Chapter 8: Billing Instructions

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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
Revision Date: August 26, 2010
Version: 10.0
8-1
Chapter 8
Indiana Health Coverage Programs Provider Manual
Current Dental Terminology (CDT) is copyrighted by the American Dental Association. 2009, 2010 American Dental Association. All
rights reserved.
Current Procedural Terminology (CPT) is copyright 2008 American Medical Association. All rights reserved. CPT® is a registered
trademark of the American Medical Association.
8-2
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Chapter 8
Indiana Health Coverage Programs Provider Manual
Chapter 8: Revision History
Document Version
Number
Revision Date
Reason for Revisions
Revisions
Completed By
Version 1.0
September 1999
Policies and procedures are
current as of March 1, 1999
New Manual
EDS Document
Management Unit
Version 2.0
June 2001
Policies and procedures are
current as of June 1, 2000
Chapters 1, 2, 3, 6, 7, 8, 9, 10,
13, 14, and Appendix A
EDS Document
Management Unit
Version 3.0
April 2002
Policies and procedures are
current as of August 1, 2001
All Chapters
EDS Client
Services and
EDS Publications
Unit
Version 4.0
April 2003
Policies and procedures are
current as of April 1, 2002
All Chapters
EDS Client
Services Unit
Version 5.0
July 2004
Policies and procedures are
current as of January 1, 2004
All Chapters
EDS Client
Services Unit
Version 5.1
February 2005
Policies and procedures are
current as of January 1, 2005
All Chapters
EDS Publications
Unit
Version 6.0
December 2006
Policies and procedures are
current as of April 1, 2006
All Chapters
EDS Publications
Unit
Version 8.0
August 2008
Policies and procedures as of
May 1, 2008
Semiannual Update
EDS Provider
Relations and
Publications Units
Version 8.1
February 2009
Policies and procedures as of
November 1, 2008
Semiannual Update
EDS Provider
Relations and
Publications Units
Version 9.0
December 2009
Policies and procedures as of
May 1, 2009
Semiannual Update
EDS Provider
Relations and
Publications Units
Version 9.1
April 22, 2010
Policies and procedures as of
November 1, 2009
Semiannual Update
HP Provider
Relations and
Publications Units
Version 10.0
August 26, 2010
Policies and procedures as of
May 1, 2010
Semiannual Update
HP Provider
Relations and
Publications Units
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
•
Updated Revenue Codes
with Descriptions table
•
Updated Hospice Care
Coverage section
•
Added Hospice Contracts
8-3
Chapter 8
Document Version
Number
Indiana Health Coverage Programs Provider Manual
Revision Date
Reason for Revisions
Revisions
Completed By
with Other Entities for
Hospice-related Services
section
8-4
•
Added Hospice Provider
Reimbursement Terms
section
•
Added Medical Education
Reimbursement section
•
Updated Blood Factor
Products Effective for
Dispense Dates of October
12, 2008, and Later table
•
Updated Stereotactic
Radiosurgery section
•
Added Notification of
Pregnancy Billing section
•
Updated Pacemakers
section
•
Updated Hub Site Services
and Billing Requirements
and Special Considerations
section
•
Updated Care Coordination
Services section
•
Updated Diabetic Test
Strips section
•
Added Drug-Related
Medical Supplies and
Medical Devices section
•
Updated Repair and
Replacement section
•
Updated HCPCS Codes –
DME/HME That Do Not
Require PA table
•
Updated Capped Rental
Items section
•
Deleted Coverage for
Influenza A (H1N1)
Vaccine Administration
section
•
Updated Incontinence,
Ostomy, and Urological
Mail Order Supplies section
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Chapter 8
Document Version
Number
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Revision Date
Reason for Revisions
•
Updated Medicare
Processed Claims Submitted
to the IHCP by the Provider
section
•
Updated HealthWatch/EPS
DT Services: Coverage and
Billing Procedures section
•
Updated Injections:
Coverage and Billing
Procedures section
•
Changed Botox Coverage
and Billing Procedures
section heading
to Botulinum Toxin
Coverage and Billing
Procedures and updated
section
•
Added Coverage of Mental
Health Codes for Children’s
Health Insurance Program
section
•
Updated Managed Care
Considerations: Risk-based
Managed Care section
•
Updated Presumptive
Eligibility – Package P
section
•
Updated Antepartum Tests
and Screenings Schedule
table
•
Added Process for
Completion of the
Notification of Pregnancy
section
•
Updated Prenatal Risk
Assessment section
•
Updated Medically HighRisk Diagnoses section
•
Updated Lenses section
•
Updated VFC Vaccine
Coverage and Billing
Procedures section
•
Updated Administration
Fee section
Revisions
Completed By
8-5
Chapter 8
Document Version
Number
8-6
Indiana Health Coverage Programs Provider Manual
Revision Date
Reason for Revisions
•
Updated CDT Codes
Allowed for Package E
Members table
•
Updated Managed Care
Considerations section
•
Deleted Carved-Out
Services section
•
Updated Topical Fluoride
Treatment section
•
Updated Radiographs
section
•
Updated Supernumerary
Tooth Extractions section
•
Updated CDT and CPT
Codes, Including Coverage
Criteria table
•
Updated CMS-1500 Claim
Form Fields table
•
Updated HCPCS Codes
Requiring Attachments table
•
Updated links to IHCP
Provider Web site
Revisions
Completed By
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Table of Contents
Chapter 8: Revision History ................................................................................. 8-3
Table of Contents ................................................................................................... 8-7
Section 1: Introduction to Billing Instructions .................................................. 8-17
General Information .......................................................................................... 8-17
Ordering Claim Forms .................................................................................. 8-18
National Provider Identifier and One-to-One Match ......................................... 8-18
Use National Provider Identifier for Referring, Rendering, or
Attending Provider when Submitting Claims via Web interChange ............. 8-19
Types of Services Billed on Each Claim Form ................................................. 8-19
Paper Claim Requirements ................................................................................ 8-21
Modifiers ....................................................................................................... 8-21
National Drug Code Billing .......................................................................... 8-21
Procedure Code Partial Units ........................................................................ 8-22
Date of Service Definition ............................................................................ 8-22
Electronic Standards .......................................................................................... 8-22
Companion Guides........................................................................................ 8-22
Paper Attachment Requirements ....................................................................... 8-22
Paper Attachments with Electronic Claims ................................................... 8-23
Report Type Code ......................................................................................... 8-24
Claim Notes ....................................................................................................... 8-24
Number of Details ............................................................................................. 8-25
Section 2: UB-04 Billing Instructions ................................................................. 8-26
Providers Using the UB-04 Claim Form ........................................................... 8-26
UB-04 Claim Form Requirements ..................................................................... 8-26
Description of Fields on the UB-04 Claim Form .............................................. 8-26
Diagnostic and Therapeutic Codes Not Reimbursable .................................. 8-54
UB-04 Claim Types........................................................................................... 8-55
Compounds – Outpatient/Outpatient Crossover............................................ 8-55
Home Health Services ....................................................................................... 8-55
Coverage ....................................................................................................... 8-55
Billing Procedures ......................................................................................... 8-55
Unit of Service .............................................................................................. 8-56
Overhead Rate ............................................................................................... 8-57
Home Health Rule Changes .............................................................................. 8-58
Multiple Visit Billing .................................................................................... 8-59
Partial Units of Service ................................................................................. 8-59
Hospital Discharge ........................................................................................ 8-59
Hospice Care Coverage ..................................................................................... 8-63
Billing Procedures ......................................................................................... 8-63
Revenue Codes.............................................................................................. 8-64
Physician Services under Revenue Codes 651 through 655 ......................... 8-67
Physician Services under Revenue Code 657 ............................................... 8-68
Prior-Authorized Physician Services ............................................................ 8-68
Hospice Contracts with Other Entities for Hospice-related Services ............ 8-68
Volunteer Physician Services........................................................................ 8-68
Emergency Services ...................................................................................... 8-68
CHOICE and Hospice Members ................................................................... 8-70
Medicare and Traditional Medicaid Eligibility Changes during the
Month ............................................................................................................ 8-70
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
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Table of Contents
Indiana Health Coverage Programs Provider Manual
Traditional Medicaid-Only – Hospice Member Who Becomes
Medicare-Eligible in Nursing Facility........................................................... 8-70
Dually Eligible Medicare/Traditional Medicaid – Member in a
Nursing Facility Who Becomes Traditional Medicaid-Only ........................ 8-71
Billing a Continuation Claim Using UB-04 Claim Form.............................. 8-71
Hospice Provider Reimbursement Terms ..................................................... 8-71
Inpatient Hospital Services ................................................................................ 8-73
Coverage ....................................................................................................... 8-73
Billing Procedures ......................................................................................... 8-74
Unit and Age Limitations on Inpatient Neonatal and Pediatric Critical
Care Services ..................................................................................................... 8-87
Stereotactic Radiosurgery .................................................................................. 8-88
Ventricular Assist Devices ................................................................................ 8-88
Noncovered Services..................................................................................... 8-89
Prior Authorization ....................................................................................... 8-89
Coding and Billing Instructions .................................................................... 8-89
Long-Term Acute Care Facility Services .......................................................... 8-91
Long-Term Acute Care Facilities.................................................................. 8-91
Coverage ....................................................................................................... 8-92
Billing Procedures ......................................................................................... 8-92
Package C ..................................................................................................... 8-92
Nursing Facility Services .................................................................................. 8-92
Member Liability .......................................................................................... 8-93
Leave Days.................................................................................................... 8-93
Autoclosure Billing ....................................................................................... 8-94
Medicare Crossover Payment Policy ............................................................ 8-95
Nursing Facilities Not Medicare-Certified .................................................... 8-95
Intermediate Care Facility for the Mentally Retarded Services......................... 8-95
Type of Bill ................................................................................................... 8-96
Leave Days.................................................................................................... 8-96
Outpatient Services............................................................................................ 8-97
Coverage ....................................................................................................... 8-97
Billing Procedures ......................................................................................... 8-97
Package B Billing .............................................................................................. 8-97
Notification of Pregnancy Billing ..................................................................... 8-98
Outpatient Surgeries .......................................................................................... 8-99
Surgical Revenue Codes .................................................................................... 8-99
Implantable DME ............................................................................................ 8-100
Corneal Tissue ................................................................................................. 8-101
Pacemakers ...................................................................................................... 8-101
Phrenic Nerve Stimulator (Breathing Pacemaker)........................................... 8-101
Prior Authorization ..................................................................................... 8-101
Coding and Billing Instructions .................................................................. 8-102
Coverage Issues .......................................................................................... 8-102
Device Monitoring ...................................................................................... 8-103
Patient-Activated Event Recorder – Implantable Loop Recorder ................... 8-104
Coverage ..................................................................................................... 8-104
Prior Authorization ..................................................................................... 8-104
Reimbursement and Billing Instructions ..................................................... 8-104
Device Monitoring ...................................................................................... 8-105
Coverage Criteria ........................................................................................ 8-106
Intraocular Lenses ........................................................................................... 8-106
NeuroCybernetic Prosthesis System – Vagus Nerve Stimulator ..................... 8-106
Coverage Criteria for the NCP System ....................................................... 8-107
8-8
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Table of Contents
Diagnosis and Procedure Codes .................................................................. 8-107
Hospital Inpatient ........................................................................................ 8-109
Physician Billing Instructions ..................................................................... 8-109
Treatment Room Visits ................................................................................... 8-110
Emergency Services ........................................................................................ 8-111
Add-on Services .............................................................................................. 8-127
Stand-alone Services ....................................................................................... 8-129
Stand-alone Laboratory Services ..................................................................... 8-131
Stand-alone Radiology Services ...................................................................... 8-131
Stand-alone Chemotherapy and Radiation Services ........................................ 8-132
Stand-alone Renal Dialysis Services ............................................................... 8-132
Composite Rate for Method I Dialysis ........................................................ 8-133
Billing Guidelines ....................................................................................... 8-133
UB-04 Completion Guidelines.................................................................... 8-134
Type of Bill Codes ...................................................................................... 8-134
Diagnosis Codes.......................................................................................... 8-134
Revenue Codes............................................................................................ 8-134
Transportation Services ................................................................................... 8-136
Outpatient Mental Health ................................................................................ 8-136
Partial Units of Service ............................................................................... 8-137
Filing UB-04 Crossover Claims ...................................................................... 8-137
Processing of Crossover Claims.................................................................. 8-137
Attachments for UB-04 Paper Claims or 837I Transaction
Submissions ................................................................................................ 8-137
UB-04 Crossover Billing Procedures .......................................................... 8-138
Billing Medicare Denied Services ................................................................... 8-139
837I Electronic Transaction ............................................................................ 8-139
Companion Guides...................................................................................... 8-139
Diagnosis Codes.......................................................................................... 8-139
Additional UB-04 and 837I Admission and Duration Changes .................. 8-140
Section 3: Telemedicine ..................................................................................... 8-141
Overview ......................................................................................................... 8-141
Definitions ....................................................................................................... 8-141
Provider/Service Requirements ....................................................................... 8-141
Conditions of Payment .................................................................................... 8-142
Hub Site Services and Billing Requirements................................................... 8-142
Spoke Site Services and Billing Requirements ............................................... 8-142
Documentation Standards................................................................................ 8-143
Special Considerations .................................................................................... 8-143
Managed Care Considerations ......................................................................... 8-143
Indiana Administrative Code (IAC) ................................................................ 8-144
Rule 38. Telemedicine Services .................................................................. 8-144
Section 4: CMS-1500 and 837P Transaction Billing Instructions ................. 8-147
Introduction ..................................................................................................... 8-147
Providers Using the CMS-1500 Claim Form or the 837P Transaction ............ 8-147
General Information ........................................................................................ 8-148
Claims Submission Addresses .................................................................... 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
Companion Guides...................................................................................... 8-157
Diagnosis Codes.......................................................................................... 8-157
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-9
Chapter 8
Table of Contents
Indiana Health Coverage Programs Provider Manual
Modifiers ......................................................................................................... 8-157
Place of Service Codes .................................................................................... 8-171
U Modifiers ..................................................................................................... 8-173
Substitute Physicians and Locum Tenens ........................................................ 8-173
Substitute Physicians .................................................................................. 8-174
Locum Tenens Physicians ........................................................................... 8-174
Anesthesia Services ......................................................................................... 8-174
Coverage and Billing Procedures ................................................................ 8-174
Care Coordination Services ............................................................................. 8-179
Coverage and Billing Procedures ................................................................ 8-179
Prenatal Care Coordination Services .......................................................... 8-180
Care Coordination Services for Human Immunodeficiency
Virus/Acquired Immune Deficiency Syndrome .......................................... 8-184
Chiropractic Services ...................................................................................... 8-189
Coverage and Billing Procedures ................................................................ 8-189
Diabetes Self-Care Management Training Services ........................................ 8-199
Coverage and Billing Procedures ................................................................ 8-199
Practitioners Eligible to Provide Services ................................................... 8-199
Procedure Codes and Units of Service ........................................................ 8-200
Diabetic Test Strips ..................................................................................... 8-201
Drug-Related Medical Supplies and Medical Devices................................ 8-202
Durable Medical Equipment and Home Medical Equipment .......................... 8-204
Coverage and Billing Procedures ................................................................ 8-204
Casting Supplies.......................................................................................... 8-215
Continuous Passive Motion – Continuous Passive Motion Device ............ 8-215
Cranial Remolding Orthosis........................................................................ 8-215
Home Infusion – Parenteral and Enteral Therapy Services......................... 8-216
Home Infusion – Parenteral and Enteral Nutrition Pumps .......................... 8-217
Clarification on Billing Food Thickener, HCPCS Code B4100.................. 8-218
Humidifiers, Nonheated or Heated ............................................................. 8-218
Incontinence, Ostomy, and Urological Mail Order Supplies ...................... 8-219
A4927 – Nonsterile Gloves, per 100 ........................................................... 8-222
A4930 – Gloves, Sterile, per Pair................................................................ 8-222
General Guidelines Applicable to Nonsterile and Sterile Gloves ............... 8-222
Orthopedic or Therapeutic Footwear .......................................................... 8-223
Osteogenic Bone Growth Stimulators ......................................................... 8-223
Oximetry ..................................................................................................... 8-224
Oxygen and Home Oxygen Equipment ...................................................... 8-225
Oxygen – Portable Systems ........................................................................ 8-227
Nebulizer with Compressor ........................................................................ 8-228
Phototherapy (Bilirubin Light).................................................................... 8-228
Pneumograms .............................................................................................. 8-228
Prosthetic Devices ....................................................................................... 8-229
ThAIRapy Vest™ ....................................................................................... 8-229
Trend Event Monitoring and Apnea Monitors ............................................ 8-229
Ventricular Assist Devices .......................................................................... 8-230
Wheelchairs – Motorized ............................................................................ 8-232
Wheelchairs – Nonmotorized...................................................................... 8-232
Wheelchair – Power Seating ....................................................................... 8-233
Wheelchair – Seat Cushions ....................................................................... 8-233
Wheelchair Accessories .............................................................................. 8-233
Documentation Required for Medical Supplies and Equipment ................. 8-234
Emergency Department Physicians ................................................................. 8-235
Coverage and Billing Procedures ................................................................ 8-235
8-10
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Table of Contents
Evaluation and Management Services ............................................................. 8-236
Coverage and Billing Procedures ................................................................ 8-236
Consultations ................................................................................................... 8-237
Office Consultation ..................................................................................... 8-237
Inpatient Consultation ................................................................................. 8-237
Hospital Observation or Inpatient Care Services ........................................ 8-237
Family Planning Services ................................................................................ 8-238
Coverage and Billing Procedures ................................................................ 8-238
Managed Care Program Considerations...................................................... 8-240
Federally Qualified Health Centers and Rural Health Clinics ......................... 8-240
Federally Qualified Health Centers ............................................................. 8-240
Rural Health Clinics .................................................................................... 8-241
Service Coverage ........................................................................................ 8-241
FQHC and RHC Covered Services ............................................................. 8-242
Service Definition ....................................................................................... 8-244
HealthWatch/EPSDT Services ........................................................................ 8-245
Coverage and Billing Procedures ................................................................ 8-245
Managed Care Considerations .................................................................... 8-247
Hearing Aids ................................................................................................... 8-247
Coverage and Billing Procedures ................................................................ 8-247
Hearing Aid Purchase ................................................................................. 8-247
Maintenance and Repair.............................................................................. 8-247
Replacement ................................................................................................ 8-248
Audiology Services ..................................................................................... 8-248
Augmentative Communication Devices .......................................................... 8-250
Coverage and Billing Procedures ................................................................ 8-250
Reimbursement ........................................................................................... 8-250
Authorization .............................................................................................. 8-250
Trial Period ................................................................................................. 8-250
Rental Versus Purchase ............................................................................... 8-251
Repair and Replacement ............................................................................. 8-251
Rehabilitation Engineering ......................................................................... 8-251
Pneumatic Artificial Voicing Systems ............................................................ 8-251
Coverage and Billing Procedures ................................................................ 8-251
Purchase ...................................................................................................... 8-251
Home and Community-Based Services Waiver Programs .............................. 8-252
Coverage and Billing Procedures ................................................................ 8-252
Injections ......................................................................................................... 8-253
Coverage and Billing Procedures ................................................................ 8-253
Compounds – Professional Claim Types .................................................... 8-255
Botulinum Toxin Coverage and Billing Procedures ................................... 8-255
Vaccines for Children Program ................................................................... 8-257
Laboratory Services ......................................................................................... 8-258
Coverage and Billing Procedures ................................................................ 8-258
Clinical Diagnostic Laboratory Procedures ................................................ 8-258
Professional and Technical Components .................................................... 8-260
Hospital Outpatient Defined ....................................................................... 8-260
Specimen Collection ................................................................................... 8-260
Handling Conveyance ................................................................................. 8-261
Lab Panels ................................................................................................... 8-261
Interpretation of Clinical Laboratory Services ............................................ 8-261
Breast Cancer Testing ................................................................................. 8-261
Billing Requirements and Prior Authorization Criteria for Genetic
Testing for Breast and Ovarian Cancer ....................................................... 8-262
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-11
Chapter 8
Table of Contents
Indiana Health Coverage Programs Provider Manual
Lead Testing................................................................................................ 8-264
Medical and Surgical Supplies ........................................................................ 8-264
Coverage and Billing Procedures ................................................................ 8-264
Limitations on Coverage ............................................................................. 8-265
Manually Priced Supplies ........................................................................... 8-265
Medicare Part B Crossover Claims ................................................................. 8-266
Coverage and Billing Procedures ................................................................ 8-266
Medicare/Medicaid Reimbursement ........................................................... 8-266
Mental Health Services ................................................................................... 8-267
Coverage and Billing Procedures ................................................................ 8-267
Outpatient Mental Health ............................................................................ 8-267
Package C ................................................................................................... 8-269
Medicaid Rehabilitation Option Services ................................................... 8-269
Coverage of Mental Health Codes for Children’s Health Insurance
Program ....................................................................................................... 8-270
Assertive Community Treatment Service ................................................... 8-275
Psychiatric Residential Treatment Facilities ............................................... 8-276
Managed Care Considerations .................................................................... 8-278
Screening and Brief Intervention Services .................................................. 8-279
Mid-Level Practitioner Services ...................................................................... 8-279
Coverage and Billing Procedures ................................................................ 8-279
Smoking Cessation Treatment Services .......................................................... 8-280
