not reimburse for angiographic procedures performed as an integral component of a
surgical procedure by the operating physician. Such procedures include, but are not limited to, the
following:
- Angiographic injection procedures during coronary artery bypass graft
- Peripheral, percutaneous transluminal angioplasty procedures
Utilization Criteria
Criteria for the use of radiological services include consideration of the following:
•
Evidence that this radiologic procedure is necessary for the appropriate treatment of illness or
injury
•
X-rays of the spinal column limited to cases of acute documented injury or a medical condition in
which interpretation of X-rays would make a direct impact on the medical or surgical treatments
•
IHCP reimbursement for X-rays of the extremities and spine for the study of neuromusculoskeletal
conditions
The IHCP does not reimburse for radiology examinations of any body part taken as a routine study not
necessary for the diagnosis or treatment of a medical condition. Situations generally not needing
radiology services include, but are not limited to, the following:
•
Fluoroscopy without films
•
Pregnancy
•
Premarital examinations
•
Research studies
•
Routine physical examinations or check-ups
•
Screening, preoperative chest X-ray
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Providers must document all services related to radiological examinations in the patient’s record.
Computerized Tomography Scans
The IHCP may reimburse for diagnostic examination of the head (head scan) and of other parts of the
body (body scans), performed by computerized tomography (CT) scanners, subject to the following
restrictions:
•
The scan should be reasonable and necessary for the individual patient.
•
The provider must find use of a CT scan to be medically appropriate considering the patient’s
symptoms and preliminary diagnosis.
•
The IHCP reimburses only for CT scans performed with equipment certified by the FDA.
•
The IHCP does not reimburse for whole abdomen or whole pelvis scans on greater than 20 cuts,
except in staging cancer for treatment evaluation.
•
The IHCP does not require PA for CT scans.
PET Scans
If the member is an inpatient, the IHCP covers the Positron Emission Tomography (PET) scan in the
DRG payment to the hospital.
All claims for reimbursement of PET scans must include an appropriate ICD-9-CM diagnosis code.
The HCPCS codes for PET scans represent the global service. Providers performing just one
component of the test should appropriately use modifier TC (technical component) or 26 (professional
component).
If the member is an outpatient and has services performed in the outpatient area of the hospital or a
freestanding facility, the provider should bill for the PET scan as follows:
•
Reimbursement for professional services, reported with the appropriate CPT code, modifier 26
(professional services), and the appropriate ICD-9-CM code, and billed on a CMS-1500 or 837P
electronic transaction, reimburse from the resource-based relative value scale (RBRVS) fee
schedule.
•
Reimbursement for the appropriate CPT code, billed with the technical component (TC) and
appropriate ICD-9-CM code on a UB-04 claim form, reimburse based on the statewide max rate.
Radionuclide Bone Scans
The IHCP reimburses for radionuclide bone scans when performed for the detection and evaluation of
suspected or documented bone disease.
Upper Gastrointestinal Studies
The IHCP reimburses for upper gastrointestinal (GI) studies when performed for detection and
evaluation of diseases of the esophagus, stomach, and duodenum.
The IHCP does not cover an upper GI study for a patient with a history of duodenal or gastric ulcer
disease unless the patient was recently symptomatic.
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The IHCP does not cover an upper GI study in the preoperative cholecystectomy patient unless
symptoms indicate an upper GI abnormality in addition to cholelithiasis, or if the etiology of the
abdominal pain is uncertain.
Hospice Providers
The attending physician’s billed charges should not include costs for services such as X-rays and
laboratory. The daily hospice care rates include these costs and are expressly the responsibility of the
hospice provider.
Renal Dialysis Physician Services
The IHCP uses the same criteria and coding methodology as Medicare, using HCPCS codes 9095190970 to bill for the management of ESRD dialysis services. Table 8.124 lists the HCPCS codes for
ESRD.
Table 8.124 – HCPCS Codes for ESRD
Code
Description
90951
End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age
to include monitoring for the adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits or other qualified health care professional
per month
90952
counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care
professional per month
90953
counseling of parents; with 1 face-to-face visit by a physician or other qualified health care
90954
End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include
monitoring for the adequacy of nutrition, assessment of growth and development, and counseling
of parents; with 4 or more face-to-face visits by a physician or other qualified health care
90955
of parents; with 2-3 face-to-face visits by a physician or other qualified health care professional
per month
90956
of parents; with 1 face-to-face visit by a physician or other qualified health care professional per
month
90957
End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to
include monitoring for the adequacy of nutrition, assessment of growth and development, and
counseling of parents; with 4 or more face-to-face visits by a physician or other qualified health
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Code
Description
care professional per month
90958
counseling of parents; with 2-3 face-to-face visits by a physician or other qualified health care
90959
counseling of parents; with 1 face-to-face visit by a physician or other qualified health care
90960
End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older;
with 4 or more face-to-face visits by a physician or other qualified health care professional per
month
90961
with 2-3 face-to-face visits by a physician or other qualified health care professional per month
90962
with 1 face-to-face visit by a physician or other qualified health care professional per month
90963
End-stage renal disease (ESRD) related services for home dialysis per full month, for patients
younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of
growth and development, and counseling of parents
90964
End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 211 years of age to include monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90965
End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 1219 years of age to include monitoring for the adequacy of nutrition, assessment of growth and
development, and counseling of parents
90966
End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20
years of age and older
90967
End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per
day; for patients younger than 2 years of age
90968
day; for patients 2-11 years of age
90969
day; for patients 12-19 years of age
90970
day; for patients 20 years of age and older
School Corporation Services
Special education services provided by a public school and contained in an Individual Education Plan
(IEP) are exempt from PA and managed care referral requirements. The IEP serves as prior
authorization for the service provided. The IHCP enrolls only school corporations recognized and
approved by the Indiana Department of Education. School corporations enrolled as IHCP providers
are exempt from requirements to obtain PA to bill for IEP services furnished to a student in Special
Education. All services must be billed by the school corporation utilizing the CMS-1500 format.