Coverage and Billing Procedures ................................................................ 8-280
Newborn Services............................................................................................ 8-282
Coverage and Billing Procedures ................................................................ 8-282
Presumptive Eligibility – Package P ............................................................... 8-284
Presumptive Eligibility Requirements ........................................................ 8-284
Qualified Provider ....................................................................................... 8-284
Billing Procedures ....................................................................................... 8-284
Obstetrical Services ......................................................................................... 8-291
Coverage and Billing Procedures ................................................................ 8-291
Antepartum Care Policy .............................................................................. 8-291
Billing for Antepartum Visits ..................................................................... 8-291
Antepartum Tests and Screenings Schedule ............................................... 8-292
Process for Completion of the Notification of Pregnancy........................... 8-295
Salivary Estriol Test for Preterm Labor Risk Assessment .......................... 8-296
Sonography ................................................................................................. 8-297
Echography ................................................................................................. 8-297
Obstetrical Delivery and Postpartum Care Billing ...................................... 8-298
Other Outpatient Office Visits .................................................................... 8-298
Normal Pregnancy ...................................................................................... 8-298
Multiple Births ............................................................................................ 8-299
High-Risk Pregnancy .................................................................................. 8-299
Additional Antepartum Visits ..................................................................... 8-304
Reimbursement ........................................................................................... 8-304
Pregnancy Services Billing Considerations ................................................ 8-304
Hoosier Healthwise Package B – Pregnancy and Urgent Care Only .......... 8-305
Proton Treatment Billing ............................................................................ 8-306
Ophthalmological Services .............................................................................. 8-306
Coverage and Billing Procedures ................................................................ 8-306
Date of Service Definition .......................................................................... 8-306
Vision Coding and the Vision Services Code Set ....................................... 8-307
Vision Procedures Limited to One Unit ...................................................... 8-307
Eye Examinations ....................................................................................... 8-309
8-12
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Table of Contents
Orthoptic or Pleoptic Training, Vision Training, and Therapies
Coverage Criteria ........................................................................................ 8-310
Lenses ......................................................................................................... 8-310
Frames ......................................................................................................... 8-312
Adoption of Modifiers for Replacement Eyeglasses ................................... 8-312
Written Correspondence ............................................................................. 8-313
Billing a Member for Services that have Exceeded Benefit Limitations .... 8-314
Prior Authorization ..................................................................................... 8-314
Vision Services and Managed Care ............................................................ 8-314
Podiatric Services ............................................................................................ 8-314
Coverage and Billing Procedures ................................................................ 8-314
Second Opinions ......................................................................................... 8-315
Office Visits ................................................................................................ 8-316
Surgical Services ......................................................................................... 8-316
Laboratory and X-ray Services ................................................................... 8-317
Prior Authorization ..................................................................................... 8-317
Podiatric Services and Managed Care......................................................... 8-317
Radiology Services .......................................................................................... 8-318
Coverage and Billing Procedures ................................................................ 8-318
Utilization Criteria ...................................................................................... 8-319
Computerized Tomography Scans .............................................................. 8-319
PET Scans ................................................................................................... 8-319
Radionuclide Bone Scans............................................................................ 8-320
Upper Gastrointestinal Studies .................................................................... 8-320
Hospice Providers ....................................................................................... 8-320
Renal Dialysis Physician Services ................................................................... 8-320
Coverage and Billing Procedures ................................................................ 8-320
School Corporation Services ........................................................................... 8-322
Coverage and Billing Procedures ................................................................ 8-322
Surgical Services ............................................................................................. 8-322
Coverage and Billing Procedures ................................................................ 8-322
Split Care .................................................................................................... 8-323
Therapy Services ............................................................................................. 8-327
Coverage and Billing Procedures ................................................................ 8-327
Outpatient.................................................................................................... 8-331
Hippotherapy............................................................................................... 8-331
Traumatic Brain Injury................................................................................ 8-332
Transportation Services ................................................................................... 8-335
Advanced Life Support – ALS .................................................................... 8-335
Basic Life Support – BLS ........................................................................... 8-335
Commercial or Common Ambulatory Service – CAS ................................ 8-336
Nonambulatory Service (Wheelchair Van) – NAS ..................................... 8-336
Taxi ............................................................................................................. 8-336
Rotary Air Ambulance Transportation ........................................................ 8-336
Retroactive Eligibility ................................................................................. 8-339
Definition of a Trip ..................................................................................... 8-339
Multiple Destinations .................................................................................. 8-339
Modifiers ..................................................................................................... 8-340
Prior Authorization ..................................................................................... 8-340
Twenty One-Way Trip Limitation and Exemptions.................................... 8-341
Emergency Transportation Services ........................................................... 8-341
Hospital Admission or Discharge ............................................................... 8-341
Members on Renal Dialysis or Members Residing in Nursing Homes ....... 8-341
Mileage ....................................................................................................... 8-342
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-13
Chapter 8
Table of Contents
Indiana Health Coverage Programs Provider Manual
Mileage Units and Rounding ...................................................................... 8-342
Multiple Passengers .................................................................................... 8-343
Accompanying Parent or Attendant ............................................................ 8-343
Additional Attendant ................................................................................... 8-344
Waiting Time .............................................................................................. 8-345
Ambulance Transportation Services ........................................................... 8-345
Level of Service Rendered Versus Level of Response ............................... 8-345
Ambulance Mileage .................................................................................... 8-346
Neonatal Ambulance Transportation .......................................................... 8-346
Oxygen and Oxygen Supplies ..................................................................... 8-347
Member Copayments .................................................................................. 8-347
Exemptions to Copayments for Transportation Services ............................ 8-347
Federal Guidelines for Copayment Policy .................................................. 8-347
Package C Transportation Services ............................................................. 8-348
Risk-Based Managed Care Hoosier Healthwise Services ........................... 8-348
Noncovered Transportation Services .......................................................... 8-348
Documentation Requirements for Transportation Services ........................ 8-348
Registration Requirements .......................................................................... 8-349
Transportation Code Sets ............................................................................ 8-350
Nonambulatory Service Provider ................................................................ 8-351
Ambulance (ALS and BLS) Provider ......................................................... 8-352
Air Ambulance ............................................................................................ 8-353
Taxi Provider .............................................................................................. 8-353
Family Member Transportation Provider .................................................... 8-353
Bus Provider................................................................................................ 8-354
Vaccines for Children ...................................................................................... 8-354
Eligible Members ........................................................................................ 8-354
Provider Enrollment in the VFC Program................................................... 8-354
Vaccines for Children Forms ...................................................................... 8-355
Vaccine Storage .......................................................................................... 8-355
VFC Vaccine Coverage and Billing Procedures ......................................... 8-355
Reporting Individual Cases of Varicella (Chickenpox) .............................. 8-358
VFC and HealthWatch ................................................................................ 8-358
Provider-Purchased Vaccine ....................................................................... 8-358
Third Party Liability.................................................................................... 8-359
Package C ................................................................................................... 8-359
Children and Hoosiers Immunization Registry Program ............................ 8-360
Medical Review Team Billing Procedures ...................................................... 8-361
MRT Reimbursement for Transportation .................................................... 8-362
MRT Procedure Codes ................................................................................ 8-362
Pre-Admission Screening and Resident Review Billing Procedures ............... 8-368
Section 5: Dental Claim Form Billing Instructions ......................................... 8-371
Introduction ..................................................................................................... 8-371
Providers Using the Dental Claim Form ......................................................... 8-371
ADA 2006 Paper Claim Form Changes and Requirements ............................ 8-371
Rendering NPI Required ............................................................................. 8-372
Date of Service Definition .......................................................................... 8-372
ADA 2006 Dental Claim Form Fields ........................................................ 8-372
Description of Fields on the ADA 2006 Dental Claim Form .......................... 8-372
837D Electronic Transaction ........................................................................... 8-376
Companion Guides...................................................................................... 8-376
Billing Procedures ........................................................................................... 8-377
Current Dental Terminology Procedure Codes ........................................... 8-377
Dental Extractions ....................................................................................... 8-377
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Package E Billing ........................................................................................ 8-377
Attachments ..................................................................................................... 8-379
Attachment Control Number ....................................................................... 8-380
Report Type Code ....................................................................................... 8-380
Return to Provider Letter ............................................................................ 8-381
Paper Claims with Attachments .................................................................. 8-381
Managed Care Considerations .................................................................... 8-381
Services Associated with Dental Services for Hoosier Healthwise
RBMC Networks ........................................................................................ 8-382
Member Eligibility Verification and Billing for Dental Services ............... 8-383
Dental Cap ....................................................................................................... 8-383
Dental Service Limitations .............................................................................. 8-386
Orthodontics................................................................................................ 8-386
Prophylaxis ................................................................................................. 8-388
Oral Evaluations.......................................................................................... 8-390
General Anesthesia ..................................................................................... 8-390
Dentures and Partials Coverage....................................................................... 8-393
Dentures and Partials .................................................................................. 8-393
Annual Dental Cap for Dentures, Relines, and Repairs .............................. 8-396
Prior Authorization ..................................................................................... 8-397
Repairs, Relines, Adjustments, Rebases of Dentures and Partials .............. 8-399
Dental Prior Authorization Form ................................................................ 8-399
Covered CDT and CPT Codes ........................................................................ 8-400
Valid Tooth Numbers ...................................................................................... 8-425
Sealants............................................................................................................ 8-428
Tooth Surface Procedure Codes ...................................................................... 8-429
Multiple Restorations Reimbursement ............................................................ 8-430
Section 6: HCBS Waiver Billing Guidelines .................................................... 8-432
Introduction ..................................................................................................... 8-432
Eligibility for HCBS Waiver Services............................................................. 8-432
Waiver Authorization .................................................................................. 8-432
Environmental Modifications...................................................................... 8-433
Special Processing Required for Home and Community-Based Services
Overlapping Hospice Level of Care or Long-Term Care Discharge Dates ..... 8-435
Billing Instructions .......................................................................................... 8-435
Waiver Providers Use LPI .......................................................................... 8-435
Paid Claim Adjustments .................................................................................. 8-440
Section 7: Informed Consent Claim Attachment Instructions....................... 8-441
Abortions and Related Services....................................................................... 8-441
Documentation Requirements ..................................................................... 8-441
Medical Abortion by Oral Ingestion of Medication .................................... 8-443
Sterilization and Hysterectomy ....................................................................... 8-445
Sterilizations ............................................................................................... 8-445
Limitations .................................................................................................. 8-445
Informed Consent ............................................................................................ 8-447
Retroactive Eligibility or Failure to Provide Proof of Eligibility .................... 8-448
Consent Forms................................................................................................. 8-448
Documentation Requirements ......................................................................... 8-449
Consent Form Instructions .............................................................................. 8-449
Hysterectomy Billing ...................................................................................... 8-451
Informed Consent and Acknowledgement Statement ................................. 8-451
Retroactive Eligibility ................................................................................. 8-452
Section 8: Healthcare Common Procedure Coding System Codes ................ 8-454
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Fee Schedule ................................................................................................... 8-454
HCPCS Codes Requiring Attachments ........................................................... 8-454
Index ................................................................................................................... 8-471
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Chapter 8
Section 1: Introduction to Billing Instructions
General Information
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 above forms where applicable. Contact the appropriate
managed care organization (MCO) 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.
Billing instructions for the NCPDP Drug Claim Form and Compound Prescription Claim Form are
available on the IHCP Web site at http://provider.indianamedicaid.com by clicking Forms on the right
side of the page.
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 on the Web at www.state.in.us/legislative/iac/title405.html.
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 IHCP Web
site at http://provider.indianamedicaid.com/general-provider-services/manuals.aspx:
•
Hospice Provider Manual
•
Medicaid Rehabilitation Option (MRO) Provider Manual
•
590 Program Provider Manual
•
HealthWatch/Early and Periodic Screening, Diagnosis, and Testing (EPSDT) Provider Manual
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•
Home and Community-Based Services Waiver Provider 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) Web site at www.cms.hhs.gov. HP does not
distribute supplies of these forms.
Providers can download drug and compound prescription claim forms from
the http://provider.indianamedicaid.com Web site in the Forms section or order them by writing to the
following:
HP Forms Request
P.O. Box 7263
Indianapolis, IN 46207-7263
National Provider Identifier and One-to-One Match
Beginning March 1, 2008, claims are denied if healthcare providers submit a claim without a billing
provider National Provider Identifier (NPI). Only atypical provider claims are exempt from this
requirement.
Effective May 23, 2008, providers’ IHCP Legacy Provider Identifier (LPI) may appear on the claim
but will not be used to process the claim. Providers are encouraged to bill with the NPI only. 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.
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 of this manual.
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Use National Provider Identifier for Referring, Rendering, or Attending Provider when
Submitting Claims via Web interChange
Nonatypical providers that submit medical (CMS-1500 format) claims via Web interChange receive an
error message when the LPI and NPI are entered for the referring or rendering provider. To resolve the
error, remove the LPI from all fields on Web interChange; report only the NPI for the referring or
rendering provider.
Nonatypical providers that submit institutional (UB-04 format) claims via Web interChange have
encountered an error message when entering the attending physician license number in the Attending
Prov NPI field. Please note that only the NPI is accepted in this field; the license number of the
attending physician should not be entered on the 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
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
Renal dialysis services
Outpatient radiological services (technical
component)
Outpatient laboratory services (technical
component)
Long-term care (LTC) facilities
Nursing facility (NF) services
Intermediate care facility for the mentally retarded
(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/MR)
Long Term Acute Care (LTAC)
Rehabilitation hospital facilities
Rehabilitation facility services
Traumatic brain injury services
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Table 8.2 – CMS-1500 Claim Form
Provider Types
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Types of Services
Advanced practice nurses
Midwife services
Nurse practitioner services
Nurse anesthetist 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 Anesthetist
(CRNA)
Nurse anesthetist services
Dentists
Oral surgery
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
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 – Medical Doctor (MD) and
Doctor of Osteopathy (DO)
Anesthesia services
Laboratory services
Medical services – professional component
Mental health services
Radiological services
Renal dialysis services
Surgical services
Podiatrists
Podiatric services
Public health agencies
Medical services
Psychiatric Residential Treatment
Facilities (PRTF)
Behavioral Health Residential Treatment
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Provider Types
Types of Services
School corporations
Therapy services – physical, occupational, speech, and
mental health
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
Paper Claim Requirements
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 the Health Insurance Portability and Accountability Act (HIPAA) electronic claim transaction
requirements.
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®) code set on the dental claim form.
National Drug Code Billing
The Federal Deficit Reduction Act of 2005 mandates that 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 percent Medicare B copayment for dually eligible
individuals, the NDC will also be required on Medicare crossover 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.
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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
will be priced by 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 Current Procedural Terminology (CPT®) and
Healthcare Common Procedure Coding System (HCPCS) codes on the UB04 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 Web site
at http://wpc-edi.com.
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 Companion Guides are located on the IHCP Web site at http://provider.indianamedicaid.com in
the EDI Solutions section.
Paper Attachment Requirements
The IHCP accepts paper attachments with electronic claims (837I, 837P, and 837D). Web interChange
claims follow the same attachment requirements.
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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 only accepts paper attachments for
electronic or paper claims 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, refer to 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 the IHCP Web site
at http://provider.indianamedicaid.com in the Forms section. The provider must complete the
following information on the IHCP Claims Attachment Cover Sheet:
- Billing provider name and service location address and ZIP Code + 4
- Billing provider National Provider Identifier (NPI) or Legacy Provider Identifier (LPI) and
service location
• Only atypical providers can use LPI and service location
- Date(s) of service of the claim
- IHCP member identification number (RID)
- The ACN for each attachment for 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
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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:
•
B4 – Referral Form – Used by Surveillance and Utilization Review (SUR) for the Right Choices
Program
•
DA – Dental Models – Used by SUR and submitted only upon request
•
DG – Diagnostic Report – Used by PA and SUR
•
EB – Explanation of Benefits – Used by TPL, Resolutions, and SUR
•
OB – Operative Note – Used by PA, Resolutions, Medical Policy, and SUR
•
P6 – Periodontal Charts – Used for specific periodontal procedures
•
RR – Radiology Reports – Used by PA, Medical Policy, and SUR
•
RB – Radiology Films – Used by PA and SUR
•
OZ – Support Data for Claim – The following are uses for progress notes:
- Invoices (Manual Pricing)
- Durable Medical Equipment delivery tickets
- Transportation run tickets
- Sterilization/Hysterectomy consent forms
- Spend-down Form 8A
- Past filing limit documentation
- PA request/response copies
- Environmental modification service requests
- Consultation reports
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.
When a provider submits claims electronically via an 837 transaction or Web interChange claim
submission, the following is true for claim notes:
•
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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.
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•
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
- CER – Certification Narrative (header only)
- DCP – Goals, Rehabilitation Potential, or Discharge Plans
- DGN – Diagnosis Description (header only)
- PMT – Payment
- TPO – Third Party Organization Notes
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
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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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 surgery center (ASC)
•
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.
UB-04 Claim Form Requirements
This section provides a brief overview of the requirements to complete the UB-04 claim form. The
IHCP no longer accepts the UB-92 claim form.
These instructions are effective for paper claim submission starting April 1, 2007. Noncompliant UB04 paper claims submitted for processing after March 1, 2008, will be returned to the provider.
Providers that have been assigned a National Provider Identifier (NPI) should include their NPI on the
paper claim form.
For more instructions about 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 http://www.nubc.org.
With the implementation of the UB-04 paper claim form, the IHCP accepts as many as 66 lines for any
one paper claim.
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The UB-04 paper claims 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 of
the IHCP Web site at http://provider.indianamedicaid.com/general-provider-services/forms.aspx.
Table 8.4 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.
•
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 8.4 gives
field information for the UB-04 claim form. Table 8.5 lists revenue codes with descriptions.
Table 8.4 – 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.
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Form Field
Indiana Health Coverage Programs Provider Manual
Narrative Description/Explanation
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.
4
Hospice bill type is 822.
•
First position – Type of Facility
•
Second position – Bill Classification
•
Third position – Frequency
Note: See http://provider.indianamedicaid.com/media/30947/type_of_bill_table.pdf for a
current list of Type of Bill codes. The National Uniform Billing Committee
(NUBC) maintains this code set, which is considered an external code set
by the 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
UNLABELED FIELD – Not applicable.
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.
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
8-28
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.
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Form Field
14
Chapter 8
Section 2: UB-04 Billing Instructions
Narrative Description/Explanation
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 and LTC.
Admission Codes
Code
Description
1
Emergency
2
Urgent
3
Elective
4
Newborn
5
Trauma Center
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.
17
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 and LTC.
Patient Status Codes
Code
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
Note
Description effective September 30, 2009, for claims with
discharge dates on or after April 1, 2008.
06
Discharged or transferred to home under care of organized home health service organization
07
Left against medical advice or discontinued care
08
Discharged or transferred to home under care of a home intravenous provider
Note: Patient status code 08 is changed from active to inactive effective
for claims received on or after September 30, 2009, for claims
with discharge dates on or after October 1, 2005.
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-29
Chapter 8
Section 2: UB-04 Billing Instructions
Form Field
Indiana Health Coverage Programs Provider Manual
Narrative Description/Explanation
20
Expired
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
Note: Long-term care facility changed to long-term care hospital for
claims with a date of receipt September 30, 2009 and after.
64
Discharged or transferred to a nursing facility – Medicaid-certified but not Medicare-certified
65
Discharged or transferred to a psychiatric hospital or psychiatric distinct part 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
Note: Effective September 30, 2009, for claims with discharge dates on
or after April 1, 2008.
18 – 24
Seven
maximum
allowed
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
05
Lien is filed
07
Medicare hospice by nonhospice provider
Accommodation Code
Code
40
Description
Same-day transfer
Prospective Payment Codes
Code
8-30
Description
61
Cost outlier
82
Noncovered by other insurance
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Form Field
Chapter 8
Section 2: UB-04 Billing Instructions
Narrative Description/Explanation
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, as appropriate.
Note: Effective July 1, 2004, when billing for a date of service that is the
same as the date of death, hospice providers must bill occurrence
code 51.
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.
53
Therapy evaluation, HHA – This code is used to show HHA billing for initial therapy
evaluations. This code exempts the evaluation from PA editing. Revenue codes specific to
therapy evaluations must be billed. Details can be found in the applicable section of the
IAC.
61
Home health overhead amount – one per day
62
Home health overhead amount – two per day; occurrence code not valid for dates of service
on or after July 1, 2008
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
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Chapter 8
Section 2: UB-04 Billing Instructions
Form Field
35a–36b
Indiana Health Coverage Programs Provider Manual
Narrative Description/Explanation
63
Home health overhead amount – three per day; occurrence code not valid for dates of
service on or after July 1, 2008
64
Home health overhead amount – four per day; occurrence code not valid for dates of service
on or after July 1, 2008
65
Home health overhead amount – five per day; occurrence code not valid for dates of service
on or after July 1, 2008
66
Home health overhead amount – six per day; occurrence code not valid for dates of service
on or after July 1, 2008
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 – Enter the Care Select primary medical provider (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 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. Revenue codes and descriptions that bypass the two-digit PMP
certification code are denoted in Table 8.5: Revenue Codes with Descriptions.