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Covered Services
Medicaid-covered IEP evaluation and treatment services are face-to-face, health-related services
provided to a student or group of students who is/are eligible to receive services under the Individuals
with Disabilities Education Act (IDEA). Services are billed by the school corporation in the CMS-1500
format. Covered services must be medically necessary, included in the Indiana Medicaid State Plan,
and required to develop or listed in a student’s Individualized Education Program (IEP) or
Individualized Family Service Plan (IFSP), including:
•
Speech/language pathology and audiology services
•
Nursing services provided by an RN
•
Health-related, including mental health, assessments and evaluations
•
Physical and occupational therapy
•
Psychological testing, evaluation, and therapy services
•
IEP-required special transportation services on dates of another covered IEP service
Additional information may also be found in School Corporation Medicaid Billing Tool Kit, Chapter
8.2, located on the Indiana Department of Education website at
http://www.doe.in.gov/sites/default/files/specialed/tool-kit13th-edition-2-28-2013.pdf.
The IHCP provides coverage for nursing services and transportation services provided by public
school corporations for students with health-related nursing and transportation needs identified in the
IEPs. School corporations may submit claims to the IHCP for nursing and transportation services
provided to Medicaid-enrolled students with health-related nursing and transportation needs identified
in IEPs.
IEP Nursing Services
Medicaid reimbursement is available for IEP nursing services rendered by an RN employed by or
under contract with a Medicaid-enrolled school corporation provider when the services are medically
necessary, as ordered by a physician and provided pursuant to a Medicaid-enrolled student’s IEP. The
IEP is the prior authorization for the IEP nursing services; thus, no additional prior authorization is
necessary. School corporations should bill the CPT code 99600 TD TM and the appropriate number of
units based on accurate start and stop times.
Aggregate daily total care time should be billed. If total daily care is eight minutes or more, the
provider may round the units up to the 15-minute unit of service and bill one unit of 99600 TD TM. If
total daily care time is seven minutes or less, the provider cannot round this up, and therefore, cannot
bill for it.
Documentation of IEP nursing services must include the start and stop times for each IEP nursing
service provided per date of service. Documentation of IEP nursing services provided off-site or during
a school field trip must note the place of service and include a description of the beginning and ending
dates and times of the school field trip. The student’s IEP must specifically authorize the Medicaidcovered IEP service for which there is a documented medical need.
Coverage and reimbursement of CPT 99600 TD TM includes all services performed in accordance
with the scope of practice for a registered nurse. Thus, CPT 99600 TD TM is an all-inclusive code,
including, but not limited to, administration of oral medication and nebulizer treatments. The exception
to this is diabetes self-management training (DSMT). If DSMT is provided pursuant to a Medicaidenrolled student’s IEP, the most appropriate code should be billed with the IEP-related modifier TM to
identify it as an IEP-related service. Providers are reminded that, as with all IEP nursing services,
DSMT must be medically necessary and provided pursuant to a Medicaid-enrolled student’s IEP.
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Additionally, all other requirements and guidelines stated in IHCP provider communications, including
the IHCP Provider Manual and provider banner pages and bulletins, must be met. Further information
may also be found in School Corporation Medicaid Billing Tool Kit, Chapter 8.2, located on the
Indiana Department of Education website (doe.in.gov).
IEP Transportation Services
Medicaid reimbursement is available for IEP transportation services rendered by personnel employed
by or contractors of a Medicaid-enrolled school corporation provider when the services are medically
necessary and provided pursuant to a Medicaid-enrolled student’s IEP. IEP-related transportation
services are not covered when provided by a member of the child’s family, unless that person is
employed by or a contractor of the school corporation.
IEP transportation services must be authorized in the child’s IEP and must be provided to enable the
child to receive another Medicaid-covered service identified in the child’s IEP. The IEP is the prior
authorization for the IEP transportation service; thus, no additional prior authorization is necessary.
Additional payment is available for an attendant, subject to the limitations in 405 IAC 5-30-8 (1) and
(2), provided the student’s IEP includes the need for an attendant, and all other Medicaid requirements
are met.
When billing IEP transportation services, modifier TM must be attached to the end of all transportation
billing codes to identify the service as IEP -related. Additionally, school corporations should follow all
IHCP transportation guidelines and rules, as stated in IHCP banner pages and bulletins, and the IHCP
Provider Manual. Additional information may be located in School Corporation Medicaid Billing Tool
Kit, located on the Indiana Department of Education website (doe.in.gov).
The following are the only transportation guidelines and regulations from which school corporations
are exempt:
•
Prior authorization requirement – The student’s IEP serves as the prior authorization for IEP
transportation services; thus, no additional PA is required, regardless of the number of one-way
trips.
•
Enrollment requirements set out in 405 IAC 5-4-2 – When transportation services provided
conform to 405 IAC 5-30-11 and requirements set out in IC 20-27 are met.
•
Copayment requirement – Pursuant to federal law, transportation copayments should not be
collected by school corporations for members who receive IEP transportation services.
•
Member’s signature on documentation – Member’s signature is not a documentation requirement
for IEP transportation services. However, school corporations are responsible for all other
transportation documentation requirements identified in IHCP bulletins and banner pages and the
IHCP Provider Manual.
Billing Procedures
Submit claims for IEP services provided to special education students enrolled in Care Select on the
CMS-1500 to the following address:
HP CMS-1500 Claims
P.O. Box 7269
If the student is enrolled in an RBMC MCE, school corporation providers must submit claims using
the CMS-1500 claim form or 837P to the address above for IEP services to HP and not to the student’s
MCE.
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Although IEP services are carved out of the IHCP managed care programs, provider cooperation is
strongly encouraged to keep the PMPs informed of health-related services provided to IHCP-eligible
special education students. Arrangements should be made to send progress reports or some other type
of documentation to the PMP of each student to promote continuity and quality of care.
Surgical Services
Providers furnishing surgical services to members enrolled in Care Select must follow existing PA
guidelines. RBMC member claims are submitted to the patients’ MCE for payment. Services that
require PA furnished to patients enrolled in RBMC must be prior authorized by the MCE in
accordance with the MCE guidelines. A surgical procedure generally includes the preoperative visits
performed on the same day or the day prior to the surgery for major surgical procedures, and the day of
the surgical procedure for minor surgical procedures.
Separate reimbursement is available for preoperative care when the provider performing the surgery
has never seen the patient, or the decision to perform surgery was made during the preoperative visit.
•
Modifier 57 – Decision for Surgery must be submitted on the CMS-1500 or 837P with the E/M
The postoperative care days for a surgical procedure include 90 days following a major surgical
procedure and 10 days following a minor surgical procedure. Separate reimbursement is available for
care provided during the global postoperative period unrelated to the surgical procedure, or for care not
considered routine, and postoperative care for surgical complications. All levels of medical care,
before surgical procedures, are reimbursed individually based on documentation of the patient’s
medical condition.
If the patient’s condition requires additional medical or surgical care outside the scope of the operating
surgeon – for example, an additional surgery performed by a different specialist for a different
diagnosis – on the same day, reimbursement for the medical care is considered individually. Medical
visits for surgical complication are reimbursed only if medically indicated and no other physician has
billed for the same or related diagnosis. The claim must indicate the specific complications, and
providers should attach documentation that clearly supports the medical necessity for the care
provided. The medical visits are billed separately from the surgical fee. Such complications may
include but are not limited to the following:
•
Cardiovascular complications
•
Comatose conditions
•
Elevated temperature above 38.4 degrees C, 101 degrees F, for two or more consecutive days
•
Medical complications, other than nausea and vomiting, due to anesthesia
•
Nausea and vomiting persisting more than 24 hours
•
Postoperative wound infection requiring specialized treatment
•
Renal failure
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Split Care
Requirements for Split Care
The IHCP requires a written agreement when the global surgical procedure is split among multiple
providers. The conditions are the same as those for Medicare and are illustrated as follows:
•
Providers billing for split care must have a written agreement outlining the date care is to be turned
over and the name of the provider receiving the patient.
•
The agreement must become part of the patient’s file.
•
The agreement must be submitted with any review or hearing request about the split-care payment.
•
Modifier 54 must not be billed unless a written agreement exists.
•
Physician must bill the appropriate CPT code without modifier 54 or 55 if a written agreement does
not exist.
Split-Care Billing Procedures and Reimbursement Calculation
When the provider that performed the surgery does not provide any postoperative care, the provider
must bill the surgical procedure code with modifier 54 – Surgical care only and the actual date of the
surgery.
Postoperative care must be billed using the surgical procedure code with modifier 55 – Postoperative
management only. The dates of service must reflect the date care was assumed and relinquished, and
the units field must include the total number of postoperative days furnished. To ensure appropriate
reimbursement when billing with modifier 55, the number of days within the date of service range
must equal the number of units (days) reported on the claim. For the purposes of defining
postoperative care units, one unit is equal to one day of postoperative care.
Note: The postoperative period begins the day after surgery.
Postoperative management claims must not be submitted until the physician managing the
postoperative care sees the patient for the first time.
The following two examples define appropriate billing procedures for split care and show how
reimbursement is calculated. The examples use procedure code 43030, a 90-day postoperative period,
and allow a total of $460.48 for the global service, as shown in Table 8.125.
Table 8.125 – Procedure Code 43030
Description
Percentage
Modifier
Preoperative
9
Intraoperative
+81
Total intraoperative
90
54
Postoperative
10
55
Total
100
Example 1
In this example, two physicians split the postoperative care. Physician A performs the surgical
procedure and manages the patient postoperatively for 60 days, as shown in Table 8.126.
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Table 8.126 – Billing Physician A
Physician A
From Date of
Service
To Date of
Service
Procedure
Code
Modifier
Units Billed
Detail 1
10/01/2008
10/01/2008
43030
54
1
Detail 2
10/02/2008
11/30/2008
43030
55
60
Calculations are made as follows:
Detail 1: Global fee of $460.48 multiplied by 0.90 (9% preoperative percentage + 81% intraoperative
percentage) multiplied by 1 unit billed equals $414.43.