Report the PMP NPI in field 78 for claim reimbursement of these hospital services.
38
UNLABELED FIELD – Not applicable.
39a – 41d
VALUE CODES – Use these fields to identify Medicare Remittance Notice (MRN) information.
The following value codes must be used along with the appropriate dollar or unit amounts for each.
Required, if applicable.
42
8-32
•
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. Refer to the IAC for covered services, limitations, and
medical policy rules. Use the specific revenue code when available. Required.
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Form Field
43
Chapter 8
Section 2: UB-04 Billing Instructions
Narrative Description/Explanation
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 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.
REQUIRED for NDC billing for Revenue codes 634, 635, and 636 when applicable.
44
HCPCS/RATES – Use the Healthcare Common Procedure Coding System (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. Seven 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
UNLABELED FIELD – Not applicable.
50A–55C
FORM FIELDS 50A-55C – Medicare is always listed first (50A), if applicable. Other insurers, such
as a Medicare supplement (commercial insurer), 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-C – Such as Medicare, Medicare supplement, and Traditional Medicaid.
Required, if applicable.
50A
PAYER – Enter the Medicare carrier’s name. Required, if applicable.
50B
PAYER – Enter the third-party carrier’s name (including Medicare Replacement/HMO) and
additional payer names. Required, if applicable.
50C
PAYER – Enter the applicable IHCP, such as Traditional Medicaid or 590 Program. Required.
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.
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-33
Chapter 8
Section 2: UB-04 Billing Instructions
Form Field
Indiana Health Coverage Programs Provider Manual
Narrative Description/Explanation
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.
Required, if applicable.
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–55C
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 – Effective October 1, 2009, healthcare providers no longer enter the
Legacy Provider Identifier (LPI) in this field.
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.
8-34
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Form Field
67
Chapter 8
Section 2: UB-04 Billing Instructions
Narrative Description/Explanation
PRIN. DIAG. CD – Provide the International Classification of Diseases, 9th Edition 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 inpatient, 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 International Classification of Diseases, Ninth Edition, Clinical Modifications (ICD9-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 (ICD9-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
UNLABELED FIELD – Not applicable.
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.
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-35
Chapter 8
Section 2: UB-04 Billing Instructions
Form Field
Indiana Health Coverage Programs Provider Manual
Narrative Description/Explanation
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.
Required, if applicable.
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
UNLABELED FIELD – Not applicable.
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.
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.
75
UNLABELED FIELD – Not applicable.
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 other physician’s (referring/PMP physician) 10-digit numeric NPI. Required for
IHCP members enrolled in Care Select.
79
OTHER – Not applicable.
80
REMARKS – Use this field for claim note text. Provide information, using as many as 80 characters
that 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
8-36
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
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
Figure 8.1 – UB-04 Claim Form
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-37
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
Table 8.5 – Revenue Codes with Descriptions
Revenue
Code
Description
1
Total charge
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
Medical/surgical/gynecological
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
Medical/surgical/gynecological
132
Obstetrics
133
Pediatric
134
Psychiatric
135
Hospice
136
Detoxification
137
Oncology
138
Rehabilitation
139
Other
8-38
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Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Revenue
Code
Chapter 8
Section 2: UB-04 Billing Instructions
Description
14X
Room and board – private (deluxe)
140
General
141
Medical/surgical/gynecological
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
Medical/surgical/gynecological
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
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-39
Chapter 8
Section 2: UB-04 Billing Instructions
Revenue
Code
Indiana Health Coverage Programs Provider Manual
Description
181
Patient convenience – No charges billed
182
Patient convenience – Charges billable
183
Therapeutic leave
184
From 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
8-40
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Revenue
Code
Chapter 8
Section 2: UB-04 Billing Instructions
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 diagnosis 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
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
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 (other than renal)
290
General
291
Rental
292
Purchase of new DME
293
Purchase of used DME
294
Supply/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
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Code
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Section 2: UB-04 Billing Instructions
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
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
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
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
Evaluation or reevaluation
439
Other occupational therapy
8-44
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Code
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Description
44X
Treatments – speech-language pathology
440
General
441
Visit charge
442
Hourly charge
443
Group rate
444
Evaluation or reevaluation
449
Other speech-language pathology
45X
Emergency room
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
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
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 EKG
549
Other ambulance
55X
Skilled nursing
550
General
551
Visit charge
552
Hourly charge
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Code
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Section 2: UB-04 Billing Instructions
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
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
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
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
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Revenue
Code
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Section 2: UB-04 Billing Instructions
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
Electrocardiogram (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
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
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 (Non-CAPD)
803
Inpatient continuous ambulatory peritoneal dialysis (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
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Revenue
Code
Chapter 8
Section 2: UB-04 Billing Instructions
Description
824
Maintenance – 100 percent
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
Maintenance – 100 percent
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 percent
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
Maintenance – 100 percent
855
Support services
859
Other outpatient CCPD
88X
Dialysis
880
General
881
Ultrafiltration
882
Home dialysis aid visit
889
Miscellaneous dialysis/other
890
Donor bank
891
Bone
892
Organ other than kidney
893
Skin
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
Description
899
Other
89X
Other donor bank
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
94X
Other therapeutic services
941
Recreational therapy
942
Education/training
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Code
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Description
943
Cardiac rehabilitation
944
Drug rehabilitation
945
Alcohol rehabilitation
946
Complex medical equipment – routine
947
Complex medical equipment – ancillary
948
Pulmonary rehabilitation
949
Other therapeutic services
95X
Other therapeutic services
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
980
981
982
983
984
985
986
987
988
Professional fees
General
Emergency room
Outpatient services
Clinic
Medical social services
EKG
EEG
Hospital visit
Consultation
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Revenue
Code
Indiana Health Coverage Programs Provider Manual
Description
989
Private duty nurse
99X
990
991
992
993
994
995
996
997
998
999
Patient convenience items
General
Cafeteria/guest tray
Private linen service
Telephone/telegraph
TV/radio
Nonpatient room rentals
Late discharge charge
Admission kits
Beauty shop/barber
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 8.6 shows a list of nonreimbursable codes under 92x and 94x.
Table 8.6 – Diagnostic and Therapeutic Services 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
code for the treatment center where injections are performed. This is also consistent with rate
setting for treatment rooms as costs for injections were 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
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revenue codes in the 92x and 94x series listed above may have previously denied with Explanation of
Benefits (EOB) code 4014 – No pricing segment on file. Claims billed with these revenue codes now
deny with EOB code 4107 – Revenue code is not appropriate or not covered for the type of service
being provided.
UB-04 Claim Types
When billing National Drug Codes (NDCs) that have one procedure code but that involve multiple
NDCs, providers will no longer need to use the KP and KQ modifiers. Providers will 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 change 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 will receive payment for all valid NDCs included in the compound
drugs.
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. As such, Medicaid
members may work, attend school outside the home, and leave the home with assistance of another
person or an assistive device, such as a wheelchair or walker. 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
refer to Rule 16, 405 IAC 5-16-3, home health agency services limitations, 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
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Indiana Health Coverage Programs Provider Manual
Note: For risk-based managed care (RBMC) members, bill the appropriate
managed care organization (MCO). Contact information can be found
in Chapter 1 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 8.7 lists revenue codes and the crosswalked HCPCS/CPT codes.
Table 8.7 – 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
552
99600 TE
552
99600 TD
559
S9349
559
99601,
99602
572
99600
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 Office
of Medicaid Policy and Planning (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. Because providers rendered no service, they cannot be reimbursed for the overhead.
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Overhead Rate
For services rendered prior to July 1, 2008 – for each encounter at the home, regardless of the type of
service provided or the number of members serviced – home health providers receive an overhead rate
for administrative costs and a staffing reimbursement component, depending on the type and number
of units of service provided. The OMPP calculates the overhead rates and staffing reimbursement.
These rates are the same for all agencies. An encounter occurs when an RN, LPN, home health aide, or
therapist enters a home, provides services to one or more members within that home, and then leaves,
thereby completing the encounter. When more than one member receives home health services in a
single household, providers must coordinate care in the most efficient manner. Providers must report
multiple-care member situations on PA requests.
Providers may only bill one overhead per provider, per recipient per day. Effective for claims with
dates of service on or after July 1, 2008, occurrence codes 62 – 66, are no longer active. Home health
claims billed with occurrence codes 62 – 66, and a date of service on or after July 1, 2008, will be
denied with the following Explanation of Benefit (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.
Occurrence codes 62 – 66 are active for claims that are billed or adjusted with dates of service through
June 30, 2008.
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 fees. Use the following six codes to identify the
overhead rate:
•
Code 61 indicates that one encounter with the member occurred on the date shown.
•
Code 62 indicates that two encounters occurred on the date shown:
- These may be the same service or a combination of services provided on one day.
- Example: One skilled nurse encounter and one home health aide encounter, or two home
health aide encounters of care.
Occurrence code not valid for dates of service on or after July 1, 2008.
•
Code 63 indicates that three encounters occurred on the date shown:
- These may be the same service or a combination of services provided on one day.
- Example: One physical therapy encounter, one skilled nurse encounter, and one home health
aide encounter.
Occurrence code not valid for dates of service on or after July 1, 2008.
•
Code 64 indicates that four encounters occurred on the date shown:
- These may be the same service or a combination of services provided on one day.
- Example: In limited pediatric cases, the need for more than three overhead charges in one 24hour period may occur.
Occurrence code not valid for dates of service on or after July 1, 2008.
•
Code 65 indicates that five encounters occurred on the date shown:
- These may be the same service or a combination of services provided on one day.
- Example: In limited pediatric cases, the need for more than four overhead charges in one 24hour period may occur.
Occurrence code not valid for dates of service on or after July 1, 2008.
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•
Indiana Health Coverage Programs Provider Manual
Code 66 indicates that six encounters occurred on the date shown:
- These may be the same service or a combination of services provided on one day.
- Example: In limited pediatric cases, the need for more than five overhead charges in one 24hour period may occur.
Occurrence code not valid for dates of service on or after July 1, 2008.
Note: Use codes 64–66 only in exceptional circumstances. The OMPP closely
monitors these codes. If the OMPP overpays a provider for overhead
component occurrences, the provider is responsible for completing a paper
adjustment form or an electronic void or replacement. Occurrence codes 64,
65, and 66 are not valid for dates of service on or after July 1, 2008.
•
If the dates of service billed are not consecutive, the provider should enter the correct 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).
•
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 cannot use occurrence codes 62 - 66 in the occurrence span code field.
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 Rule Changes
Effective July 1, 2008, pursuant to 405 IAC 1-4.2-4 (a) (1) home health agency reimbursement for
State fiscal year 2009 forward will result in one overhead cost rate per provider, per recipient, per day.
Home health agency rates for State fiscal year 2009 and after will be based on a new rate-setting
methodology that is based on 95 percent of the unweighted median as the basis for rates. See 405 IAC
1-4.2-4 (b). The State fiscal year 2008 reimbursement methodology expired June 30, 2008. (LSA
Document #07-31, Section 5.)
Table 8.8 – Home Health Services
Code
8-58
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
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Multiple Visit Billing
When providers make multiple visits for the same prior authorized service to a member in 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 of this manual.
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, 2009. The nurse performed two hours of RN services in the morning, and a
second nurse performed two hours of LPN services in the evening of July 15, 2009.
Detail 1: Revenue Code 552 with HCPCS 99600 TD. Date of Service is 7/15/09 and 2 in the units of
service.
Detail 2: Revenue Code 552 with HCPCS 99600 TE. Date of Service is 7/15/09 and 2 in the units of
service.
Note: In this example, providers will bill for only one overhead for dates of service July
1, 2009, and after, by entering a 61 occurrence code with a corresponding date of
7/15/09 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 refer to Chapter 6 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.
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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.
•
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.
•
Use occurrence code 53 to show HHA billing for initial therapy evaluations. This code exempts
evaluations from PA editing. Providers must bill revenue codes specific to therapy evaluations.
•
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:
•
Durable medical equipment (DME)
•
Home medical equipment (HME)
•
Home health agencies (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:
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•
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 IFSSA Drug
Claim Form using the appropriate National Drug Code (NDC).
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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.
•
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 percent.
•
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
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•
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.
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 managed care
entity (MCE) to obtain PA. The contact information can be found in
Chapter 1 of this manual.
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HHAs can bill for S9349, 99601, and 99602 using standard home health care 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 and are 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.
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.
Hospices 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
Indianapolis, IN 46207-7271
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. Refer to the Hospice Provider Manual
on the IHCP Web site at http://provider.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.
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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 percent of the 95 percent nursing facility (NF) case mix rate for
the room and 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 percent of the 95 percent NF case mix rate associated with each
hospitalization up to 15 days per occurrence.
•
One day equals one unit of service.
•
Revenue code 185 may be billed on the same day as other hospice revenue codes.
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.
•
One day equals one unit of service.
Note: When an IHCP-only hospice member, residing in his or her private home, is
admitted to an 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
8-64
•
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.
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•
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 an
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 percent 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 percent 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.
•
One day equals one unit of service.
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 percent 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.
•
Providers also cannot bill for NF room and board for the date the member is physically discharged
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.
•
One day equals one unit of service.
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According to 405 IAC 1-16-2(i), when a recipient 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.
•
One day equals one unit of service.
•
According to 405 IAC 1-16-2(i), when a recipient 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 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.
•
One day equals one unit of service.
Revenue Code 659: Dually Eligible Nursing Facility Members Only
•
Use this revenue code for dually eligible members residing in an NF.
•
This code represents the room and board portion of the hospice per diem.
•
The IHCP pays the hospice provider an additional 95 percent of the NF case mix rate to cover
room and board 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.
•
Providers also cannot bill for NF room and board for the date the member is physically discharged
from the nursing facility.
•
One day equals one unit of service.
Use of Condition Code 07 by 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
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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.
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 Centers for
Medicare & Medicaid Services (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 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 to group home staff. Any questions about the Medicaid hospice
program should be directed to Family and Social Services Administration (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
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Physician Services under Revenue Code 657
Bill reimbursement for a hospice-employed physician’s direct patient services, 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.
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 statute 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 ISDH before enrollment in the IHCP. They are required
to comply with the the Medicare hospice Conditions of Participation at 42 CFR Part 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.
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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 Traditional Medicaid-only hospice
members and dually eligible Medicare and Traditional Medicaid hospice members provide guidelines
for hospice providers.
Traditional Medicaid-Only – Hospice Member Residing in the Private Home
If the Traditional Medicaid-only hospice member has private insurance, 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, 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.
Traditional Medicaid-Only – Hospice Member Residing in a Nursing Facility
If the Traditional Medicaid-only hospice member has private insurance, 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 the room and board services.
The hospice provider must attach to the UB-04 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, 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, the hospice provider must
bill Medicare for the hospice services and the IHCP for the outstanding balance.
Dually Eligible Medicare and Traditional Medicaid Hospice Member Residing in a
Nursing Facility
If a dually eligible Medicare hospice member has private insurance, Medicare and Traditional
Medicaid require that the hospice provider bill the private insurance company first for the hospice
services and the room and board services.
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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 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 percent by the state of Indiana, DA stipulates that 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
A Traditional Medicaid-only hospice member residing in an NF may become Medicare-eligible during
a one-month billing period. Inversely, a dually eligible Medicare and Traditional Medicaid hospice
member residing in an NF may become a Traditional Medicaid-only hospice member during a onemonth billing period. The change in eligibility status changes how the hospice provider completes the
UB-04 for those dates of service.
Traditional Medicaid-Only – Hospice Member Who Becomes Medicare-Eligible in
Nursing Facility
The hospice provider must complete the necessary paperwork to enroll the Traditional Medicaid-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 MCO 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 a Traditional Medicaid-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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Chapter 8
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Dually Eligible Medicare/Traditional Medicaid – Member in a Nursing Facility Who
Becomes Traditional Medicaid-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 MCO or CMO Hospice
Authorization Unit.
The following example provides guidelines for completing the UB-04 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 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 be more than three pages long and contain 66 detail lines. 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 form 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 nursing facility (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 percent or greater on the day the leave begins. If the NF occupancy
percentage falls below 90 percent following the date the leave began, the hospice provider can
continue to bill the 50 percent of the NF’s case mix reimbursement rate for the entire hospital or
therapeutic leave.
When the NF occupancy is below 90 percent on the date that 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 explanation of benefits (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
percent.
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 following page of the IHCP Web
site: http://provider.indianamedicaid.com/provider-specific-information/hospice/forms.aspx.
Mail the completed form and a check for the overpayment amount to:
HP Refunds
P.O. Box 2303 Dept. 130
Indianapolis, IN 46206-2303
The following example shows how to calculate the amount of an overpayment for revenue code 653 or
654.
Table 8.9 – Nursing Home Room and Board Calculation
Nursing Home Room and Board Level of Care
Letter
Represented
8-72
Description
Amount
A
Nursing Home’s Room and Board Rate
$136.98
B
Payment Percentage of the Room and Board Rate
95
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Nursing Home Room and Board Level of Care
Letter
Represented
Description
Amount
C
Medicaid Reimbursement Per Day (A*B=C)
$130.13
D
Number of Days in the Month
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
31
Table 8.10 – 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 8.10, line C) of $3,934.52
and no reimbursement for Room and Board (Table 8.9, 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.
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Billing Procedures
Mail inpatient hospital claims to the following address for processing:
HP Inpatient Hospital Claims
P.O. Box 7271
Indianapolis, IN 46207-7271
Note: For RBMC members, bill the appropriate MCO.
Specified Coding Level
The IHCP adheres to the coding guidelines published in the 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.
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.
Continued Bill
If a complete itemization of services requires multiple UB-04 claim forms, providers must enter the
total charges on the last page of the bill, not at the bottom of each UB-04 claim form:
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•
Mark the UB-04 claim form page number in the area provided on line 23. As many as three pages
can be submitted as one claim.
•
Complete the first 22 lines on page one of the UB-04 claim form.
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•
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 47.
Medical Education Reimbursement
The change in medical education reimbursement is effective for encounter or shadow claims (claims
that are forwarded to HP after being adjudicated by a managed care organization) received from the
MCOs with a From Date of Service of January 1, 2010, and after. Based upon shadow claims data
received from the MCOs, HP Enterprise Services processes and issues the medical education payments
to the hospitals.
All medical education payment calculations are made once the MCO has posted the claim payment
information, and the shadow claim has been posted to IndianaAIM. Providers should allow 30 – 45
calendar days from the time the MCO 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
Inpatient Blood Factor Claims
Indiana Medicaid will reimburse providers for claims for blood factor products administered during
inpatient hospital stays at the lowest of the following:
•
Estimated Acquisition Cost (84 percent of the Average Wholesale Price)
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•
Inpatient blood factor – State maximum allowable cost (MAC)
•
Submitted charge
Effective for claims with administration dates on or after October 12, 2008, blood factor that is used
during inpatient hospital stays should now be billed separately from the inpatient hospital diagnosisrelated group or Level of Care claim. If a patient is admitted prior to October 12, 2008, and blood
factor is administered prior to October 12, 2008, the charges should remain on the inpatient claim.
Hospitals are prohibited from submitting any charges for blood factor administered on or after October
12, 2008, 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 NPIs for their facility 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
Indianapolis, IN 46207-7263
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.
Table 8.11 – Blood Factor Products Effective for Dispense Dates of October 12, 2008, and
Later
NDC
8-76
Procedure Code
Blood Factor Product
00944294410
J7192
ADVATE 1,201-1,800 UNITS VIAL
00944294510
J7192
ADVATE 1,801-2,400 UNITS VIAL
00944294610
J7192
ADVATE 2,400-3,600 UNITS VIAL
00944294110
J7192
ADVATE 200-400 UNITS VIAL
00944294210
J7192
ADVATE 401-800 UNITS VIAL
00944294310
J7192
ADVATE 801-1,200 UNITS VIAL
68516460002
J7190
ALPHANATE 1,000-1,500 UNITS VL
68516460302
J7190
ALPHANATE 1,000-400 UNIT VIAL
68516460402
J7190
ALPHANATE 1,500-600 UNIT VIAL
68516460101
J7190
ALPHANATE 250-100 UNIT VIAL
68516460001
J7190
ALPHANATE 250-500 UNIT VIAL
68516460201
J7190
ALPHANATE 500-200 UNIT VIAL
68516360005
J7193
ALPHANINE SD 1,000 UNITS VIAL
68516360202
J7193
ALPHANINE SD 1,000 UNITS VIAL
68516360006
J7193
ALPHANINE SD 1,500 UNITS VIAL
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Revision Date: August 26, 2010
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Indiana Health Coverage Programs Provider Manual
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Procedure Code
Chapter 8
Section 2: UB-04 Billing Instructions
Blood Factor Product
68516360302
J7193
ALPHANINE SD 1,500 UNITS VIAL
68516360002
J7193
ALPHANINE SD 250-1,500 UNIT VL
68516360004
J7193
ALPHANINE SD 500 UNITS VIAL 05
68516360102
J7193
ALPHANINE SD 500 UNITS VIAL 06
64193024402
J7194
BEBULIN VH IMMUNO 200-1,200 UNIT
58394000105
J7195
BENEFIX 1,000 UNIT VIAL
58394000106
J7195
BENEFIX 1,000 UNIT VIAL
58394000101
J7195
BENEFIX 1,000 UNITS VIAL
58394000802
J7195
BENEFIX 2,000 UNIT VIAL
58394000803
J7195
BENEFIX 2,000 UNIT VIAL
58394000301
J7195
BENEFIX 250 UNIT VIAL
58394000305
J7195
BENEFIX 250 UNIT VIAL
58394000306
J7195
BENEFIX 250 UNIT VIAL
58394000201
J7195
BENEFIX 500 UNIT VIAL
58394000205
J7195
BENEFIX 500 UNIT VIAL
58394000206
J7195
BENEFIX 500 UNIT VIAL
64193022205
J7198
FEIBA VH IMMUNO 1,750-3,250 IU
64193022203
J7198
FEIBA VH IMMUNO 400-650 UNITS
64193022204
J7198
FEIBA VH IMMUNO 651-1,200 UNIT
64193022302
J7198
FEIBA NF 400-650 UNIT VIAL 07/
64193022402
J7198
FEIBA NF 651-1200 UNIT VIAL 07
64193022502
J7198
FEIBA NF 1750-3250 UNIT VIAL 0
00053813004
J7192
HELIXATE FS 1,000 UNITS VIAL
00053813005
J7192
HELIXATE FS 2,000 UNIT VIAL
00053813001
J7192
HELIXATE FS 250 UNIT VIAL
00053813002
J7192
HELIXATE FS 500 UNIT VIAL
00053813302
J7192
HELIXATE FS 1,000 UNITS VIAL
00053813402
J7192
HELIXATE FS 2,000 UNIT VIAL
00053813102
J7192
HELIXATE FS 250 UNIT VIAL
00053813202
J7192
HELIXATE FS 500 UNIT VIAL
00053813502
J7192
HELIXATE FS 3,000 UNITS VIAL
00944293301
J7190
HEMOFIL M 1,701-2,000 UNITS VL
00944293504
J7190
HEMOFIL M 1,701-2,000 UNITS VL
00944293001
J7190
HEMOFIL M 220-400 UNITS VIAL
00944293501
J7190
HEMOFIL M 220-400 UNITS VIAL
00944293101
J7190
HEMOFIL M 401-800 UNITS VIAL
00944293502
J7190
HEMOFIL M 401-800 UNITS VIAL
00944293201
J7190
HEMOFIL M 801-1,700 UNITS VIAL
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Revision Date: August 26, 2010
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Indiana Health Coverage Programs Provider Manual
Procedure Code
Blood Factor Product
00944293503
J7190
HEMOFIL M 801-1,700 UNITS VIAL
00053762010
J7187
HUMATE-P 1,000 UNITS KIT
00053761510
J7187
HUMATE-P 1,200 UNITS KIT
00053762020
J7187
HUMATE-P 2,000 UNITS KIT
00053761520
J7187
HUMATE-P 2,400 UNITS KIT
00053762005
J7187
HUMATE-P 500 UNITS KIT
00053761505
J7187
HUMATE-P 600 UNITS KIT
63833061602
J7187
HUMATE-P 1,200 UNITS KIT A
63833061702
J7187
HUMATE-P 2,400 UNITS KIT A
63833061502
J7187
HUMATE-P 600 UNITS KIT A
55688010602
J7191
HYATE:C 400-700 UNIT VIAL
13533066550
J7190
KOATE-DVI 1,000 UNITS KIT
13533066520
J7190
KOATE-DVI 250 UNIT KIT
13533066530
J7190
KOATE-DVI 500 UNITS KIT
00026037250
J7192
KOGENATE FS 1,000 UNITS VIAL
00026037950
J7192
KOGENATE FS 1,000 UNITS VIAL
00026378550
J7192
KOGENATE FS 1,000 UNITS VIAL
00026379550
J7192
KOGENATE FS 1,000 UNITS VIAL
00026378660
J7192
KOGENATE FS 2,000 UNIT VIAL
00026379660
J7192
KOGENATE FS 2,000 UNIT VIAL
00026037220
J7192
KOGENATE FS 250 UNIT VIAL
00026037920
J7192
KOGENATE FS 250 UNITS VIAL
00026378220
J7192
KOGENATE FS 250 UNIT VIAL
00026379220
J7192
KOGENATE FS 250 UNITS VIAL
00026378770
J7192
KOGENATE FS 3,000 UNIT VIAL
00026379770
J7192
KOGENATE FS 3,000 UNIT VIAL
00026037230
J7192
KOGENATE FS 500 UNIT VIAL
00026037930
J7192
KOGENATE FS 500 UNITS VIAL
00026379330
J7192
KOGENATE FS 500 UNIT VIAL
00026378330
J7192
KOGENATE FS 500 UNITS VIAL
00944130410
J7190
MONARC-M 1,701-2,000 UNITS VL
00944130110
J7190
MONARC-M 220-400 UNITS VIAL
00944130210
J7190
MONARC-M 401-800 UNITS VIAL
00944130310
J7190
MONARC-M 801-1,700 UNITS VIAL
00053765604
J7190
MONOCLATE-P 1,000 UNITS KIT
00053765605
J7190
MONOCLATE-P 1,500 UNITS KIT
00053765601
J7190
MONOCLATE-P 250 UNIT KIT
00053765602
J7190
MONOCLATE-P 500AHFU KIT
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Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
NDC
Procedure Code
Chapter 8
Section 2: UB-04 Billing Instructions
Blood Factor Product
00053766804
J7193
MONONINE 1,000 UNITS VIAL
00053766802
J7193
MONONINE 500 UNITS VIAL
00169706001
J7189
NOVOSEVEN 1,200 MCG VIAL
00169706101
J7189
NOVOSEVEN 2,400 MCG VIAL
00169706201
J7189
NOVOSEVEN 4,800 MCG VIAL
00169701001
J7189
NOVOSEVEN RT 1,000 MCG VIAL
00169702001
J7189
NOVOSEVEN RT 2,000 MCG VIAL
00169705001
J7189
NOVOSEVEN RT 5,000 MCG VIAL
68516320004
J7194
PROFILNINE SD 1,000 UNITS VIAL
68516320202
J7194
PROFILNINE SD 1,000 UNITS VIAL
68516320003
J7194
PROFILNINE SD 1,000-1,500 UNIT
68516320005
J7194
PROFILNINE SD 1,500 UNITS VIAL
68516320302
J7194
PROFILNINE SD 1,500 UNITS VIAL
68516320002
J7194
PROFILNINE SD 500 UNITS VIAL
68516320101
J7194
PROFILNINE SD 500 UNITS VIAL
00944283110
J7192
RECOMBINATE 220-400 UNIT VIAL
00944293810
J7192
RECOMBINATE 220-400 UNIT VIAL
00944283210
J7192
RECOMBINATE 401-800 UNIT VIAL
00944293802
J7192
RECOMBINATE 401-800 UNIT VIAL
00944283310
J7192
RECOMBINATE 801-1,240 UNIT VL
00944293803
J7192
RECOMBINATE 801-1,240 UNIT VL
58394000502
J7192
REFACTO 1,000 UNITS VIAL
58394000504
J7192
REFACTO 1,000 UNITS VIAL
58394001102
J7192
REFACTO 2,000 UNITS VIAL
58394001104
J7192
REFACTO 2,000 UNITS VIAL
58394000702
J7192
REFACTO 250 UNITS VIAL
58394000704
J7192
REFACTO 250 UNITS VIAL
58394000602
J7192
REFACTO 500 UNITS VIAL
58394000604
J7192
REFACTO 500 UNITS VIAL
67467018102
C9267
WILATE 900-900 UNIT KIT
67467018101
C9267
WILATE 450-450 UNIT KIT
58394001401
J7185
XYNTHA 1,000 UNIT KIT
58394001501
J7185
XYNTHA 2,000 UNIT KIT
58394001201
J7185
XYNTHA 250 UNIT KIT
58394001301
J7185
XYNTHA 500 UNIT KIT
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Present on Admission Indicators and Hospital-Acquired Conditions
Effective for inpatient and inpatient crossover claims with a ‘From’ date of service on or after October
1, 2009, the IHCP adopted a hospital-acquired conditions (HAC) policy for Medicaid claims using our
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 present on admission (POA) indicators will be 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 will not be used for AP DRG
grouping. That is, the claim will be paid as though any secondary diagnoses included in Table 8.12
were not present on the claim.
Table 8.12 – Final HAC List as Published in FFY 2009 Final Rule
Applicable ICD-9 Codes
CC – Complicating Condition
MCC – Major Complicating Condition
Description
Foreign Object Retained After Surgery
998.4 (CC) and 998.7 (CC)
Air Embolism
999.1 (MCC)
Blood Incompatibility
999.6 (CC)
Pressure Ulcers Stages III and IV
707.23 (MCC) and 707.24 (MCC)
Falls and Trauma
CC/MCC codes within these ranges:
•
Fractures
•
800 – 829
•
Dislocations
•
830 – 839
•
Intracranial Injuries
•
850 – 854
•
Crushing Injuries
•
925 – 929
•
Burns
•
940 – 949
• Electric Shock
Catheter-Associated Urinary Tract Infection (UTI)
• 991 – 994
996.64 (CC), and excludes the following from
acting as a CC/MCC:
•
CC – 112.2, 590.10, 590.3, 590.80,
590.81, 595.0, 597.0, 599.0
Vascular Catheter-Associated Infection
• MCC – 590.11, 590.2
999.31 (CC)
Manifestations of Poor Glycemic Control
MCC –
•
250.10 – 250.13
•
250.20 – 250.23
•
249.10 – 249.11
• 249.20 – 249.21
CC –
•
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Applicable ICD-9 Codes
CC – Complicating Condition
MCC – Major Complicating Condition
Description
Surgical Site Infection, Mediastinitis After Coronary
Artery Bypass Graft (CABG)
519.2 (MCC) and one of the following
procedure codes:
Surgical Site Infection Following Certain Orthopedic
Procedures
• 36.10 – 36.19
999.67 (CC) or 998.59 (CC) and one of the
following procedure codes:
Surgical Site Infection Following Bariatric Surgery
for Obesity
Deep Vein Thrombosis (DVT)/ Pulmonary
Embolism (PE) Following Certain Orthopedic
Procedures
•
81.01 – 81.08
•
81.23 – 81.24
•
81.31 – 81.38
•
81.83
• 81.85
278.01 and 998.59 (CC) and one of the
following procedure codes:
•
44.38
•
44.39
• 44.95
453.40 – 453.42 (MCC) or 415.11 (MCC) or
415.19 (MCC) and one of the following
procedure codes:
•
81.54
•
00.85 – 00.87
•
81.51 – 81.52
Notes: If a claim contains a hospital-acquired condition diagnosis with a POA
indicator of “U” or “N,” the HAC diagnosis will be suppressed when the
claim processes through the DRG grouper. The OMPP will not pay the
complicating condition/major complicating condition (CC/MCC) for HACs.
The POA indicator of “1” is only applicable 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.
Claims containing HAC diagnoses with POA indicators of “Y” or “W” will
process through the AP DRG grouper and process per normal inpatient
policy.
Claims submitted by a nonexempt hospital that do not include a POA
indicator for the principal and any secondary diagnoses will be denied. The
provider will need to correct and resubmit the claim.
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Exempt Hospitals
POA indicator reporting is mandatory for all Medicaid claims involving inpatient admission to general
acute care hospitals with a primary specialty of Acute Care – 010. However, the following types of
hospitals are EXEMPT from the Medicaid HAC policy and POA indicator reporting:
•
Critical access hospitals (CAHs)
•
Long-term acute care hospitals (LTACs) (primary specialty 013)
•
Inpatient psychiatric hospitals (primary specialty 011)
•
Inpatient rehabilitation facilities (primary specialty 012)
Psychiatric or rehabilitation units of acute care hospitals, also known as a distinct part of an acute care
hospital, enrolled with primary specialty 010 are required to submit the POA indicator on their claims.
The list of critical access hospitals was identified using information obtained from Medicare. Hospitals
that are not sure of their CAH status should contact the HP Provider Enrollment Department at 1-877707-5750 for confirmation.
Present on Admission Indicator
POA is defined as “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 will be ignored and not
used for AP DRG grouping.
Common POA Explanations of Benefits
The following table lists common POA explanations of benefits (EOBs).
Table 8.13 – Common POA EOBs
EOB Code
EOB Description
4250
The Principal Diagnosis POA Indicator is Missing or Invalid – this
edit will post 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
will post to the claim for secondary diagnoses 1-24 if the POA is
missing or invalid. The specific diagnosis field will be 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
The current list of HACs was published by the CMS in the August 19, 2008, FFY 2009 Inpatient
Prospective Payment System final rule (73 FR 48471) and includes diagnoses listed in Chapter 8. The
IHCP will continue to follow CMS’ HAC determinations, including any future additions or changes to
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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, effective October 1, 2008, at http://www.cdc.gov/nchs/data/icd9/icdguide08.pdf.
Medicare Exhaust Claims
Benefits Exhausted Prior to Inpatient Admission
The IHCP reimburses acute care hospitals for dually eligible (Medicare and Medicaid) IHCP members
who exhaust their inpatient hospital Medicare Part A benefits prior to admission to acute care
hospitals.
When a Medicare Part A stay is exhausted by Medicare prior to admission, providers must bill the date
of admission through the date of discharge on the UB-04 claim form. Do not bill the IHCP for partial
inpatient stays. The Medicare Remittance Notification (MRN) must be submitted with the claim to
show benefits were exhausted prior to the date of admission.
Providers must bill services payable to Medicare Part B before billing the exhaust claim to Medicaid.
Because these claims are considered Medicaid primary claims, all IHCP filing limit rules apply. Refer
to Chapter 10 for information about waiving filing limit procedures and supplying appropriate
documentation for claim adjudication.
Benefits Exhausted During an Inpatient Stay
When a dually eligible member exhausts Medicare Part A benefits during an inpatient stay, the claim
automatically crosses over from Medicare and adjudicates according to the IHCP inpatient crossover
reimbursement methodology. Once the coinsurance and deductible amounts are considered, no
additional payment will be made on the claim. This is also true for claims that do not automatically
cross over but are submitted via the Web or paper.
The IHCP will continue to reimburse Medicare Part B charges, as long as the revenue codes billed on
the Medicare Part A and B claims are not the same. If the same revenue codes appear on both claims,
the claim will deny for duplicate billing.
Medicare Replacement Plans Claim Submission Instructions
The following instructions apply when submitting claims for service adjudicated by a Medicare health
maintenance organization (HMO) replacement plan:
•
Submit claims to the regular IHCP claims process address. Do not send the claims to the medical
or institutional crossover post office boxes.
- CMS-1500 claims: Enter the payment received from the Medicare replacement plan in field
29, not field 22. Do not enter any amounts in field 22.
- UB-04 claims: Enter the payment received from the Medicare replacement plan in the Prior
Payment form locators 54 A through C, as appropriate. Enter the words “Replacement Plan”
in the Payer Name form locators 50A through 50C, as appropriate. Do not enter any reference
to Medicare in Payer Name form locators, as this causes the claim to be treated as a crossover
claim.
- With every claim form, submit a copy of the Medicare replacement plan Remittance Advice
(RA), Medicare Remittance Notice (MRN), or the explanation of payment/benefits from the
replacement policy carrier.
- The words “Medicare Replacement Policy” must be written on the top of the claim form
and on the top of the attachments submitted with the claim.
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Claims may be submitted electronically using the above process. The words “Medicare
Replacement Policy” must be written at the top of the attachment.
These claims are processed as third-party liability (TPL) claims. Standard Medicaid prior
authorization rules apply to these claims, as do timely filing limits.
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.
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:
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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.
•
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.
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•
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 to be considered part of the same episode of care. Exclusions to this
policy are claims priced according to the Level of Care (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 Level of Care (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 the UB-04 form locator 17 on the claim form.
For detailed reimbursement information about transfers and readmissions, refer to Chapter 7 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 explanation of benefits (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. For dates of service prior to January 1, 2006,
submit an 8A Form attached for each month in which the member was in the facility on the spenddown met date.
Effective January 1, 2006, 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.
Inpatient Mental Health
405 IAC 5-20-1 (b) (c) (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 the member’s 22nd birthday, inpatient psychiatric services are available.
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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 in Appendix A, Rule 20.
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 salaried, contracted,
or independent providers, and 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 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
this admission.
Up to and including date of service December 31, 2006, the IHCP carves out of the RBMC network
any mental health services, including substance abuse treatment, rendered in freestanding psychiatric
hospitals and pays them on an FFS basis. The carved-out definition in the Carved-Out Services
subsection later in this chapter provides additional information. Providers should bill claims for mental
health services in a freestanding psychiatric hospital on a UB-04 claim form; these claims are not the
financial responsibility of the MCO. Inpatient mental health services, including substance abuse
treatment, provided to RBMC network members in acute care facilities are the responsibility of the
MCO in which the member is enrolled. On and after January 1, 2007, these services are the
responsibility of the MCO in which the member belongs, excluding PRTF services and MRO services,
which will continue to be carved out.
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Inpatient Mental Health and Substance Abuse Services
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 Premature Newborns
Coding claims for premature 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 and 765 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
1,250 grams – 1,499 grams
6
1,500 grams – 1,749 grams
7
1,750 grams – 1,999 grams
8
2,000 grams – 2,499 grams
9
2,500 grams and over
Do not use these codes as principal diagnosis codes.
When a premature infant 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
Current Procedural Terminology (CPT®) Code 99298 – Subsequent intensive care, per day, for the
evaluation and management of the recovering very low birth weight infant (present body weight less
than 1500 grams). This CPT code is limited to one unit per day.
CPT Code 99300 – Subsequent intensive care, per day, for the evaluation and management of the
recovering infant (present body weight less than 2501-5000 grams). This CPT code is limited to one
unit per day.
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CPT Code 99295 – Initial neonatal critical care, per day, for the evaluation and management of a
critically ill neonate, 28 days of age or less. This CPT code has an age limit of 0-1 year of age. This
CPT code is limited to one unit per day.
CPT Code 99296 – Subsequent inpatient neonatal critical care, per day, for the evaluation and
management of a critically ill neonate, 28 days of age or less. This code has an age limit of 0-1 year of
age. This CPT code is limited to one unit per day.
CPT Code 99293 – 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 99294 – 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 G0243 and 77301U5. 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:
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•
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
(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 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- or
Medicaid-approved 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.
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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 percent.
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- 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 above.
•
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 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.
Coding and Billing Instructions
Tables 8.15 to 8.17 list the appropriate codes for billing implantation and removal of the VADs. The
tables include the following:
•
Table 8.15 lists the diagnosis codes appropriate for implantation of a VAD. The diagnosis code
should be billed on the UB-04 claim form with the corresponding ICD-9-CM procedure code.
•
Table 8.16 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 8.17 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.
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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
Table 8.15 – ICD-9-CM Diagnosis Codes
Code
Description
410.xx
Acute myocardial infarction
411.1
Intermediate coronary syndrome
411.81
Acute coronary occlusion without myocardial infarction
414.9
Chronic ischemic heart disease, unspecified
422.xx
Acute myocarditis in diseases classified elsewhere
425.x
Cardiomyopathy
426.xx
Conduction disorders
427.xx
Cardiac dysrhythmias
428.xx
Heart failure
429.4
Functional disturbances following cardiac surgery
785.51
Cardiogenic shock
997.1
Cardiac complications
Note: xx represents diagnosis code placeholders. For example, 410.xx means all
diagnoses in the 410 series are applicable.
Table 8.16 – 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
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Code
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Description
Insertion of implantable heart assist system
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 8.17 – 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
0048T
Implantation of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or
dual cannulation
0049T
Prolonged extracorporeal percutaneous transseptal ventricular assist device, greater than 24 hours,
each subsequent 24 hours period
0050T
Removal of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual
cannulation
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.
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Coverage
Inpatient long-term care (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 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 intermediate care facilities for the mentally
retarded (ICFs/MR). For detailed information about reimbursement for LTC facilities, refer to
Chapter 7. Providers should mail LTC paper claims to the following address for processing:
HP Nursing Home Claims
P.O. Box 7271
Indianapolis, IN 46207-7271
NFs and ICFs/MR may bill using the UB-04, electronic 837I transaction, or Web interChange claim
formats. If submitting paper claims, NFs must follow the general instructions for completing the UB04 claim form, as well as the specific instructions that follow.
Package C
LTC facility services are not covered for Package C members.
Nursing Facility Services
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 also acceptable. 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 longterm care providers must have a State-approved Form 450B or OMPP Form 450B 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, 837 electronic, or Web interChange institutional claim format. Any inappropriate billing and
reimbursement is subject to recoupment by the Surveillance and Utilization Review (SUR)
Department.
Providers can bill short-term stays of less than 30 days on discharge of the patient. Providers can bill
long-term stays of 30 days or more monthly, or more frequently if desired.
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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.
Calculating and assigning 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 reimburses for reserved beds for members provided that the criteria in 405 IAC 5-31-8 is
met.