Detail 2: Global fee of $460.48 multiplied by 0.10 equals the total postoperative allowance of $46.048
divided by 90 (number of global days assigned) equals $0.5116 per day multiplied by 60 (number of
postoperative days reported) equals $30.699 or $30.70.
As shown in Table 8.127, Physician B performs the balance of the postoperative care for 30 days.
Table 8.127 – Billing Physician B
Physician B
Detail 1
From Date of
Service
To Date of
Service
12/01/2008
12/30/2008
Procedure
Code
43030
Modifier
55
Units Billed
30
Detail 1: Global fee of $460.48 multiplied by 0.10 equals the total postoperative allowance of $46.048
divided by 90 (number of global days assigned) equals $0.5116 per day multiplied by 30 (number of
postoperative days reported) equals $15.348 or $15.35. When only one provider is responsible for the
surgery and all the postoperative care, the provider must bill the surgical procedure, without modifier
54 or 55. The IHCP-allowed amount in this case would be 100% of the RBRVS fee.
Note: Modifiers 54 and 55 are used only to split postoperative care between
multiple providers.
Example 2
In this example, the same provider bills for the surgery and all the postoperative care. Physician A
performs and bills for the surgical procedure and all the postoperative care, as shown in Table 8.128.
Table 8.128 – Billing Physician A
Physician A
Detail 1
From Date of
Service
10/01/2008
To Date of
Service
10/01/2008
Procedure
Code
43030
Modifier
Units Billed
1
The global fee for procedure code 43030 is $460.48. Therefore, reimbursement for this service should
be made at $460.48.
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Exceptions and Special Billing Considerations
If more than one physician in the same group practice participates in a portion of a patient’s care,
included in a global surgery package, only the physician who performs the surgery can submit a bill.
Split-care modifiers are not applicable, and the surgeon’s claim must include only the surgical
procedure. Although other physicians participated in the care, all are within the same group practice.
There is no need to split the reimbursement because the physician group is reimbursed the global fee.
If a transfer of care does not occur, occasional post-discharge services for a physician other than the
surgeon are reported with the appropriate E/M code. Modifiers are not required.
If the transfer of care occurs immediately after surgery, the physician who provides the postoperative
care while the patient remains in the hospital bills using subsequent hospital care codes. Once the
patient is released from the hospital, the physician responsible for postoperative care bills using the
surgical procedure code with modifier 55. The surgeon should bill the appropriate surgical procedure
code with modifier 54. This situation can occur when an itinerant (traveling) surgeon is used.
If a physician provides follow-up services during the postoperative period for minor procedures
performed in the emergency department, the physician must bill the appropriate level of office visit
code. The emergency department physician who performed the surgical service bills the surgical
procedure code without a modifier.
If the services of a physician, other than the surgeon, are required during a postoperative period for an
underlying condition or medical complication, the other physician reports the appropriate E/M code,
and split-care modifiers are not required on the claim. For example, a cardiologist may manage the
underlying cardiovascular condition during the postoperative period for a cardiovascular procedure
that was performed by a cardiothoracic surgeon.
If a patient is returned to surgery for a related procedure during the postoperative period and billed
using modifier 78, the IHCP-allowed amount is calculated by multiplying the RBRVS fee amount by
the surgical care only (intraoperative) percentage on the Medicare fee schedule data base (MFSDB). In
these situations, the preoperative percentage is not added to the intraoperative percentage for
calculating the allowed amount described in the first example. In addition, a new postoperative period
is not allowed for the related procedure. The number of postoperative days allowed following the
return to surgery is equal to the number of postoperative days remaining from the original procedure.
Billing certain modifiers on the same detail is restricted as follows to avoid processing issues:
Modifier 54 (intraoperative) cannot be billed on the same detail as modifiers 55, 78, 80, 81, 82, AA,
P1 through P5, QJ, QK, QX, QZ, QO, QQ, X6, and W5 through W7, or the detail denies for an invalid
modifier combination.
Billing certain modifiers on the same detail is restricted as follows, to avoid processing issues:
•
Modifier 54 (intraoperative) cannot be billed on the same detail as modifiers: 55, 78, 80, 81, 82,
P1 through P5, QK, QX, and QZ, or the detail denies for an invalid modifier combination.
•
Modifier 55 (postoperative) cannot be billed on the same detail as modifiers: 54, 78, 80, 81, 82,
P1 through P5, QK, QX, and QZ, or the detail denies for an invalid modifier combination.
Cosurgeons
Cosurgeons must append modifier 62 to the surgical service. Modifier 62 cuts the reimbursement rate
to 62.5% of the rate on file.
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Multiple Procedures
When two or more covered surgical procedures are performed during the same operative session,
multiple surgery reductions apply to the procedures based on the following adjustments:
•
100% of the global fee for the most expensive procedure
•
50% of the global fee for the second most expensive procedure
•
25% of the global fee for the remaining procedures
All surgeries that are performed on the same day, by the same rendering physician, must be billed on
the same claim form. Otherwise the claim may be denied, and the original claim needs to be adjusted
for any additional payment.