Providers should use the appropriate room and board revenue code for the days the member was a
patient in the NF, and they should use the applicable leave-of-absence revenue code for the days the
member was out of the NF. The IHCP only reimburses for bed-hold days to nursing facilities that have
occupancy rates of 90 percent or greater. This policy change is addressed in 405 IAC 5-31-8.
To determine eligibility for IHCP payment for bed-hold days, each nursing facility must determine the
occupancy rate as of the date that an IHCP resident leaves the facility for hospital or therapeutic leave.
If the facility’s occupancy rate is equal to or greater than 90 percent as of the date the IHCP resident
leaves the facility for hospital or therapeutic leave, the facility is permitted to receive IHCP
reimbursement for the bed-hold days for the duration of that resident’s leave of absence, subject to the
limitations prescribed by 405 IAC 5-31-8. If the facility’s occupancy rate is less than 90 percent, the
facility is not permitted to receive IHCP reimbursement for any bed-hold days for the duration of that
resident’s leave of absence.
The facility must code for leave days using the revenue codes as indicated in Table 8.18. For internal
recordkeeping purposes, facilities must continue to submit claims for bed-hold days regardless of
whether those leave days are eligible for IHCP payment. Bed-hold days not eligible for payment must
be billed using revenue code 180. The bed-hold days appear on the explanation of benefits (EOB) as a
payment denial but still allow the OMPP to track unpaid leave days. Bill bed-hold days eligible for
IHCP payment pursuant to 405 IAC 5-31-8 using either revenue code 183 or 185, as applicable.
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Code any leave day, whether eligible for payment or not, on the claim using one of the codes listed in
Table 8.18.
Table 8.18 – 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 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 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. Since January
1998, IndianaAIM has used the patient status code from the UB-04 claim form (locator box 22, STAT)
to close the member’s Level of Care (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.
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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 of this
manual for more 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 put the resident over personal resources. In this case, the nursing facility must notify the
county caseworker, who will redetermine 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 the Web
at http://provider.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 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 the Mentally Retarded Services
Intermediate care facilities for the mentally retarded (ICFs/MR) are divided into three distinct
categories:
•
Small ICF/MR – 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
- Intensive training
- Sheltered living
- Small behavioral management residences for children
- Small extensive needs medical residences for adults
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•
Large, private ICF/MR – More than eight beds
•
State-operated facilities – More than eight beds
Indiana Health Coverage Programs Provider Manual
ICFs/MR 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/MR reimbursement rate is an inclusive rate. Therefore, ICFs/MR cannot bill separately for
medical and nonmedical supply items, personal care items, or therapies. The small ICF/MR
reimbursement rate also includes day services as part of the inclusive rate. However, ICFs/MR can bill
separately when billing crossover claims. Any inappropriate billing or reimbursement is subject to
recoupment by the SUR 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/MR.
Type of bill 67X denotes a group home or small ICF/MR.
Leave Days
Reimbursement is available for reserving beds for members in a private or State-operated ICF/MR,
provided that the criteria set out in 405 IAC 5-13-6 is met.
Providers must use the appropriate room and board revenue code for the days the member was a
patient in the ICF/MR and use the applicable leave of absence revenue code for the days the member
was out of the ICF/MR.
The two types of reimbursed leave days are as follows:
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•
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, then the member must be discharged from the ICF/MR. If the member is discharged from
the ICF/MR following a hospitalization in excess of 15 consecutive days, then the ICF/MR is still
responsible for appropriate discharge planning. Discharge planning is required if the ICF/MR does
not intend to provide ongoing services following the hospitalization for those members who
continue to require ICF/MR 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/MR.
The leave days need not be consecutive. If the member is absent for more than 60 days per year,
then 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.
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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.
Billing Procedures
Mail outpatient claims to the following address for processing:
HP Outpatient Claims
P.O. Box 7271
Indianapolis, IN 46207-7271
Note: RBMC members must bill the appropriate MCO.
The following clarifications may assist providers using the UB-04 claim form. Detailed information
about reimbursement for outpatient services is in Chapter 7 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. In
other words, the IHCP covers a service provided to a pregnant woman for the treatment of a chronic or
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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.
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 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. See Informed Consent Claim
Attachment Instructions section.
Notification of Pregnancy Billing
Effective December 1, 2009, hospitals can submit claims for Notification of Pregnancy (NOP). Submit
claims for NOP using the UB-04 claim form to the appropriate managed care organization following
the guidelines below for reimbursement.
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 from hospitals must be coded with the following:
- Revenue Code 960
- CPT® code 99354 and modifier TH
Note: The revenue code, CPT code, and modifier must be billed together to be
reimbursed the NOP fee when billed on the UB claim form.
Duplicate NOPs will not be reimbursed.
For more information on submitting a NOP through Web interChange, see the Process for Completion
of the Notification of Pregnancy section.
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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, 71X, 72X, and 76X, are defined as surgical revenue codes when
accompanied by a surgical CPT or HCPCS code. The IHCP then 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 then 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.
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 is reflective of 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 8.19 identifies the ASC groups.
Table 8.19 – 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
T – Telemedicine
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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 percent of that rate, and it reimburses
the procedure with the second highest ASC rate or bilateral procedure at 50 percent 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 either 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 8.20:
Table 8.20 – Revenue Codes
Revenue Code
Description
36X
Operating room services
45X
Emergency department
49X
Ambulatory surgical care
51X
Clinic
52X
Freestanding clinic
70X
Cast room
71X
Recovery room
72X
Labor/delivery room
76X
Treatment/observation room
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 above. 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 for more information about
PA). Providers should submit claims for these items on the CMS-1500 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 8.21 lists the implantable durable medical
equipment.
Table 8.21 – Implantable Medical Equipment
Category
8-100
Type
Notes
Cardiac Pacemakers
Single-chamber
C1786, C2619
Cardiac Pacemakers
Dual-chamber
C1785, C2620
Cardiac Pacemakers
Other than singleor dual-chamber
C2621
Implantable Loop Recorders
N/A
See Patient-Activated Event Recorder—
Implantable Loop Recorder.
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Category
Phrenic Nerve Stimulators
New Technology Intraocular
Lenses
Vagal Nerve Stimulators
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Type
N/A
N/A
N/A
Implantable Infusion Pumps
Nonprogrammable
Implantable Infusion Pumps
Programmable
Notes
See Phrenic Nerve Stimulator (Breathing
Pacemaker).
See Intraocular Lenses.
See NeuroCybernetic Prosthesis System –
Vagus Nerve Stimulator.
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. Effective December 15, 2006, HCPCS code
V2785 is reimbursed 100 percent of the cost invoice.
Pacemakers
Effective December 15, 2006, when the implantation is performed in an outpatient surgical setting,
IHCP reimburses the cost of single- and dual-chamber pacemakers identified in Table 8.21 in addition
to the ASC rate. The facility purchasing the pacemaker must submit, as an attachment to the CMS1500 or 837P electronic transaction, a manufacturer’s cost invoice showing the purchase price for the
pacemaker. The IHCP reimburses the provider at 100 percent of the cost invoice for this device.
Phrenic Nerve Stimulator (Breathing Pacemaker)
IHCP began covering the phrenic nerve stimulator (breathing pacemaker) effective for claims with
dates of service of October 26, 2000. Specific coverage criteria have been developed and must be met
for reimbursement to be made. This section provides coverage and billing information to allow
providers to submit claims for this device.
This device 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.
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
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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 will be used. The claim
for the device must be submitted as a durable medical equipment (DME) item on a CMS-1500 claim
form. When the device is implanted as an outpatient procedure, the 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. The hospital providing the equipment for implantation must be enrolled as a DME provider
with a DME Legacy Provider Identifier (LPI).
Table 8.22 provides the CPT codes and description information to use when submitting claims either
as an inpatient or outpatient.
Table 8.22 − CPT Codes for Inpatient and Outpatient Claims
CPT Code
64577
64585
95970
95974
Description
Incision for implantation of neurostimulator
electrodes; autonomic nerve
Revision or removal of peripheral
neurostimulator electrodes
Initial programming
Intraoperative or subsequent programming,
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 care giver of adequate quality and the availability
of nursing and medical care
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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 will 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 include employment or attending school. Increased mobility will allow
the patient to function without interference of large equipment.
– Patient’s skin integrity will be better maintained because of increased mobility.
– Patient has 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.
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
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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).This change is effective for claims with service dates of October 26,
2000, or after. 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 patientactivated event recorder – ILR, also referred to as the implantable loop recorder.
Coverage
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 require prior
authorization (PA), but will be subject to retrospective review according to IHCP criteria. If a
replacement recorder activator is needed, PA is required.
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 code
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 8.23 illustrates
coding for each place of service:
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Table 8.23 − Place of Service Codes
Inpatient
Outpatient
Physician’s Office
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 8.24 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 8.24 − 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
93727
Electronic analysis of ILR system (includes retrieval
of recorded and stored ECG data, physician review,
and interpretation of retrieved ECG data and
reprogramming)
E0616
Implantable cardiac event recorder 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 93727 and should be billed only
subsequent to the date of insertion. Initial analysis and monitoring is included in the fee for insertion;
therefore, code 93727 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.
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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 either 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.
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 durable medical equipment (DME) NPI.
NeuroCybernetic Prosthesis System – Vagus Nerve Stimulator
Effective October 23, 2000, the IHCP will reimburse for the NeuroCybernetic Prosthesis (NCP)
System, a vagus nerve stimulator. This system 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 which surgery has failed or is not recommended.
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Coverage Criteria for the NCP System
The IHCP has approved the following criteria:
•
Coverage of the NCP System is effective for dates of service on or after October 23, 2000.
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 will 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 will not be 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 mental retardation, cerebral palsy, stroke, progressive fatal
neurologic disease, or progressive fatal medical disease).
Diagnosis and Procedure Codes
The following diagnosis and procedure codes are to be used when billing for the implantation,
revision, programming and reprogramming, and removal of the vagus nerve stimulator device.
Table 8.25 – ICD-9 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 8.26 – 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
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Table 8.27 – Surgeon CPT Procedure Codes for Vagus Nerve Stimulator Device
Code
Description
64573
Incision for implantation of neurostimulator electrodes; cranial nerve
64553
Percutaneous implantation of neurostimulator electrodes; cranial nerve
61885
Incision and subcutaneous placement of cranial neurostimulator pulse generator or
receiver, direct or indirect coupling, with connection to a single electrode array
64585
Revision or removal of peripheral neurostimulator electrodes
61888
Revision or removal of cranial neurostimulator pulse generator or receiver
Table 8.28 – Neurologist CPT Procedure Codes for Vagus Nerve Stimulator Device
Code
Description
95970
Electronic analysis of implanted neurostimulator pulse generator system (for
example, rate, pulse amplitude and duration, configuration of wave form, battery
status, electrode selectability, output modulation, cycling, impedance, and patient
compliance measurements); simple or complex neurostimulator pulse generator,
without programming
95974
Complex cranial nerve neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, with or without nerve-interface testing,
first hour
95975
Complex cranial nerve neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, with or without nerve interface testing,
each additional 30 minutes after first hour (list separately in addition to code for
primary procedure)
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 8.29 indicates the procedure codes to be used 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.
Table 8.29 – CPT Procedure Codes for Vagus Nerve Stimulator Device
Category
Implantation
CPT
Code
64573
64553
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PA
Required
Description
Incision for implantation of
neurostimulator electrodes;
cranial nerve
Yes
Percutaneous implantation of
neurostimulator electrodes;
cranial nerve
Yes
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Category
Revision/
Removal
CPT
Code
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Description
PA
Required
61885
Incision and subcutaneous
placement of cranial
neurostimulator pulse generator
and or receiver, direct or
indirect coupling with
connection to a single electrode
array
Yes
64585
Revision or removal of
peripheral neurostimulator
electrodes
No
61888
Revision or removal of cranial
neurostimulator pulse generator
or receiver
No
The surgical procedure involves two separate incisions. Therefore, 64573 and 61885 or 64553 and
61885 CPT codes should be used. Reimbursement is based on 100 percent of the highest ASC group
and 50 percent 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, will be 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 using a
DME provider number, and prior authorization must be obtained.
Note: Providers may not separately bill for individual components when
implanting the complete system.
If a provider does not have a DME provider number, the provider can obtain
an application on the Indiana Medicaid Web site
at http://provider.indianamedicaid.com in the provider enrollment section.
Additional information can be found in Chapter 4 of the manual.
Hospital Inpatient
In situations where a complicating factor is present and the patient requires admission to the hospital
for the procedure, the procedure and equipment will be reimbursed according to the appropriate DRG
payment. Prior authorization is not required for the admission or the device, which 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 will bill professional services on the CMS-1500 claim form, using the appropriate
procedure codes in the following tables.
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Table 8.30 – Procedure Codes for Vagus Nerve Stimulator Device
Category
Implanting
Revision/Removal
CPT
Code
PA
Required
Description
64573
Incision for implantation of neurostimulator
electrodes; cranial nerve
Yes
64553
Percutaneous implantation of neurostimulator
electrodes; cranial nerve
Yes
61885
Incision and subcutaneous placement of cranial
neurostimulator pulse generator and/or receiver,
direct or indirect coupling with connection to a
single electrode array
Yes
64585
Revision or removal of peripheral neurostimulator
electrodes
No
61888
Revision or removal of cranial neurostimulator pulse
generator or receiver
No
Note: Surgeons will use the above codes. Anesthesia practitioners will use the
above codes using the appropriate modifier(s).
The following codes in Table 8.31 should be used by the neurologist for interrogation and
programming services performed on patients with implants.
Table 8.31 – Interrogation and Programming Services Codes for Implant Patients
Code
PA
Required
Description
95970
Electronic analysis of implanted neurostimulator pulse generator system (for
example, rate, pulse amplitude and duration, configuration of wave form,
battery status, electrode selectability, output modulation, cycling, impedance
and patient compliance measurements); simple or complex neurostimulator
pulse generator, without programming.
No
95974
Complex cranial nerve neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, with or without nerve interface
testing, first hour.
No
95975
Complex cranial nerve neurostimulator pulse generator/transmitter, with
intraoperative or subsequent programming, with or without nerve interface
testing; each additional 30 minutes after first hour (list separately in addition
to code for primary procedure).
No
Treatment Room Visits
For purposes of the IHCP’s outpatient prospective payment system, treatment rooms include
emergency department, clinic, cast room, labor and delivery room, recovery room, and observation
room.
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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.
Reimbursement is limited to one unit per day, per patient, per provider. Services must be billed on the
UB-04 claim form using the appropriate revenue code. The treatment room revenue codes are listed in
Table 8.32.
Table 8.32 – Treatment Room Services
Revenue Code
Description
45X
Emergency department
51X
Clinic
52X
Freestanding clinic
70X
Cast room
72X
Labor/delivery room
76X
Treatment/observation room
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 below, if they are billed in conjunction with a
treatment room. These 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 services are denied if billed in conjunction with a treatment room service.
Emergency Services
Facility payment for services rendered in the emergency department is the same statewide flat rate for
an emergency diagnosis and for a nonemergency diagnosis.
While authorization is not required for emergencies, the IHCP may not cover nonauthorized services
rendered to a Care Select member without an emergency diagnosis. The IHCP may suspend these
claims for review to determine whether the provider met the prudent layperson standard for an
emergency medical condition. If the review determines that the provider did not meet the prudent
layperson standard, the claim is denied. If the provider did meet the prudent layperson standard, the
IHCP pays only revenue code 45X, as long as the primary medical provider (PMP) NPI is indicated in
field 78 of the UB-04 claim form.
The IHCP reimburses revenue codes 70X, 71X, 72X, and 76X at a flat rate regardless of the diagnosis
code on the claim.
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For a service to be considered an emergency, the provider must enter the applicable emergency
diagnosis code as the principal diagnosis in field 67 on the UB-04.
Note
For members enrolled in an MCO, providers must contact the member’s
MCO for more specific guidelines.
Table 8.33 shows a comprehensive list of all diagnosis codes considered emergency for outpatient
reimbursement.
Table 8.33 – Emergency Diagnosis Codes
0010
0011
0019
0020
0021
0022
0023
0029
0030
0031
0032
00320
00321
00322
00323
00324
00329
0038
0039
0040
0041
0042
0043
0048
0049
0050
0051
0052
0053
0054
0058
00581
0059
0060
0063
0064
00640
00641
0065
0070
0071
0072
0073
0075
0078
0079
0080
00800
00801
00802
00803
00804
00809
0081
0082
0083
00841
00842
00843
00844
00845
00846
00847
00849
0085
0086
00861
00862
00863
00865
00866
00867
00869
0088
0090
0091
0092
0093
0116
01160
01161
01162
01163
01164
01165
01166
01170
01171
01172
01173
01174
01175
01176
01200
01201
01202
01203
01204
01205
01206
0130
01300
01301
01302
01303
01304
01305
01306
0131
01310
01311
01312
01313
01314
01315
01316
0132
01320
01321
01322
01323
01324
01325
01326
0133
01330
01331
01332
01333
01334
01335
01336
01340
01342
01343
01344
01346
01350
01351
01352
01353
01354
01355
01356
01360
01361
01362
01363
01364
01365
01366
01380
01381
01382
01383
01384
01385
01386
01390
01391
01392
01393
01394
01395
01396
01400
01401
01402
01403
01404
01405
01406
01660
01661
0180
01800
01801
01802
01803
01804
01805
01806
01880
01881
01882
01883
01884
01885
01886
0188
0189
01890
01891
01892
01893
01894
01895
01896
0200
0201
0202
0203
0204
0205
0208
0209
0210
0211
0212
0213
0218
0219
0220
0221
0222
0223
0228
0229
0230
0231
0232
0233
0238
0239
024
025
0260
0261
0269
0270
0271
0272
0278
0279
0310
0320
0321
0323
03281
03282
03283
03284
03285
03289
0329
0338
0339
0341
0360
0361
0362
0363
0364
03640
03641
03642
03643
0368
03681
03682
03689
0369
037
038
0380
0381
03819
0382
0383
0384
03840
03841
03842
03843
03844
03849
0388
0389
039
0390
0391
0392
0393
0394
0398
0399
0400
04041
04042
04500
04501
04502
04503
0451
04510
04511
04512
04513
0452
04520
04521
04522
04523
04590
04591
04592
04593
0470
0471
0478
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0479
0490
0491
0498
0499
0520
0521
0522
0527
0528
0530
05320
05321
05322
0543
0545
05472
0550
0551
0560
05600
05601
05609
05821
05829
0620
06200
0621
0622
0623
0624
0625
0628
0629
0630
06300
0631
06310
0632
06331
0638
06380
0639
064
06400
06640
06641
06642
06649
0700
0701
0702
07020
0703
07030
0704
07041
07042
07043
07044
07049
0705
07051
0706
07070
07071
0709
071
0720
0721
0722
0723
07271
0730
0740
0741
0742
07420
07421
07422
07423
0786
07982
08240
08241
08249
09487
09817
09882
09883
09884
09886
1000
10081
101
1040
1100
1101
1102
1103
1104
1105
1106
1120
1121
1122
1123
1124
1125
1141
1142
1143
1144
1145
1150
1151
1200
1201
1202
1203
1230
1231
1232
1233
1234
1235
1236
1280
1281
1303
1304
1305
13101
13102
13103
1340
1341
1342
135
1360
1361
1362
13621
13629
1363
1364
1365
1390
1391
1400
1401
1403
1404
1405
1406
1500
1501
1502
1503
1504
1505
1570
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Revision Date: August 26, 2010
Version: 10.0
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Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-115
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Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-117
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-119
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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8-120
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-121
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-123
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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8-124
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-125
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
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Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Chapter 8
Section 2: UB-04 Billing Instructions
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E9857
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V1253
V1254
V0181
V0182
V0189
V4321
V4322
V4614
V6284
V8701
V8732
V9796
Add-on Services
The IHCP reimburses add-on services at a flat statewide rate when billed with a stand-alone procedure.
Table 8.34 lists add-on services.
Note: Add-on services are not allowed with any surgical revenue codes.
Table 8.34 – Add-on Services
Revenue
Code
Description
250
Pharmacy – general
251
Generic drugs
252
Brand drugs
253
Take-home drugs
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
8-127
Chapter 8
Section 2: UB-04 Billing Instructions
Indiana Health Coverage Programs Provider Manual
Revenue
Code
8-128
Description
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
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
Library Reference Number: PRPR10004
Revision Date: August 26, 2010
Version: 10.0
Indiana Health Coverage Programs Provider Manual
Revenue
Code
Chapter 8
Section 2: UB-04 Billing Instructions
Description
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
Supplies incidental to other diagnostic
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 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 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 8.35 lists the
revenue codes for stand-alone services.
Table 8.35 – 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
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Revenue Code
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Description
410
Respiratory services – general
412
Inhalation services
413
Hyperbaric oxygen therapy
419
Other respiratory
42X
Physical therapy
43X
Occupational therapy
44X
Speech-language pathology
460
Pulmonary function – general
469
Other pulmonary function
47X
Audiology
481
Cardiac catheter laboratory
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
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Description
841
CAPD OP/home – composite
851
CCPD OP/home – composite
890
Donor bank – general
921
Peripheral vascular lab
922
Electromyelogram
923
Pap smear
924
Allergy test
925
Pregnancy test
94X
Therapeutic services
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.