Bilateral Procedures
Providers submitting CMS-1500 claims or 837P transactions using modifier 50, indicating bilateral
procedure, must enter only one unit in field 24G on the CMS-1500. The use of modifier 50 ensures that
the procedure code is priced at the lower of 150% of the billed charge or the rate on file. Providers
should note that if the CPT code description specifies the procedure as bilateral, modifier 50 should not
be used on the CMS-1500 or 837P.
Prior Authorization
Chapter 6: Prior Authorization of this manual provides additional information on PA for this service.
Note: For RBMC members, contact the appropriate MCE for PA instructions.
Therapy Services
This section outlines IAC criteria for therapy services.
405 IAC 5-22-6(a) states the IHCP requires prior review and authorization for all therapy services with
the following exceptions:
•
Initial evaluations
•
Emergency respiratory therapy
•
Any combination of therapy ordered in writing prior to a member’s release or discharge from
inpatient hospital care, which may continue for a period not to exceed 30 units, sessions, or visits in
30 calendar days
•
Deductible and copay for services covered by Medicare Part B
•
Oxygen equipment and supplies necessary for the delivery of oxygen with the exception of
concentrators
•
Therapy services provided by a NF or large private or small ICF/IID, included in the facility’s per
diem rate
•
Physical therapy, occupational therapy, and respiratory therapy ordered in writing by a physician to
treat an acute medical condition, except as required in Sections 8, 10, and 11 of this rule
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405 IAC 5-22-6(b) provides that, unless specifically indicated otherwise, the following criteria for PA
of therapy services apply to occupational therapy, physical therapy, respiratory therapy, and speech
pathology:
•
The IHCP requires written evidence of physician involvement and personal patient evaluation to
document acute medical needs. A physician must order the therapy. Providers must attach a current
plan of treatment and progress notes about the necessity and effectiveness of therapy to the PA
request and make this available for audit.
•
A qualified therapist or qualified assistant under the direct supervision of the therapist, as
appropriate, must provide the therapy.
•
Therapy must be of such a level of complexity and sophistication, and the condition of the member
must be such, that they require the judgment, knowledge, and skills of a qualified therapist.
•
The IHCP reimburses only for medically reasonable and necessary therapy.
•
The IHCP does not cover therapy rendered for diversional, recreational, vocational, or avocational
purpose, or for the remediation of learning disabilities or developmental activities that can be
conducted by nonmedical personnel.
•
The IHCP covers therapy for rehabilitative services for a member no longer than two years from
the initiation of the therapy unless a significant change in medical condition requires longer
therapy. Providers can prior authorize habilitative services for a member younger than 18 years old
for a longer period on a case-by-case basis. Providers can prior authorize respiratory therapy
services for a longer period on a case-by-case basis.
•
The IHCP does not cover maintenance therapy.
•
When a member is enrolled in therapy, ongoing evaluations to assess progress and redefine therapy
goals are part of the therapy program. The IHCP does not separately reimburse for ongoing
evaluations.
•
One hour of billed therapy must include a minimum of 45 minutes of direct patient care with the
balance of the hour spent in related patient services.
•
The IHCP does not approve therapy services for more than one hour per day, per type of therapy.
The IHCP does not prior authorize requests for therapy that duplicate other services provided to a
patient. 405 IAC 5-22-8 provides that physical therapy services are subject to the following
restrictions:
•
A licensed physical therapist or certified therapist assistant under the direct supervision of a
licensed physical therapist must perform physical therapy service. Only the activities in this
subdivision related to the therapy can be performed by someone other than a licensed therapist or
certified therapist assistant who must be under the direct supervision of a licensed physical
therapist.
•
The IHCP allowance for the modality provided by the licensed therapist includes payment for the
following services, and providers may not bill separately for them:
- Assisting patients in preparation for treatment, as necessary during treatment, and at the
conclusion of treatment
- Assembling and disassembling equipment
- Assisting a physical therapist in the performance of appropriate activities related to the
treatment of the individual patient
- Following established procedures pertaining to the care of equipment and supplies
- Preparing, maintaining, and cleaning treatment areas and maintaining supportive areas
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- Transporting patients, records, equipment, and supplies in accordance with established policies
and procedures
- Performing established clerical procedures
•
The IHCP limits evaluations and reevaluations to three hours of service per member evaluation. For
the initial evaluation, the IHCP does not require PA. For any additional reevaluations, the IHCP
does require PA unless conducted during the initial 30 days after hospital discharge and the
discharge orders include physical therapy orders. The IHCP does not authorize reevaluations more
than one time per year unless the provider submits documentation indicating significant change in
the patient’s condition. The provider is responsible for determining whether evaluation services
have been previously provided.
•
Physical therapy services ordered in writing to treat an acute medical condition provided in an
outpatient setting may continue for a period not to exceed 12 one-hour sessions, or visits within 30
calendar days without PA. This exception includes the provision of splints, crutches, and canes.
Providers must obtain PA for additional services.
•
The IHCP does not require PA for physical therapy services provided by a NF or large private or
small ICF/IID, which are included in the facility’s per diem rate. The IHCP does not reimburse
these services separately.
405 IAC 1-11.5-2(c)(4) allows for the reimbursement of services provided by certified physical
therapist assistants (PTAs). This rule amends 405 IAC 5-22-8 regarding supervision requirements for
services provided by certified PTAs. The PTA is precluded from performing and interpreting tests,
conducting initial or subsequent assessments, and developing treatment plans. Under direct
supervision, a PTA is still required to consult with the supervising physical therapist daily to review
treatment. The consultation can be either face-to-face or by telephone.