Refer to the CMS-1500 and 837P Transaction Billing Instructions section of this chapter for specific
CMS-1500 billing instructions.
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. For radiology procedures, do not
fragment 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.
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The CMS-1500 and 837P Transaction Billing Instructions section of this chapter provides specific
CMS-1500 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.
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.
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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
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)
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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.
UB-04 Completion Guidelines
The UB-04 claim form has 22 lines; therefore, providers cannot bill an entire month on one page.
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
be more than three pages. Providers must complete the continuation claim as follows:
1. Complete the first 22 lines on page one of the UB-04 claim form.
2. Mark the UB-04 claim form page numbers in the area provided on line 23.
3. 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.
4. Complete the subsequent UB-04 claim forms for the remaining dates of service of the month,
numbering each page in the area provided on line 23.
5. 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 47.
Providers that prefer not to complete a continuation claim can complete separate UB-04 claim forms.
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 – Acute renal failure
•
585.x – Chronic renal failure
•
586 – Renal failure unspecified
Revenue Codes
•
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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, outpatient or home, rendered per day.
Providers should indicate a “1” in field 46, Service Units, on the UB-04 claim form. The IHCP
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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.
Note: Providers can submit claims for revenue codes 820, 821, 830, 831, 840, 841,
849, 850, 851, and 881with 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.
•
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 or J0886 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.
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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, 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.
To enroll as a transportation provider, providers can access
http://provider.indianamedicaid.com/become-a-provider/enroll-as-a-provider.aspx to enroll online or
download a Provider Enrollment Application. Providers can also contact HP Provider Enrollment at 1877-707-5750. Chapter 4 of this manual provides specific enrollment information and criteria.
Specific billing information for transportation services is provided in the Transportation Services
section in this chapter.
Outpatient Mental Health
As required by the House Enrolled Act (HEA) 1396, the Covered Services Rule, 405 IAC 5-20, and 405
IAC 5-21, 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.
Providers must bill all professional services associated with outpatient mental health services on the
CMS-1500 claim form or 837P transaction.
Up to and including date of service December 31, 2006, outpatient mental health services, including
substance abuse and chemical dependency services rendered in freestanding psychiatric hospitals, are
carved out of the RBMC delivery system and paid on an FFS basis. The carved-out definition in
the Carved-Out Services subsection of this chapter provides further information. Bill claims for mental
health services in a freestanding psychiatric hospital on a UB-04 claim form or 837I transaction. These
claims are not the financial responsibility of the MCOs. Outpatient mental health services, including
substance abuse treatment, provided to members in an RBMC delivery system in acute care facilities
are the MCO’s financial responsibility. On and after January 1, 2007, these services will no longer be
carved out, excluding services for PRTF and MRO services.
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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 of 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.
•
The IHCP provider file does not reflect the Medicare provider number. Chapter 4 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
Indianapolis, IN 46207-7271
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.
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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 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. The following billing instructions help to ensure accurate
processing of all UB-04 Medicare crossover claims:
•
Use fields 39-41 to indicate a value code of A1 to reflect the Medicare deductible amount, a value
code of A2 to reflect the Medicare coinsurance amount, and a value code of 06 to reflect the blood
deductible amount. Use a value code of 80 to reflect covered days.
•
Use fields 50a–54a to reflect Medicare information only. Use form field 54a to indicate the
Medicare paid amount. Do not include the Medicare allowed amount or contract adjustment
amount in field 54. Do not include Medicare Replacement/HMO policy information in these
fields.
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 Medicare supplement carrier information. Use form field 54b to
denote any Medicare supplemental carrier or third-party liability payment information, which
includes Medicare Replacement/HMO policy information.
•
Use field 55c to reflect the amount calculated in the following equation:
- Total claim amount - Medicare 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.
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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.
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 addenda 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 Web site at http://wpc-edi.com.
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 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 the IHCP Web site
at http://provider.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.
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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 long-term care (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, other.
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Section 3: Telemedicine
Overview
Effective April 1, 2007, telemedicine services are covered by the Indiana Health Coverage Programs
(IHCP). This section discusses applicable coverage parameters and billing guidelines. Telemedicine
services are covered by Medicaid within the parameters specified in rule 405 IAC 5-38, which is
presented in the Indiana Administrative Code (IAC) section.
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.
•
Interactive Television (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 health care 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 will not
be 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; or
(2) Telephone or any other means of communication for consultation from one
provider to another
Provider/Service Requirements
The following service or provider types are not permitted to be reimbursed for telemedicine per 405
IAC 5-38:
•
Ambulatory surgical centers
•
Outpatient surgical services
•
Home health agencies or services
•
Radiological services
•
Laboratory services
•
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
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•
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. 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 to 99245 and 99251 to 99255
•
Office or other outpatient visit – 99201 to 99205 and 99211 to 99215
•
Individual psychotherapy – 90804 to 90809
•
Psychiatric diagnostic interview – 90801
•
Pharmacologic management – 90862
•
End-stage renal disease (ESRD) services – 90951 to 90970
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.
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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 for services rendered via telemedicine apply, 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 will be 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 to 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 only reimbursed for
hands-on services and are therefore not permitted to bill for telemedicine services.
Managed Care Considerations
Refer questions to the appropriate managed care organization (MCO) for risk-based managed care
considerations.
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FQHCs and RHCs may submit claims to an MCO 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.
Indiana Administrative Code (IAC)
Rule 38. Telemedicine Services
405 IAC 5-38-1 General provisions
Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 1. (a) 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 Medicaid within the parameters
specified in this rule.
(b) Telemedicine is not the use of a:
(1) telephone transmitter for transtelephonic monitoring; or
(2) telephone or any other means of communication, consultation from one (1) doctor to another.
(Office of the Secretary of Family and Social Services; 405 IAC 5-38-1; filed Feb 28, 2007, 2:42 p.m.:
20070328-IR-405060029FRA readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA)
405 IAC 5-38-2 Definitions
Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 2. The following definitions apply throughout this rule:
(1) “Hub site” means the location of the physician or provider rendering consultation services.
(2) “Interactive television” or “IATV” means the videoconferencing equipment at the hub and spoke
site that allows real time, face-to-face consultation.
(3) “Spoke site” means the location where the patient is physically located when services are provided.
(4) “Store and forward” means the electronic transmission of medical information for subsequent
review by a health care provider at the hub site. Restrictions placed on store and forward
reimbursement in this rule shall not disallow the permissible use of store and forward technology to
facilitate reimbursable services.
(Office of the Secretary of Family and Social Services; 405 IAC 5-38-2; filed Feb 28, 2007, 2:42 p.m.:
20070328-IR-405060029FRA; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR405070311RFA)
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405 IAC 5-38-3 Description of service
Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 3. (a) 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.
(4) A computer or television monitor to allow the patient to have:
(A) real-time;
(B) interactive; and
(C) face-to-face communication with the hub specialist/consultant via IATV technology.
(b) Services may be rendered in an inpatient, outpatient, or office setting. (Office of the Secretary of
Family and Social Services; 405 IAC 5-38-3; filed Feb 28, 2007, 2:42 p.m.: 20070328-IR405060029FRA; readopted filed Sep 19, 2007, 12:16 p.m.:
20071010-IR-405070311RFA)
405 IAC 5-38-4 Limitations
Authority: IC 12-8-6-5; IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 4. Telemedicine shall be limited by the following conditions:
(1) The patient must be:
(A) physically present at the spoke site; and
(B) participate in the visit.
(2) The physician or practitioner who will be examining the patient from the hub site must determine if
it is medically necessary for a medical professional to be at the spoke site. Separate reimbursement for
a provider at the spoke site is payable only if that provider’s presence is medically necessary. 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. Such documentation is subject to postpayment
review. If a health care provider’s presence at the spoke site is medically necessary, billing of the
appropriate evaluation and management code is permitted.
(3) Reimbursement for telemedicine services is available only when the hub and spoke sites are greater
than twenty (20) miles apart. Adequate documentation must be maintained as service is subject to
postpayment review.
(4) Store and forward technology is not reimbursable by Medicaid. The use of store and forward
technology is permissible as defined under section 2(4) of this rule.
(5) The following service or provider types may not be reimbursed for telemedicine:
(A) Ambulatory surgical centers.
(B) Outpatient surgical services.
(C) Home health agencies or services.
(D) Radiological services.
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(E) Laboratory services.
(F) Long term care facilities, including nursing facilities, intermediate care facilities, or community
residential facilities for the developmentally disabled.
(G) Anesthesia services or nurse anesthetist services.
(H) Audiological services.
(I) Chiropractic services.
(J) Care coordination services.
(K) DME, medical supplies, hearing aids, or oxygen.
(L) Optical or optometric services.
(M) Podiatric services.
(N) Services billed by school corporations.
(O) Physical or speech therapy services.
(P) Transportation services.
(Q) Services provided under a Medicaid waiver.
(Office of the Secretary of Family and Social Services; 405 IAC 5-38-4; filed Feb 28, 2007, 2:42 p.m.:
20070328-IR-405060029FRA; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR405070311RFA)
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Chapter 8
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 throughout this document. Providers should refer
to the Indiana Health Coverage Programs (IHCP) Companion Guides for specific information about
electronic billing. View the HIPAA Companion Guides from the IHCP Web site
at http://provider.indianamedicaid.com/general-provider-services/electronic-data-interchange-(edi)solutions/ihcp-companion-guides.aspx.
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 anesthetist (CRNA)
•
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
•
Dentists – oral surgery
•
Diabetes self-management
•
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
•
Laboratories – lab services, professional component
•
Mental health providers – Medicaid Rehabilitation Option (MRO) services, outpatient mental
health services
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•
Mid-level practitioners – anesthesiology assistant services, physician assistant services,
independent practice school psychologists, and advanced practice nurses under
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-9th Edition-Clinical Modification (ICD-9CM) 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 is numeric diagnosis codes, Volume 2 is an alphabetic index, and
Volume 3 is a tabular list of codes and an alphabetic index for procedures.
•
Healthcare Common Procedure Coding System (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 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
Indianapolis, IN 46207-7269
HP Medical Crossover Claims
P.O. Box 7267
Indianapolis, IN 46207-7267
Note: For risk-based managed care (RBMC) members, providers should send
claims to the appropriate managed care organization (MCO) unless
otherwise indicated.
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.
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 qualifier.
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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
Indianapolis, IN 46206-1937
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 8.36 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.
Figure 8.2 shows a sample copy of the CMS-1500, Version 08-05 claim form.
Table 8.36 − CMS-1500, Version 08-05 Claim Form Locator Descriptions
Form Locator
Narrative Description/Explanation
1
INSURANCE CARRIER SELECTION – Enter X for Traditional Medicaid. Required.
1a
INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1) – Enter the member IHCP identification
(RID) number. 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.
3
PATIENT’S BIRTH DATE – Enter the member’s birth date in MMDDYY format. Optional.
SEX – Enter an 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
PATIENT STATUS – Enter X in the appropriate box. Optional.
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.
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Form Locator
Narrative Description/Explanation
9b
OTHER INSURED’S DATE OF BIRTH – If other insurance is available, and the policyholder is
other than the member shown in fields 1a and 2, enter the requested policyholder birth date in
MMDDYY format. Optional.
SEX – Enter X in the appropriate box. Optional.
9c
EMPLOYER’S NAME OR SCHOOL NAME – If other insurance is available, and the policyholder
is other than the member shown in fields 1a and 2, enter the requested policyholder information.
Required, if applicable.
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
RESERVED FOR LOCAL USE – 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
EMPLOYER’S NAME OR SCHOOL NAME – Enter the requested member information.
Required, if 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 9a–9d. Required, if applicable.
12
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE – Not applicable.
13
INSURED’S OR AUTHORIZED PERSON’S SIGNATURE – Not applicable.
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 for payment for pregnancy-related services.
15
IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE – Enter date in
MMDDYY format. Optional.
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.
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Form Locator
Narrative Description/Explanation
NAME OF REFERRING PROVIDER OR OTHER SOURCE – Enter the name of the referring
physician. Required, if applicable. For waiver-related services, enter the provider name of the case
manager. Required for Care Select PMP.
17
Note: The term referring provider includes those physicians primarily responsible
for the authorization of treatment for lock-in or restricted card 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 is the qualifier that applies 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 is the qualifier that applies 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.
17b
NPI – Enter the 10-digit numeric NPI of the referring provider, ordering provider, or other source.
Required when applicable and for Care Select PMPs.
18
HOSPITALIZATION DATES RELATED TO CURRENT SERVICES – Enter the requested
FROM and TO dates in MMDDYY format. Required, if applicable.
19
RESERVED FOR LOCAL USE – Enter the Care Select primary medical provider (PMP) two-digit
alphanumeric certification code. Required for Care Select members when the physician rendering
care is not the PMP or a physician in the PMP’s group or a clinic.
Note: Report the PMP qualifier and ID number in 17a.
20
OUTSIDE LAB? – Not applicable.
CHARGES – Not applicable.
21.1 to 21.4.
DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – Complete fields 21.1, 21.2, 21.3, and/or
21.4 to field 24E by detail line. Enter the ICD-9-CM diagnosis codes in priority order. A total of four
codes can be entered. At least one diagnosis code is required for all claims except those for waiver,
transportation, and medical equipment and supply services. Required.
22
MEDICAID RESUBMISSION CODE, ORIGINAL REF. NO. – Applicable for Medicare Part B
crossover claims only. For crossover claims, the combined total of the Medicare coinsurance,
deductible, and psych 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.
23
PRIOR AUTHORIZATION NUMBER – The prior authorization (PA) number is not required, but
entry is recommended to assist in tracking services that require PA. Optional.
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
terminated.
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Form Locator
Narrative Description/Explanation
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 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. Required.
For a complete listing of POS codes, go to
http://www.cms.hhs.gov/PlaceofServiceCodes/03_POSDatabase.asp.
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 CODE – Enter number 1–4 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.
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.
Required, if applicable.
24I
Top Half –
Shaded Area
RENDERING ID QUALIFIER – Enter the qualifier indicating what the number reported in the
shaded area of 24J represents – 1D for IHCP LPI rendering provider number or ZZ for rendering
provider taxonomy code.
1D is the qualifier that applies 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 is the qualifier that applies to the provider taxonomy code. The taxonomy code includes 10
alphanumeric characters. The taxonomy code may be required for a one-to-one match.
Taxonomy – Enter the taxonomy code of the rendering provider. Taxonomy may be needed to
establish a one-to-one NPI/LPI match if the provider has multiple locations.
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Form Locator
Narrative Description/Explanation
24J
Top Half –
Shaded Area
RENDERING PROVIDER ID – Enter either the LPI if entering the 1D qualifier in 24I or the
taxonomy if entering the ZZ qualifier in 24I for the Rendering Provider ID. 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.
29
AMOUNT PAID – Enter the payment received from any other source, excluding the 8A deductible
and the Medicare 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.
30
BALANCE DUE – TOTAL CHARGE (field 28) – AMOUNT PAID (field 29) = BALANCE DUE
(field 30). This is a 10-digit field, such as 99999999.99. Required.
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
Signature on File certification form will have their claims processed when a signature is omitted from
this field. The form is available on the IHCP Web site, Provider Services page
at http://provider.indianamedicaid.com/become-a-provider/enroll-as-a-provider.aspx. Required if
applicable.
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.
32a
SERVICE FACILITY LOCATION NPI – Not applicable.
32b
SERVICE FACILITY LOCATION QUALIFIER AND ID NUMBER – Not applicable.
33
BILLING PROVIDER INFO & PH # – Enter the billing provider office location name, address, and
the ZIP Code+4. 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.
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Form Locator
33b
Narrative Description/Explanation
BILLING PROVIDER QUALIFIER AND ID NUMBER – Healthcare providers may enter a
billing provider qualifier of ZZ and taxonomy code. Taxonomy may be needed to establish a one-toone NPI/LPI match if the provider has multiple locations.
If the billing provider is an atypical provider, enter the qualifier 1D and the LPI. Required.
Note: Qualifiers are ZZ = Taxonomy and 1D = LPI
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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 institutional 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 Web site at http://wpc-edi.com.
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 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 companion guides are located on the IHCP Web site at
http://provider.indianamedicaid.com/general-provider-services/electronic-data-interchange-(edi)solutions/ihcp-companion-guides.aspx in the EDI Solutions section.
Some data elements that providers submit 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
IndianaAIM accepts procedure modifiers for providers billing on the CMS-1500 claim form or 837P.
Modifiers allow greater flexibility in billing the type or degree of services rendered, and the IHCP
encourages providers to incorporate modifiers into their IHCP billing practices. The IHCP recognizes
CPT and HCPCS 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.
The modifiers are categorized according to type. Table 8.37 lists the definition for each modifier type.
Table 8.38 lists the CMS-1500 modifiers.
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Table 8.37 – 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
modifiers must be linked to the procedure code in IndianaAIM.
Physical Status
Used to modify the anesthesia units submitted on the claim form. These
modifiers must be linked to the procedure code in IndianaAIM.
Medical
Direction
Used in anesthesia processing. Procedure code linkage is not required for
these modifiers.