For dates of service from January 1, 2011 through June 29, 2011, a limit of 25 therapy visits for each
type of therapy, per rolling 12-month period, applies to physical, speech and occupational therapies,
for members age 21 or older.
A “visit” is defined by the type of therapy and date of service. For example, a member receives
physical therapy from a provider during a one-hour visit. That member receives physical therapy
services defined with procedure codes 97116, 97140, 97530, and 97532 during the visit. This is
counted as one “visit” toward the member’s limitation.
Effective June 30, 2011, the service limitations detailed in the previous paragraphs were eliminated but
are applied to any claims submitted with dates of service from January 1, 2011, through June 29, 2011.
Prior authorization is required for all members age 21 or older for physical, speech, and occupational
therapy, effective for dates of service on or after June 30, 2011.
Therapy services for members less than 21 years of age remains unchanged, and current prior
authorization requirements remain in effect.
Covered Procedures for Physical Therapist Assistants
The IHCP has identified procedures that can be performed by a PTA and are eligible for
reimbursement. Providers must bill these services with the modifier HM – Less than a bachelor’s
degree. Pricing for these services reimburses at 75% of the reimbursement level for a physical
therapist. Table 8.129 lists the physical therapy services that PTAs may perform.
Note: This information does not apply to First Steps services.
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Table 8.129 – Physical Therapy Services that May Be Performed by a PTA
CPT Code
Description
29200
Strapping; thorax
29240
Strapping; shoulder (eg, Velpeau)
29260
Strapping; elbow or wrist
29280
Strapping; hand or finger
29505
Application of long leg splint (thigh to ankle or toes)
29515
Application of short leg splint (calf to foot)
29520
Strapping; hip
29530
Strapping; knee
29540
Strapping; ankle and/or foot
29550
Strapping; toes
29580
Strapping; Unna Boot
97012
Application of a modality to 1 or more areas; traction, mechanical
97014
Application of a modality to 1or more areas; electrical stimulation (unattended)
97016
Application of a modality to 1or more areas; vasopneumatic devices
97018
Application of a modality to 1 or more areas; paraffin bath
97022
Application of a modality to 1 or more areas; whirlpool
97024
Application of a modality to 1 or more areas; diathermy (eg, microwave)
97026
Application of a modality to 1 or more areas; infrared
97028
Application of a modality to 1 or more areas; ultraviolet
97032
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15
minutes
97033
Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97034
Application of a modality to 1 or more areas; contrast baths, each 15 minutes
97035
Application of a modality to 1 or more areas; ultrasound, each 15 minutes
97036
Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
97110
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility
97112
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for
sitting and/or standing activities
97113
Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with
therapeutic exercise
97116
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair
climbing)
97124
Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage,
petrissage, and/or tapotement (stroking, compression, percussion)
97140
Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage,
manual traction), 1 or more regions, each 15 minutes
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CPT Code
Description
97150
Therapeutic procedure(s), group (2 or more individuals)
97530
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to
improve functional performance), each 15 minutes.
97760
Orthotic(s) management and training, (including assessment and fitting when not
otherwise reported), upper extremity(s) and/or trunk, each 15 minutes
97761
Prosthetic training, upper and/or lower extremity(s), each 15 minutes
Evaluation and testing codes are excluded from this list as PTAs may not administer tests or perform
evaluations.
405 IAC 5-22-10 states that respiratory therapy services are subject to the following restrictions:
•
The IHCP reimburses for respiratory therapy service only when performed by a licensed respiratory
therapist or a certified respiratory therapy technician who is an employee or contractor of a
hospital, medical agency, or clinic.
•
The IHCP considers the equipment necessary for rendering respiratory therapy part of the
provider’s capital equipment.
•
The IHCP does not require PA for oxygen provided in a NF, because it is included in the per diem
for the facility and providers cannot bill separately for it.
•
For respiratory therapy given on an emergency basis, the IHCP does not require PA.
•
For a period not to exceed 14 hours or 14 calendar days, providers can perform respiratory therapy
services ordered in writing for the acute medical diagnosis of asthma, pneumonia, bronchitis, and
upper respiratory infection without PA. If the member requires additional services after that date,
the provider must obtain PA.
•
For respiratory therapy services provided by a NF or large private or small ICF/IID, which are
included in the facility’s established per diem rate, the IHCP does not require PA.
405 IAC 5-22-11 states that occupational therapy services are subject to the following restrictions:
•
A registered occupational therapist or a certified occupational therapy assistant under the direct onsite supervision of a registered occupational therapist must perform the occupational therapy
service. The registered occupational therapist must perform the evaluation for the IHCP to
reimburse the provider.
•
The IHCP limits evaluations and reevaluations to three hours of service per evaluation. For the
initial evaluation, the IHCP does not require PA. For any additional reevaluations, the IHCP does
require PA unless conducted during the initial 30 days after hospital discharge when the discharge
orders include occupational therapy orders. The IHCP does not authorize reevaluations more than
one time per year unless the provider submits documentation indicating significant change in the
patient’s condition. The provider is responsible for determining whether evaluations have been
previously provided.
•
The IHCP does not cover general strengthening exercise programs for recuperative purposes.
•
The IHCP does not cover passive range-of-motion services as the only or primary mode of therapy.
•
The IHCP does not reimburse for occupational therapy psychiatric services.
•
Occupational therapy services ordered in writing to treat an acute medical condition provided in an
outpatient setting may continue for a period not to exceed 12 one-hour sessions, or visits in 30
calendar days without PA. This exception includes provision of splints, crutches, and canes.
Providers must obtain PA for additional services.
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•
The IHCP does not require PA for occupational therapy services provided by a NF or large private
or small ICF/IID, which are included in the facility’s established per diem rate.
Note: For RBMC members, contact the appropriate MCE for billing and PA
instructions.
The IHCP reimburses for therapy services provided outside Indiana, subject to PA as provided by 405
IAC 5-5-2.
Note: The IHCP does not cover home health agency services outside Indiana.
Providers should refer to the section on Home Health Services in this chapter for billing guidelines
related to provision of therapy by HHAs.
Outpatient
Outpatient providers bill occupational therapy, physical therapy, and speech therapy as stand-alone
services. For these services, providers bill using the revenue code only and the IHCP reimburses at a
flat, statewide fee on a per-hour basis or unit billed. Providers cannot bill for fractional units for less
than one hour. Providers must accumulate and report time in one-hour increments. The section
Outpatient Services in Section 2 under the UB-04 Billing Instructions provides additional information.
Hippotherapy
The IHCP covers hippotherapy for physical therapy. To be covered, a licensed physical therapist must
provide the services, and providers must bill for the services using the appropriate HCPCS code from
the following list:
•
97110 – Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop
strength and endurance, range of motion, and flexibility
•
97112 – Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of
movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting
and/or standing activities
•
97530 – Therapeutic activities, direct (one-on-one) patient contact by provider (use of dynamic
activities to improve functional performance), each 15 minutes
•
97533 – Sensory integrative techniques to enhance sensory processing and promote adaptive
responses to environmental demands direct (one-on-one) patient contact by the provider, each 15
minutes. This code can be used only for patients with a diagnosis of traumatic brain injury (TBI).
A physician must order the services and include them in the patient’s treatment plan. Existing PA
requirements for physical therapy apply to hippotherapy.
Note: Procedure code S8940 (hippotherapy per person, equestrian, hippotherapy,
per session), is not covered by the IHCP.
Traumatic Brain Injury
405 IAC 5-29-1(25)(I) states that cognitive rehabilitation is a noncovered service, except for the
treatment of traumatic brain injury.
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The IHCP limits CPT code 97532 – Development of cognitive skills to improve attention, memory,
problem solving (including compensatory training), direct (one-on-one) patient contact by the
provider, each 15 minutes, and CPT code 97533 – Sensory integrative techniques to enhance sensory
processing and promote adaptive responses to environmental demands, direct (one-on-one) patient
contact by the provider, each 15 minutes, to the specific traumatic brain injury diagnoses.
Transportation Services
Advanced Life Support – ALS
Advanced life support (ALS) is defined by Indiana Code (IC) 16-18-2-7 and the Indiana Emergency
Medical Services Commission (EMSC) as follows:
Care given at the scene of an accident, act of terrorism, or illness, care given during transport, or care
given at the hospital by a paramedic, emergency medical technician-intermediate, and care that is more
advanced than the care usually provided by an emergency medical technician or an emergency medical
technician-basic advanced.
The term advanced life support may include any of the following acts of care:
•
Defibrillation
•
Endotracheal intubation
•
Parenteral injection of appropriate medications
•
Electrocardiogram interpretation
•
Emergency management of trauma and illness
The IHCP provides reimbursement for medically necessary emergency and nonemergency ALS
ambulance services when the level of service rendered meets the EMSC definition of ALS.
Note: In accordance with IC 16-31-3-1, vehicles and staff that provide emergency
services must be certified by the EMSC to be eligible for reimbursement for
transports involving either ALS or basic life support (BLS) services.
Basic Life Support – BLS
IC 16-18-2-33.5 defines BLS as the following:
•
Assessment of emergency patients
•
Administration of oxygen
•
Use of mechanical breathing devices
•
Application of antishock trousers
•
Performance of cardiopulmonary resuscitation (CPR)
•
Application of dressings and bandage materials
•
Application of splinting and immobilization devices
•
Use of lifting and moving devices to ensure safe transport
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• Use of an automatic or semiautomatic defibrillator
•
Administration of epinephrine through an auto-injector
The EMSC has provided in 836 IAC 1-1-1(12)(K) that an emergency medical technician-basic
advanced may perform electrocardiogram interpretation, manual external defibrillation, and
intravenous fluid therapy.
The terms basic life support and BLS services do not include invasive medical care techniques or
advanced life support. The IHCP provides reimbursement for medically necessary emergency and
nonemergency BLS ambulance services when the level of service rendered meets the EMSC definition
of BLS.
Commercial or Common Ambulatory Service – CAS
The IHCP provides reimbursement for transportation of ambulatory (walking) members to or from an
IHCP-covered service. Commercial or Common Ambulatory Service (CAS) transportation may be
provided in any type of vehicle; however, providers must bill all transportation services according to
the level of service rendered. For example, if an ambulance provides transportation of an ambulatory
member but no ALS or BLS services are medically necessary for the transport of the member, the
ambulance provider must bill the CAS charges. For CAS transportation, providers can bill separately
for base rate, waiting time, and mileage, and receive reimbursement.