Table 8.38 – CMS-1500 Modifiers
Modifier
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Type
Description
21
Informational
Prolonged evaluation and management (E/M) services
22
Review
Unusual procedural services
23
Anesthesia
Unusual anesthesia, general anesthesia not usually required
24
Informational
Unrelated E/M service by the same physician during a
postoperative period
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, not covered
47
Informational
Anesthesia by a surgeon
50
Processing
Bilateral procedure
51
Informational
Multiple procedures
52
Informational
Reduced services
53
Informational
Discontinued procedure
54
Processing
Surgical care only
55
Processing
Postoperative management only
56
Processing
Preoperative management only
57
Informational
Decision for surgery
58
Informational
Staged or related procedure or service by the same physician
during the postoperative period
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Modifier
Type
Description
59
Informational
Distinct procedural service
62
Processing
Two surgeons
63
Informational
Procedure performed on infants less than 4 kg
66
Processing
Surgical team
73
Informational
Discontinued outpatient hospital/ambulatory surgical center
(ASC) procedure prior to the administration of anesthesia
74
Informational
Discontinued outpatient hospital/ASC procedure after the
administration of anesthesia
76
Informational
Repeat procedure by same physician
77
Informational
Repeat procedure by another physician
78
Informational
Return to the operating room for a related procedure during
the postoperative period
79
Informational
Unrelated procedure or service by the same physician during
the postoperative period
80
Processing
Assistant surgeon
81
Processing
Minimum assistant surgeon
82
Processing
Assistant surgeon (when qualified resident surgeon not
available)
8P
Informational
Performance modifier in OS
90
Informational
Reference (outside) laboratory
91
Informational
Repeat clinical diagnostic laboratory test
99
Review
Multiple modifiers
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 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
AJ
Processing
Clinical social worker
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Modifier
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Type
Description
AK
Processing
Nonparticipating physician
AM
Informational
Physician, team member service
AP
Informational
Ophthalmological examination
AQ
Informational
Physician service in an unlisted health professional shortage
area (HPSA)
AR
Informational
Physician scarcity area
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
BA
Informational
Item furnished in conjunction with parenteral 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
The member has been informed of the purchase and rental
options and has elected to rent the item
BU
Informational
The member has been informed of the purchase and rental
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 end-stage renal dialysis (ESRD) beneficiary’s
dialysis
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 for
ESRD or MCP
CE
Informational
Medical necessity AMCC test separate reimbursement
CF
Informational
AMCC test not composite rate
CR
Informational
Catastrophe/disaster related
DE
Informational
From diagnosis (DX) site to facility
DH
Informational
Origin – diagnostic or therapeutic
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Modifier
Type
Description
DN
Informational
Origin – diagnostic or therapeutic
DR
Informational
Origin – diagnostic or therapeutic
E1
Informational
Upper left, eyelid
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
Hematocrit (Hct) greater than 39 percent or hemoglobin
(Hgb) greater than 13 g = 3 cycle
From facility to DX site
EE
Informational
From facility to another
EG
Informational
From residential facility to hospital based dialysis facility
EH
Informational
From facility to hospital
EI
Informational
From residence to facility to transfer
EJ
Informational
From residential facility to nonhospital-based dialysis
facility
Subsequent claim for defined course of therapy, such as
epoetin (EPO), sodium hyaloronate, infliximab
EM
Informational
Emergency reserve supply – for end-stage renal disease
(ESRD) benefit only
EN
Informational
From facility to skilled nursing facility (SNF)
EP
Informational
From residence facility to doctor’s office
Service provided as part of Medicaid Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) program
ER
Informational
From facility to residence
ES
Informational
From residence facility to accident
ET
Informational
Emergency services
EX
Informational
From facility to hospital
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
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
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Modifier
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Type
Description
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
FC
Informational
Part credit, replaced device
FP
Informational
Service provided as part of an IHCP 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
Most recent URR reading of 65 to 69.9
G4
Informational
Most recent URR reading of 70 to 74.9
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 on file
GB
Informational
Claim being resubmitted because it is no longer covered
under a global payment demonstration
GC
Informational
Service has been performed in part by a resident under the
direction of a teaching physician
GD
Informational
Hospital-based dialysis facility to a diagnostic or therapeutic
site
GE
Informational
Service has been performed by a resident without the
presence of a teaching physician, under the primary care
exception
GG
Informational
Performance and payment of screening mammogram and
diagnostic mammogram on the same patient, same day
GH
Informational
Diagnostic mammogram converted from screening
mammogram on same day
GJ
Informational
OPT OUT physician or practitioner emergency or urgent
service
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 member notice (ABN)
GM
Informational
Multiple patients on one ambulance trip
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Modifier
Type
Description
GN
Informational
Service delivered under an outpatient speech language
pathology plan of care
GO
Informational
Service delivered under an outpatient occupational therapy
plan of care
GP
Informational
Service delivered under an outpatient physical therapy plan
of care
GQ
Informational
Via asynchronous telecommunications system
GR
Informational
Hospital-based dialysis facility to residence
GS
Informational
Dosage of EPO or darbepoietin alfa has been reduced 25
percent of preceding month’s dosage
GT
Informational
Via interactive audio and video telecommunication systems
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
GY
Informational
Item or service statutorily excluded or does not meet the
definition of any Medicare 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
HE
Processing
Mental health program
HF
Informational
Substance abuse program
HG
Informational
Opioid addiction treatment program
HH
Informational
Integrated mental health/substance abuse program
HI
Informational
Integrated mental health and mental
retardation/developmental disabilities program
HJ
Informational
Employee assistance program
HK
Informational
Specialized mental health programs for high-risk
populations
HL
Informational
Intern
HM
Processing
Less than bachelor degree level
HN
Informational
Bachelor’s degree level
HO
Informational
Master’s degree level
HP
Informational
Doctoral level
HQ
Informational
Group setting
HR
Informational
Family/couple with client present
HS
Informational
Family/couple without client present
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Modifier
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Type
Description
HT
Informational
Multi-disciplinary team
HU
Informational
Funded by child welfare agency
HV
Informational
Funded state addictions agency
HW
Informational
Funded by state mental health agency
HX
Informational
Funded by county/local agency
HY
Informational
Funded by juvenile justice agency
HZ
Informational
Funded by criminal justice agency
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
JA
Informational
Administered intravenous
JB
Informational
Administered subcutaneous
JD
Informational
Nonhospital-based dialysis to DX
JE
Informational
Nonhospital-based dialysis to residence
JG
Informational
From nonhospital-based dialysis to hospital-based dialysis
facility
JH
Informational
Nonhospital-based dialysis to hospital
JI
Informational
From nonhospital-based dialysis facility to site of transfer
between types of ambulance
JJ
Informational
From nonhospital-based dialysis to nonhospital-based
dialysis
JN
Informational
Nonhospital dialysis to SNF
JP
Informational
Nonhospital dialysis to doctor of medicine (MD) office
JR
Informational
Nonhospital dialysis to residence
JS
Informational
From nonhospital-based dialysis to accident
JW
Informational
Drug amount discarded/not administered to any patient
JX
Informational
From nonhospital-based dialysis to inter stop
K0
Informational
Lower extremity prosthesis functional level 0
K1
Informational
Lower extremity prosthesis functional level 1
K2
Informational
Lower extremity prosthesis functional level 2
K3
Informational
Lower extremity prosthesis functional level 3
K4
Informational
Lower extremity prosthesis functional level 4
KA
Informational
Add-on option/accessory for wheelchair
KB
Informational
Beneficiary Requested Upgrade for ABN, more than four
modifiers identified on claim
KB
Informational
Beneficiary Requested Upgrade for ABN, more than four
modifiers identified on claim
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Chapter 8
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Modifier
Type
Description
KC
Informational
Replacement of special power wheelchair interface
KD
Informational
Drug or biological infused through DME
KF
Informational
Item designated by the Food and Drug Administration
(FDA) as Class III device
KH
Informational
Durable medical equipment, prosthetics, orthotics, and other
supplies (DMEPOS) item, initial claim, purchase or first
month rental
KI
Informational
DMEPOS item, second or third month rental
KJ
Informational
DMEPOS item, parenteral enteral nutrition (PEN), pump or
capped rental, months four to 15
KL
Informational
DMEPOS item delivered via mail
KM
Pricing
Replacement of facial prosthesis including new
impression/moulage
KN
Pricing
Replacement of facial prosthesis using previous master
model
KO
Informational
Single drug unit dose formulation
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 bidding area
KV
Informational
DMEPOS item, professional service
KX
Informational
Specific required documentation on file
KZ
Informational
New coverage not implemented by managed care
LC
Informational
Left circumflex coronary artery
LD
Informational
Left anterior descending coronary artery
LL
Informational
Lease rental-use when DME equipment rental is applied
against the purchase price
LR
Informational
Laboratory round trip
LS
Informational
FDA monitored intraocular lens implant
LT
Informational
Procedures performed on the left side of the body
M2
Informational
Medicare secondary payer
MP
Informational
Multiple patients seen
MS
Informational
Six-month DME maintenance and service fee for reasonable
and necessary parts and labor not covered under any
manufacturer or supplier warranty
ND
NE
NG
Informational
Informational
Informational
From SNF to DX site
From SNF to a resident
SNF to hospital-based dialysis facility
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Modifier
NH
NI
NJ
NN
NP
NR
Type
Informational
Informational
Informational
Informational
Informational
Informational
Description
NS
NU
NX
P1
P2
P3
P4
Informational
Pricing
Informational
Physical status
Physical status
Physical status
Physical status
P5
Physical status
P6
Physical status
Physical status
PD
Informational
From MD to diagnostic site
PE
Informational
From a physician’s office to a residential, domiciliary, or
custodial facility
From MD office to residence
PG
Informational
From MD office to hospital-based dialysis
PH
Informational
From MD office to hospital
PI
Informational
From MD to transfer between types of ambulance
PJ
Informational
From MD to nonhospital-based dialysis
PL
Informational
Progressive additional lenses
PN
Informational
From MD office to SNF
PP
Informational
From one MD office to another
PR
Informational
From MD office to residence
PS
Informational
From MD office to scene of accident
PX
Informational
From MD office to hospital
Q0
Informational
Invest clinical research
Q1
Informational
Routine clinical service provided in a clinical research study
that is an approved clinical research study
Q2
Informational
CMS Office of Research, Development, and Information
(ORDI) demonstration project procedure or service
Q3
Informational
Live kidney donor: surgery and related services
Q4
Informational
Service for ordering/referring physician qualifies as a
service exemption
From SNF to hospital
From SNF to transfer between types of ambulance
SNF to nonhospital-based dialysis
From SNF to SNF
From SNF to MD office
New when rented – DME which was new at the time of
rental is subsequently purchased
From SNF to residence
From SNF to scene of accident
New durable medical equipment purchase
From SNF to hospital with stop at MD office
A normal healthy patient
A patient with mild systemic disease
A patient with severe systemic disease
A patient with severe systemic disease that is a constant
threat to life
A moribund patient who is not expected to survive without
the operation
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Modifier
Type
Description
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 exception
QB
Informational
Physician providing services in a rural health professional
shortage area (HPSA)
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 one liter per minute
(LPM)
QF
Informational
Prescribed amount of oxygen exceeds four LPM
QG
Informational
Prescribed amount of oxygen greater than four LPM
QH
Informational
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
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
QQ
Informational
Claim submitted with a statement of intent
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
QU
Informational
Physician providing services in urban HPSA
QV
Informational
Item or service provided as routine care in a Medicare
qualifying clinical trial
QW
Informational
Clinical Laboratory Improvement Amendments (CLIA)
waived test
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Modifier
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Type
Description
QX
Processing
Certified registered nurse anesthetist (CRNA) service, with
medical direction by a physician, for services on or after
January 1, 1992
QY
Informational
Anesthesiologist medically directs one CRNA
QZ
Anesthesia
CRNA service, without medical direction by a physician, for
services on and after December 1, 1992
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
RE
Informational
From residence to custodial facility
RH
Informational
From residence to hospital
RG
Informational
Residence to hospital-based dialysis
RI
Informational
From residence to site of transfer between types of
ambulance
RJ
Informational
Residence to nonhospital dialysis facility
RN
Informational
From residence to SNF
RP
Informational
Replacement and repair for dates of service on or before
December 31, 2008
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 MD
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
SE
Informational
State-funded program or services
SF
Informational
Second opinion ordered by a professional review
organization
SG
Informational
Ambulatory surgical center (ASC) facility service
SH
Informational
Second concurrently administered infusion therapy
SI
Informational
From accident to site of transfer between types of ambulance
SJ
Informational
Third or more concurrently administered infusion therapy
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
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Modifier
Type
Description
SP
Informational
From accident to MD 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)
TE
Informational
Licensed practical nurse (LPN)/licensed vocational nurse
(LVN)
TG
TH
TJ
TK
TL
TM
TN
TP
TQ
Pricing
Informational
Informational
Informational
Informational
Informational
Informational
Informational
Informational
Complex/high tech level of care
Obstetrical treatment/services – prenatal or postpartum
Program group, child and/or adolescent
Extra patient or passenger, nonambulance
Early intervention/individualized family service plan
Individualized education program
Rural/outside providers’ customary service area
Medical transport, unloaded vehicle
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
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Modifier
Type
Description
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/weekends
TW
Informational
Backup equipment
U1
Informational
Medicaid Level of Care 1, as defined by each state
U2
Informational
Medicaid Level of Care 2, as defined by each state
U3
Informational
Medicaid Level of Care 3, as defined by each state
U4
Informational
Medicaid Level of Care 4, as defined by each state
U5
Informational
Medicaid Level of Care 5, as defined by each state
U6
Informational
Medicaid Level of Care 6, as defined by each state
U7
Informational
Medicaid Level of Care 7, as defined by each state
U8
Informational
Medicaid Level of Care 8, as defined by each state
Note: The U8 modifier is used for the
replacement and repair of glasses for
dates of service on or after January 1,
2009.
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U9
Informational
Medicaid Level of Care 9, as defined by each state
UA
Informational
Medicaid Level of Care 10, as defined by each state
UB
Informational
Medicaid Level of Care 11, as defined by each state
UC
Informational
Medicaid Level of Care 12, as defined by each state
UD
Pricing
Disease management education
UE
Pricing
Used durable medical equipment
UF
Informational
Services provided in the morning
UG
Informational
Services provided in the afternoon
UH
Informational
Services provided in the evening
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
VP
Informational
Aphakic patient
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Use single-character modifiers in combination for ambulance 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 8.39 lists the modifiers used for ambulance transports.
Table 8.39 – Modifiers – Ambulance Transport
Modifier
Description
D
Diagnostic or therapeutic site, other than P or H
E
Residential, domiciliary, or custodial facility (nursing home, not SNF)
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 positron emission
tomography (PET) scan modifiers (N, E, P, and S).
Place of Service Codes
Table 8.40 lists the Place of Service codes.
Table 8.40 – Place of Service Codes
Place of Service Code(s)
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
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Place of Service Code(s)
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Place of Service Name
14
Group Home
15
Mobile Unit
16-19
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
50
Federally Qualified Health Center
51
Inpatient Psychiatric Facility
52
Psychiatric Facility – Partial Hospitalization
53
Community Mental Health Center
54
Intermediate Care Facility/Mentally Retarded
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
Public Health Clinic
72
Rural Health Clinic
73-80
Unassigned
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Place of Service Code(s)
Place of Service Name
81
Independent Laboratory
82-98
Unassigned
99
Other Place of Service
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 more specific POS for each service
rendered.
For 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, 2009, 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.
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 MCO 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.
A U modifier indicates that 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.
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.
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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 either
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.
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.
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
•
Field block
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•
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.
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.
•
Physical status – Providers should utilize the appropriate status modifier to denote any conditions
described in the modifier descriptions listed in Table 8.41.
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Table 8.41 – Status Modifiers – Anesthesia
Modifier
P1
P2
P3
P4
P5
P6
Description
A normal healthy patient for an elective operation
A patient with mild systemic disease
A patient with severe systemic disease
A patient with a severe systemic disease that is a constant threat to
life
A moribund patient who is not expected to survive without the
operation.
A declared brain-dead patient whose organs are being removed for
donor purposes.
Elective
0 units
0 units
1 unit
2 units
3 units
0 units
Utilization
Anesthesiologists performing the following procedures must bill with the AA modifier and must bill
these procedures in units:
•
36555 – Insertion of nontunneled centrally inserted central venous catheter; under 5 years of age
•
36620 – Arterial catheterization or cannulation for sampling, monitoring, or transfusion (separate
procedure); percutaneous
•
36625 – Arterial catheterization or cannulation for sampling, monitoring, or transfusion (separate
procedure); cutdown
•
93503 – Insertion and placement of flow directed catheter (for example, Swan-Ganz) for
monitoring purposes
•
99116 – Anesthesia complicated by utilization of total body hypothermia (list separately in
addition to code for primary anesthesia procedure)
•
99183 – Physician attendance and supervision of hyperbaric oxygen therapy, per session
•
99185 – Hypothermia; regional
Do not bill procedure code 99140 – Anesthesia complicated by emergency conditions (specify) with the
AA modifier.
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.
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Medical Direction and Certified Registered Nurse Anesthesiologist Billing
Requirements
Anesthesia services that are medically directed by an anesthesiologist are priced at 30 percent of the
allowed rate. Anesthesia services that are rendered by a certified registered nurse anesthesiologist
(CRNA) are priced at 60 percent of the allowed amount.
CRNAs enrolled in the IHCP provider program must use anesthesia CPT codes (00100-01999).
CRNAs that bill with their individual rendering NPI must not use modifiers listed in Table 8.42.
Anesthesia procedure code modifiers listed in Table 8.42 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 8.42 – Procedure Code Modifiers – Anesthesia (CRNAs)
Modifier
Description
QS
Monitored anesthesia care services
QX
CRNA with medical direction by a physician
QZ
CRNA without medical direction by a physician
QK
Medical direction of two, three, or four concurrent anesthesia
procedures involving qualified individuals
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. This method of billing is the same for any other surgery and for obstetrical
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anesthesia, 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 8.43 is a list of applicable vaginal and cesarean delivery CPT codes.
Table 8.43 – 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 or 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
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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 mental retardation 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
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
Coverage and Billing Procedures
Care coordination is the process that integrates services according to an individual’s needs. This
process includes comprehensive assessment, development of an individualized service plan, linking
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individuals with services, monitoring services received, and measuring individual progress and
evaluation. It also includes development of collaborative arrangements among service providers that
are simultaneously serving the individual’s needs, resulting in an integrated system of services. The
IHCP, in collaboration with the Indiana State Department of Health (ISDH), promote the Pregnancy
Care Coordination Programs. The IFSSA in collaboration with the ISDH promotes the HIV/AIDS Care
Coordination Programs.
Notes: Providers interested in becoming prenatal care coordinators should contact
HP for further information about certification.
Providers interested in becoming HIV/AIDS care coordinators should
contact the ISDH for more information about certification.
Care coordination services may obtain the Care Coordination Outcome Report form from the IHCP
Web site at http://provider.indianamedicaid.com/general-provider-services/forms.aspx or by calling HP
Customer Assistance at (317) 655-3240 in the local area or toll free at 1-800-577-1278.
Care coordination services are available for enrolled IHCP members who have Human
Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS), are pregnant, have
a mental illness diagnosis, or have an emotional disturbance. IHCP members must be enrolled in the
IHCP to be eligible for the services to be paid. Providers can verify eligibility for a member through
the Eligibility Verification System (EVS). Failure to do so may result in denial of payment. The
member’s name must appear on the claim form exactly as it appears in the eligibility file. The IHCP
reminds providers to check eligibility every time they render a service.
Care coordination services are not covered for Package C members.
The IHCP allows reimbursement on a fee-for-service (FFS) basis. Eligible members may receive care
coordination services only from an appropriate and enrolled care coordination provider. There is a oneyear claim filing limit from the date of service.
Third-Party Liability (Private Insurance) and Care Coordination Claims
For HIV/AIDS care coordination services, providers must use diagnosis code 042 – HIV/AIDS and
procedure code G9012 – Other Specified Case Management. Providers must bill a principal diagnosis
code of V68.9 – Unspecified administrative purpose for care coordination claims, and providers should
use it only for HIV/AIDS.
Federal regulations require the IHCP to be the payer of last resort; however, it is rare for insurance to
cover care coordination services. Therefore, the IHCP does not require that any provider file for
reimbursement from third-party insurers. The claims can be submitted directly to the IHCP.
Prenatal Care Coordination Services
Note: Payment for care coordination services must not duplicate payments made to
public agencies or private entities under other program authorities for the
same purpose.
Care coordination services provide case management services for pregnant women. Care coordination
is an active, ongoing process of assisting the member to identify, access, and use community resources
and coordinating the services to meet individual needs. This includes locating service sources, making
appointments for services, arranging transportation to services, and following up to verify
appointments or reschedule appointments for women whose pregnancies are at risk for low birth
weight or poor pregnancy outcome. Pregnant women identified as high-risk patients due to medical or
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psychosocial conditions may also receive pregnancy care coordination services through the IHCP. For
more information, refer to 405 IAC 5-11.
Enrollment of Prenatal Care Coordinators
Reimbursement is available for care coordination services provided to eligible pregnant women by any
of the following professionals:
•
Physician licensed by the State under IC 25-22.5-1
•
Registered nurse licensed by the State
•
Social worker with a baccalaureate or master’s degree from a school accredited by the Council on
Social Work Education or a social worker certified by the State
•
Dietitian registered with the Commission on Dietetic Registration of the American Dietetic
Association
•
Community health worker under the supervision of one of the professionals listed
Additional information about enrollment is included in Chapter 4 of this manual.
Care Coordination Services Risk Assessment Form
Providers must keep record of a risk assessment in the member’s file to substantiate services beyond
the initial assessment. If the provider deems a pregnancy not at risk during the initial assessment, but
later factors put the outcome at risk, services can be resumed. Providers must maintain documentation
of the hig risk pregnancy in the member’s file. All the forms used to document prenatal care
coordination services are available on the IHCP Web site at http://provider.indianamedicaid.com.
Providers use pregnancy care coordination services to prevent preterm or poor pregnancy outcomes by
facilitating the linking of the pregnant women to all necessary services, including medical, health
promotion, and social services. Physicians, registered nurses, social workers, and registered dietitians
with certified training in pregnancy case management can provide these services on a trimester basis,
including the following services:
•
Follow-up activities to ensure services were received
•
Home visits, including the initial and postpartum home visit
•
Referral to social service agencies
Prenatal Care Coordination and Managed Care
If the initial assessment indicates a high-risk condition that could potentially result in a poor pregnancy
outcome, members can receive prenatal care coordination services as an intervention. Once the
pregnancy has been identified as being high-risk, the prenatal care coordinator must conduct additional
prenatal reassessments to gather vital information about the pregnancy. The Outcome Report, which is
to be completed during the final postpartum visit, is used to assess mother and baby’s health resulting
from individualized services delivered throughout the high-risk pregnancy.
Care Select pregnancy care coordination services require PMP authorization. In field 19 of the CMS1500 claim form or 837P transaction, providers must indicate the two-character certification code,
provided by the PMP. For RBMC members assigned to an MCO, providers must contact the MCO for
further information. MCO contact information is included in Chapter 1.
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Statewide Mandatory Risk-Based Managed Care Impact on Prenatal Care
Coordination
RBMC for all Hoosier Healthwise members expanded across Indiana in 2005. Prenatal Care
Coordination (PNCC) Program providers should monitor IHCP providers throughout Indiana. The
PNCC Program providers must contract with Hoosier Healthwise MCOs in their county to continue to
receive reimbursement for services. The MCO maintains responsibility for the delivery and payment of
PNCC services for its members. The IHCP encourages prenatal care coordinators to contract with all
MCOs in their county. There are three state MCOs. The Indiana PNCC Program is being standardized
to facilitate contracting and providing services with the three MCOs.
Note: Reimbursement rate for prenatal care coordinator services remains
unchanged. Reimbursement for the appropriate ICD-9 code, billed on a
CMS-1500 claim form, is a maximum of $240 per qualifying member.
Providers submit billing to the member’s MCO. Data for the mandatory
Medicaid Prenatal Outcome Report form that is attached to the Postpartum
Assessment Form billing form is now incorporated into the standardized
assessment forms to facilitate data gathering.
The IHCP requires that all certified prenatal care coordinators and community health workers use the
mandatory standardized Combined Initial and Reassessment Prenatal Care Coordination Assessment
Form (CIRPNCCAF), the Postpartum Assessment Form (PPAF), and Medicaid Prenatal Outcome
Report. Also, use the following forms when required:
•
Care Coordination Outcome Report: Providers use this form to report statistical data for care
coordination services in Indiana. In the past, the Care Coordination Outcome Report was
completed by the care coordinator and submitted with the postpartum visit billing claim when sent
to HP. Prenatal care coordinators no longer send claims or outcome reports to HP unless a client is
a member of Care Select or not enrolled in an MCO. With RBMC mandatory in all counties,
providers send assessment forms to the MCO in which the member is enrolled. To cut down on
reports received by the MCOs, the data found on the Care Coordination Outcome Report has been
incorporated into the CIRPNCCAF and the PPAF.
Note: The areas highlighted in gray on the CIRPNCCAF and the PPAF contain
information previously included on the Medicaid Prenatal Outcome Report.