Nonambulatory Service (Wheelchair Van) – NAS
The IHCP reimburses for nonambulatory services (NAS) or wheelchair services when a member must
travel in a wheelchair to or from an IHCP-covered service. Providers must bill claims for ambulatory
members transported in a vehicle equipped to transport nonambulatory members according to the CAS
level of service and rate, and they must not bill according to the vehicle type. For NAS transportation,
providers can bill separately for base rate, waiting time, and mileage, and receive reimbursement.
Taxi
Taxi providers transport ambulatory members and may operate under authority from a local governing
body (city taxi or livery license). Taxi providers whose rates are regulated by local ordinance must bill
the metered or zoned rate, as established by local ordinance, and the IHCP reimburses them up to the
maximum allowable fee. The IHCP reimburses taxi providers whose rates are not regulated by local
ordinance at the lower of their submitted charge or the maximum allowable fee based on trip length.
The IHCP does not separately reimburse taxi providers for mileage above the maximum allowable rate
for the trip; however, providers must have mileage documented on the driver’s ticket by odometer
readings or mapping software.
Rotary Air Ambulance Transportation
Base Rate and Mileage
The IHCP provides reimbursement for a base rate and mileage. The base rate and mileage are
reimbursed at the lower of the usual and customary charge or the IHCP-established max fee. The base
rate is an all-inclusive rate including coverage of treatments and services that are an integral part of
care while in transit; it includes but is not limited to oxygen, drugs, supplies, reusable devices and
equipment, and extra attendants.
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Table 8.130 – Rotary Air Ambulance Codes – Provider Specialty 261: Air Ambulance
HCPCS Code
Description
A0431
Ambulance service, conventional air service, transport, one way (rotary wing)
A0436
Rotary wing air mileage, per statute mile
The air ambulance mileage rate is calculated to the nearest suitable hospital per actual loaded (patient
onboard) miles flown and is expressed in statute miles (not nautical miles). Transportation providers
are expected to transport members along the shortest, most efficient route to the nearest suitable
hospital. All rotary air transportation providers must document mileage on the trip ticket. Providers
must bill the IHCP for whole units only. Partial mileage units must be rounded to the nearest whole
unit. For example, if the provider transports a member between 15.5 miles and 16.0 miles, the provider
must bill 16 miles. If the provider transports the member between 15.0 and 15.4 miles, the provider
must bill 15 miles.
Providers are reminded that additional reimbursement is not available for multiple passengers in a
rotary air ambulance, nor is separate reimbursement available for an accompanying parent or attendant
in a rotary air ambulance.
Prior Authorization
Providers are reminded that prior authorization is required for air ambulance services. The IHCP
acknowledges PA for rotary air transport will be approved after services have been rendered due to the
nature of the services. A PA request must include a brief description of the care and description of the
clinical circumstances necessitating the need for the transportation. Providers must indicate the
transportation was an emergency by using the Y indicator in field 24I on the CMS-1500 or in the
Emergency Indicator on the 837P.
Medical Necessity
Rotary air ambulance transport is a covered service when the member has a potentially life-threatening
condition that does not permit the use of another form of transportation. The IHCP reimburses rotary
air transportation services to a hospital facility under medically appropriate circumstances. Medical
necessity is established only when the member’s condition is such that the time needed to transport a
member by ground, or the instability of transportation by ground, poses a threat to the member’s
survival or seriously endangers the member’s health.
The following list includes examples of medical conditions in which rapid transport may be necessary.
This list does not guarantee reimbursement nor is it intended to be all inclusive. Diagnosis alone does
not serve as justification for reimbursement.
•
Intracranial bleeding requiring neurosurgical intervention
•
Cardiogenic shock
•
Burns requiring treatment in a burn center
•
Conditions requiring treatment in a Hyperbaric Oxygen Unit
•
Multiple severe injuries
•
Life-threatening trauma
Generally, transport by rotary wing air ambulance may be necessary because the member’s condition
requires rapid transport to a treatment facility, and great distances or other obstacles preclude such
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rapid delivery by ground transport to the nearest appropriate facility. Transport by rotary wing air
ambulance may also be necessary because the member is inaccessible by a ground or water vehicle.
Air transport must be to the nearest suitable hospital. If the air transport was medically necessary but
the member could have been treated at a nearer hospital than one to which they were transported, the
air transportation mileage reimbursement is limited to the rate for the distance from the point of pickup
to the nearer hospital. Additionally, transportation by air ambulance is covered only for transport to a
hospital. Air ambulance services are not covered for transport to a facility that is not an acute care
hospital. Transport to a nursing facility, a physician’s office, or a beneficiary’s home by rotary air
ambulance is not reimbursable.
Special Circumstances
In addition to the previous general instructions, additional information concerning coverage and billing
follows for three special circumstances – hospital-to-hospital transfers, patient expiration, and bad
weather.
Hospital-to-Hospital Transfer
Air ambulance transport is covered for transfer of a patient from one hospital to another if the medical
appropriateness criteria is met, for example, transportation by ground ambulance would endanger the
member’s health, and the transferring hospital does not have adequate facilities to provide the medical
services needed by the patient. Examples of such specialized medical services that are generally not
available at all types of facilities may include, but are not limited to, burn care, cardiac care, trauma
care, and critical care.
A pati

Chapter 8: Billing Instructions

Transcription

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