A copy of the appropriate assessment form is faxed to the MCO at the time of
each claim. The outcome information is collected throughout the pregnancy
and postpartum period. Contact each MCO for specific information on
transmission of assessment forms.
•
Prenatal Risk Assessment Form: PNCC services that will be reimbursed by the IHCP include a
prenatal risk assessment, one initial assessment and follow-up, one reassessment and follow-up
per trimester occurring after the initial assessment, and one postpartum assessment. In the past,
PNCC providers used suggested forms for each of these assessments. To standardize the PNCC
Program, all providers are required to complete the CIRPNCCAF and the PPAF. The Prenatal
Risk Assessment Form is available on the IHCP Web site Forms page at
http://provider.indianamedicaid.com/general-provider-services/forms.aspx.
Access all forms on the Forms page of the IHCP Web site
at http://provider.indianamedicaid.com/general-provider-services/forms.aspx.
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For inquiries about the Combined Initial and Reassessment Prenatal Care Coordination Assessment
Form or the Postpartum Assessment Form, providers should contact each MCO or call the following
number:
Indiana State Department of Health at (317) 233-1344
Procedure Codes for Billing Prenatal Care Coordination Services
H1000 – Initial Assessment
This service must occur during the prenatal period.
The billing limit for this code is one unit per pregnancy and must include the following:
•
Case finding risk assessment; care plan development; two encounters, one of which must be a
home visit; coordination, referral, and linkage to appropriate support services; and follow-up
monitoring
•
Documentation including an Initial Assessment form and an individual care plan
H1004 – Reassessment
The billing limit for this code is one unit per trimester, following the trimester of initial assessment.
•
Available only for at-risk pregnancies
•
Includes review and update of care plan; coordination referral and linkage to appropriate support
services; two encounters, one of which must be either a home visit or a visit at the care
coordinator’s office; and follow-up monitoring. Document this with a Reassessment form and a
follow-up record.
99501 – Home Visit for Postnatal Assessment and Follow-up Care
The billing limit for this code is one unit per child per pregnancy.
•
Must be completed within 60 days postpartum, preferably within two weeks.
•
Must follow an initial assessment and is only reimbursable for a pregnancy determined to be atrisk.
•
Includes a home visit referral and linkage to appropriate support services. A copy of the Care
Coordination Outcome Report is available online at http://provider.indianamedicaid.com/generalprovider-services/forms.aspx.
•
Must be documented by a Care Coordination Outcome Report. Attach a completed copy of the
Care Coordination Outcome Report to the claim for the postpartum visit submitted for payment.
Providers should document multiple births on the claim form to explain duplicate billing of postpartum
assessment and outcome services. For claims for multiple births, providers must attach the Care
Coordination Outcome Report to the claim for the postpartum visit for each child born of the
pregnancy.
Care Coordination Outcome Report
The IHCP uses a Prenatal Care Coordination Outcome Report form to report statistical data for care
coordination services in Indiana. Use the expanded Care Coordination Outcome Report during the
postpartum visit to assess and report postpartum and newborn results. The postpartum visit (99502) is
the only service that requires a copy of the Care Coordination Outcome Report form to be completed
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by the care coordinator and submitted with the claim when billing for the visit. The Care
Coordination Outcome Report is available from the IHCP Web site
at http://provider.indianamedicaid.com/general-provider-services/forms.aspx.
Care Coordination Services for Human Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome
The IHCP provides targeted case management or care coordination services to members with HIV and
AIDS, available statewide.
Definition of Service
HIV and AIDS care coordination is a specialized form of case management for members with HIV
infection. Care coordination consists of goal-oriented activities that locate, create, facilitate access to,
coordinate, and monitor the full range of HIV-related health and human services. The purpose is to
encourage the cost-effective use of medical and community resources and to promote the well-being of
the individual while ensuring the individual’s freedom of choice. To ensure freedom of choice, the
individual signs a Freedom of Choice/Intent to Participate Form acknowledging an understanding of
the services provided and identifying the chosen care coordination provider. Care coordination services
are those that assist Traditional Medicaid-eligible individuals from the targeted group to access needed
medical, psychological, social, educational, and other services.
Member Eligibility
To be eligible for reimbursement for care coordination, a member must be a Traditional Medicaid,
Hoosier Healthwise, or Care Select member and have a documented HIV infection. Medical
documentation or verification of medical diagnosis of HIV infection must be in the member’s care
coordination file. Providers can verify the diagnosis with the following types of documentation:
•
Confidential, positive HIV test result
•
A physician’s statement
•
Hospital discharge statement or other medical reports that verify the diagnosis
•
Medical prescription for AZT, ddI, or ddC, or copy of approval for participation in the AIDS Drug
Assistance Program (ADAP) or the Early Intervention Program (EIP)
Enrollment of HIV and AIDS Care Coordinators
To receive reimbursement for HIV and AIDS care coordination services, the service provider must be
enrolled in the IHCP. Refer to Chapter 4 for provider enrollment requirements and information.
Procedure Code for Billing HIV/AIDS Care Coordination
The IHCP policy for billing HIV care coordination services states that providers must use primary
diagnosis code 042 – HIV/AIDS and procedure code G9012 – Other Specified Case Management. HIV
and AIDS care coordination services are self-referral services under the Hoosier Healthwise and Care
Select programs. HIV/AIDS care coordination claims are not subject to managed care edits; therefore,
there is no requirement for a PMP’s certification code and NPI on the CMS-1500 claim form or the
837P transaction. Providers serving members in the RBMC delivery system should contact the
appropriate managed care organization for claim filing requirements.
One unit of service equals 15 minutes.
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Restrictions
•
As determined by the Assessment of Intensity of Care Coordination/Worksheet for Data Entry
form, care coordination services must not exceed a maximum of 128 units, or 32 hours, per
calendar quarter, or three-month period, per member.
Note: The following provides information about the Assessment of Intensity of Care
Coordination/Worksheet for Data Entry form:
– Developed to substantiate the need for higher intensity levels of service as
well as to collect data.
– Completed at the beginning of each quarter to determine the maximum
number of hours allowed per member.
– Expected that most members use between six and one-half hours and nine
hours per quarter and some use less.
– Anticipated that few members require more than nine hours per quarter.
– Describes the supporting factors for the number of care coordination
hours used. Substantiate supporting factors through self-report, medical
records, caregiver records, other agency reports, or physical
observation. Document substantiation in the member’s file.
•
When providers reach the maximum level of hours allowed in a given quarter, submit a new and
updated Assessment of Intensity of Care Coordination/Worksheet for Data Entry form to request
additional hours.
•
Eligible members may receive HIV and AIDS care coordination services that are reimbursable by
the IHCP from only one HIV and AIDS care coordination service provider.
Care Coordination Services Provider Requirements
The following are care coordination service provider requirements:
•
Each year, service providers must take required updated training about the nature of HIV infection
and institutional and community intervention resources.
•
Service providers must maintain written documentation of all services provided. Documentation is
subject to postpayment review and audit by the OMPP or its contracted agent.
•
Service providers must provide care coordination services that are structured and time-goal
oriented.
•
Service providers must develop a plan of care for each member that reflects individual needs and
includes strategies, outcome objectives, and time frames for each individual who receives care
coordination services. Providers must update the plan of care at least annually to reflect changing
needs.
•
The IHCP requires service providers to keep comprehensive records on all members on forms
approved by the OMPP and the Division of Disability, Aging, and Rehabilitative Services
(DDARS). The following records must be available in each member’s file and updated annually if
applicable:
- Determination of eligibility
- Documentation of a verified diagnosis of HIV infection
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-
-
Intake form
Assessment and reevaluation of the member’s present problems, indications of medical and
physical status, indications of psychological status, quality of social supports, living
arrangements, and status of other relevant factors
Documentation of service provider referrals
Progress notes
Comprehensive plan of care
Documentation of member and service provider contacts, including face-to-face contacts
Signed release-of-information form
•
Service providers must permit access to and examination of records by those authorized by the
OMPP, its agent, or federal personnel. Providers must maintain records for seven years and
perform record destruction, such as burning or shredding documents, in a confidential manner.
•
Service providers must develop the member’s plan of care on or before the 30th day following the
date of the initial intake process. At least annually, providers must complete reevaluations and
update the plan of care. Providers must maintain ongoing contacts either face-to-face or by
telephone with the member or member’s representative at least once every 30 days from the date
of the initial intake process. If providers cannot maintain contact, they must make notation of
attempted contacts and the process used in the file to determine whether services continue.
•
The IHCP requires service providers to engage in face-to-face consultations with members or
member representatives at least once every 90 days, measured from the date of the initial intake
process, at a place mutually agreed on by both parties.
•
Service providers must have sufficient care coordination, support, and administrative staff to meet
the service demands in the area, allowing for a reasonable care coordinator to member ratio. The
recommended national standard ratio for HIV and AIDS care coordination is 1:35.
•
Service providers must obtain input about member service satisfaction from members, summarize
this input at least annually, and have this information available for review.
•
The IHCP requires service providers to provide quarterly reports to the DDARS on the approved
forms.
•
Service providers must have the data collection and analysis capability required to prepare
monthly statistical reports concerning member demographics, including but not limited to: age,
race, sex, risk exposure category, and other relevant data in a format approved by the DDARS.
•
Service providers must develop and maintain a current list of support services in the community
available to members who are HIV infected, as well as established referral mechanisms.
•
The IHCP requires service providers to maintain member files in a secure area to protect member
confidentiality. Information stored on computerized data systems must have password protection.
Providers must adopt and adhere to a written policy protecting confidentiality that states that all
information about the member is confidential information. The service provider cannot use any
information obtained about the member in any way except as necessary for the proper discharge of
responsibilities. Providers must treat all information, such as personal facts and circumstances
concerning the member, as privileged communication and cannot divulge it without the written
consent of the member or the member’s legal representative.
•
Service providers ensure that services are available to all eligible members regardless of age, race,
sex, sexual orientation or preference, ethnicity, religion, national origin, or handicap.
•
Service providers must comply with licensing and accreditation standards as required by the
OMPP or its agent.
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•
Service providers determine whether the member is eligible for services in accordance with the
OMPP and the DDARS established policy and procedures.
•
Service providers comply with procedures for administrative review of the appeals of applicants
and members.
•
The IHCP requires service providers to prepare and submit claims in accordance with stated
policies and procedures of the OMPP or its agent.
HIV/AIDS Care Coordination Services by Care Coordinators
The following are the approved activities of the care coordinator:
•
Intake and assessment – The care coordinator completes a Freedom of Choice/Intent to Participate
Form, an intake and an assessment on the areas in the following list, and an Assessment of Care
Coordination/Worksheet for Data Entry form:
- Presenting problems
- Medical and physical status
- Indicators of psychosocial status
- Indicators of developmental and intellectual status
- Living arrangements
- Status of other relevant factors
•
Plan of Care Development – Based on the information gathered in the assessment, the care
coordinator and the member develop a comprehensive plan of care using the following techniques.
The care coordinator must develop the plan of care on or before the 30th day after the date of the
initial intake:
- Prioritizing the needs identified in the assessment
- Developing outcome goals that address identified needs
- Identifying factors that may impinge on the implementation of the plan of care
- Proposing and discussing preliminary strategies for meeting outcome goals and obtaining
signed approval from the member or the member’s legal representative
- Specifying the time frame for meeting outcome goals
- Developing evaluation criteria to measure whether outcome goals are being met
- Identifying specific services, costs, and sources of payment
- Contracting with the member or the member’s legal representative to apportion the rights and
responsibilities between the member and the care coordinator
- Developing procedures for emergency situations
•
Implementation – The care coordinator negotiates agreements with service providers, coordinates
delivery of service, maintains the member’s record, and implements the plan of care developed
with the member or member representative. The care coordinator works to ensure nonduplication
and cost-effectiveness of services, and maintains member records in accordance with reporting
requirements. The care coordinator acts as a facilitator in resolving access problems that arise in
implementing the plan of care and acts as an advocate for the development of new services.
•
Monitoring – The care coordinator ensures implementation of the services identified in the plan of
care by monitoring planned interventions in a timely fashion and obtaining confirmation of
scheduled interventions by the member, the service provider, or both.
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•
Evaluation – The care coordinator periodically engages in the following activities to measure the
quality and the effectiveness of the plan of care:
- Analysis of information generated through the monitoring function, such as quality and
effectiveness of interventions, appropriateness of goals and strategies, the member’s legal
representative’s commitment to participate in the plan of care, and the member or member’s
legal representative’s satisfaction with the plan of care.
- Comparison of plan of care objectives with actual outcomes of the intervention.
•
Reevaluation – The care coordinator makes scheduled reevaluations to the plan of care in view of
continuing or changing needs of the member based on the periodic evaluation. Evaluations and
reevaluations require ongoing contact with the member. As part of the reevaluation process and in
addition to the following list, the care coordinator completes the Assessment of Care
Coordination/Worksheet for Data Entry Form at the beginning of every quarter, starting with the
date of the initial assessment. When there is a change in member needs, the care coordinator does
the following:
- Revises the plan of care outcome goals
- Reevaluates the priority of member needs
- Revises the plan of care strategies
- Realigns technical service resources
- Proposes and discusses new strategies for meeting outcome goals subject to member or
representative approval
- Specifies new time frames for meeting outcome goals
- Enters into a new contract with the member or representative to reapportion the rights and
responsibilities of the member and the care coordinator
•
Termination – On reevaluation of the plan of care, the care coordinator and the member or the
member’s legal representative determine whether services should continue. The decision is made
based on whether the following is true:
- Care coordination services are still required.
- The member or member’s legal representative elects to continue care coordination services.
- The member or representative is upholding his or her contracted agreement set forth in the
plan of care.
- The member or representative is cooperating with the agreed-upon plan of care.
- The member is aggressive or noncooperative with the care coordinator.
Billable versus nonbillable activities – Any of the activities of care coordination are billable when
provided on behalf of a specific member. Progress notes written the same day as a care coordination
service are billable. Nonbillable activities include time spent completing or reviewing claim forms for
care coordination, implicit paperwork, and activities not related to a particular member. The
reimbursement rate includes administrative expenses, which are therefore not billable. Transporting
members, general provider recruitment, and ongoing counseling are not billable.
HIV/AIDS Care Coordination and Managed Care
HIV/AIDS care coordination services are self-referral services under the Hoosier Healthwise and Care
Select programs. Providers serving Hoosier Healthwise members in the RBMC delivery system should
contact the appropriate MCO for filing these claims. MCO contact information is included in Chapter
1.
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HIV/AIDS care coordination claims are not subject to managed care edits; therefore, there is no
requirement for a PMP’s certification code and NPI on the CMS-1500 claim form or the 837P
transaction.
Chiropractic Services
Coverage and Billing Procedures
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.
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
8.44 as the primary diagnosis, followed by the appropriate chiropractic diagnosis code and chiropractic
procedure code.
Table 8.44 – 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 office visits and spinal manipulation or physical
medicine treatments per member per calendar year. As part of this limitation, the IHCP reimburses for
no more than five office visits out of the total 50 treatment or office visits per member per calendar
year. Reimbursement is not available for durable medical equipment (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
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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.
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 8.45 through 8.50 identify the procedure codes that chiropractors should bill to the IHCP.
Table 8.45 – Covered IHCP Chiropractic Codes for Office Visits
CPT
Code
Description
99201
Office or other outpatient visit for evaluation and management of new patient;
problems are self-limited or minor
99202
Office or other outpatient visit for evaluation and management of new patient;
presenting problems are of low or moderate severity
99203
Office or other outpatient visit for evaluation and management of new patient;
presenting problems are of moderate severity
99211
Office or other outpatient visit for the evaluation and management of an established
patient; presenting problem(s) are minimal
99212
Office or other outpatient visit for the evaluation and management of an established
patient; presenting problem(s) are self-limited or minor
99213
Office or other outpatient visit for the evaluation and management of an established
patient; presenting problem(s) are low to moderate severity
Table 8.46 – Covered IHCP Chiropractic Codes for Manipulative Treatment
CPT
Code
Description
98940
Chiropractic manipulative treatment (CMT); spinal, one to two regions
98941
CMT, spinal, three to four regions
98942
CMT, spinal, five regions
98943
CMT, extraspinal, one or more regions
Chiropractors may perform laboratory tests that fall within their scope of practice for the state of
Indiana, IC 25-10-1 and Title 846, which include blood analysis and urinalysis.
8-190
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Table 8.47 – 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; two or three views
72050
Radiologic examination, spine, cervical; minimum of four views
72052
Radiologic examination, spine, cervical; complete, including oblique and flexion and/or
extension studies
72069
Radiologic examination, spine, thoracolumbar, standing (scoliosis)
72070
Radiologic examination, spine; thoracic, two views
72072
Radiologic examination, spine; thoracic, three views
72074
Radiologic examination, spine; thoracic, minimum of four views
72080
Radiologic examination, spine; thoracolumbar, two views
72090
Radiologic examination, spine; scoliosis study, including supine and erect studies
72100
Radiologic examination, spine, lumbosacral; two or three views
72110
Radiologic examination, spine, lumbosacral; minimum of four views
72114
Radiologic examination, spine, lumbosacral; complete, including bending view
72120
Radiologic examination, spine, lumbosacral; bending view only, minimum of four
views
72170
Radiologic examination, pelvis; one or two views
72190
Radiologic examination, pelvis; complete, minimum of three views
72200
Radiologic examination, sacroiliac joints; less than three views
72202
Radiologic examination, sacroiliac joints; three or more views
72220
Radiologic examination, sacrum and coccyx, minimum of two views
73000
Radiologic examination; clavicle, complete
73010
Radiologic examination; scapula, complete
73020
Radiologic examination, shoulder; one view
73030
Radiologic examination, shoulder; complete, minimum of two views
73050
Radiologic examination; acromioclavicular joints, bilateral, with or without weighted
distraction
73060
Radiologic examination; humerus, minimum of two views
73070
Radiologic examination, elbow, anteroposterior and lateral views
73080
Radiologic examination, elbow, complete, minimum of three views
73090
Radiologic examination; forearm, two views
73100
Radiologic examination, wrist; two views
73110
Radiologic examination, wrist; complete, minimum of three views
73120
Radiologic examination, hand; two views
73130
Radiologic examination, hand; minimum of three views
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CPT
Code
Description
73140
Radiologic examination, finger(s), minimum of two views
73500
Radiologic examination, hip, unilateral; one view
73510
Radiologic examination, hip, complete, minimum of two views
73520
Radiologic examination, hips, bilateral, minimum of two views of each hip, including
anteroposterior view of pelvis
73550
Radiologic examination, femur, two views
73560
Radiologic examination, knee; one or two views
73562
Radiologic examination, knee; three views
73564
Radiologic examination, knee; complete, four or more views
73565
Radiologic examination, knee; both knees, standing, anteroposterior
73590
Radiologic examination; tibia and fibula, two views
73600
Radiologic examination, ankle; two views
73610
Radiologic examination, ankle; complete, minimum of three views
73620
Radiologic examination, foot; two views
73630
Radiologic examination, foot; complete, minimum of three views
73650
Radiologic examination; calcaneus, minimum of two views
73660
Radiologic examination, toe(s), minimum of two views
Table 8.48 – Covered Chiropractic Codes for Physical Medicine Services
CPT
Code
8-192
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
97010
Application of a modality to one or more areas; hot or cold packs
97012
Application of a modality to one or more areas; traction, mechanical
97014
Application of a modality to one or more areas; electrical stimulation (unattended)
97016
Application of a modality to one or more areas; vasopneumatic devices
97018
Application of a modality to one or more areas; paraffin bath
97022
Application of a modality to one or more areas; whirlpool
97024
Application of a modality to one or more areas; diathermy
97026
Application of a modality to one or more areas; infrared
97028
Application of a modality to one or more areas; ultraviolet
97032
Application of modality to one or more areas; electrical stimulation (manual), each 15
minutes
97033
Application of modality to one or more areas; iontophoresis, each 15 minutes
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CPT
Code
Description
97034
Application of modality to one or more areas; contrast baths, each 15 minutes
97035
Application of modality to one or more areas; ultrasound, each 15 minutes
97036
Application of modality to one or more areas; Hubbard tank, each 15 minutes
97039
Physical medicine treatment to one area; unlisted modality (specify type and time if
constant attendance)
97110
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility
97112
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility; neuromuscular
reduction of movement, balance, coordination, kinesthetic sense, posture, and/or
proprioception for sitting and/or standing activities
97113
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility; aquatic therapy with
therapeutic exercises
97116
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility; gait training (including
stair climbing)
97124
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility; massage, including
effleurage, pestrissage, and/or tapotement (stroking, compression, percussion)
97139
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility; unlisted procedure
(specify)
97140
Manual therapy techniques (for example, mobilization/manipulation, manual lymphatic
drainage, manual traction), one or more regions, each 15 minutes
Table 8.49 identifies the appropriate primary ICD-9-CM diagnosis codes for billing chiropractic
services to the IHCP.
Table 8.49 – Primary ICD-9-CM Codes for Chiropractic Services
Diagnosis Code
Description
739.0
Occipitocervical (Occ-C1)
739.1
Cervical (C1-C7)
739.2
Thoracic (T1-T12)
739.3
Lumbar (L1-L5)
739.4
Sacral (S)
739.5
Pelvic region
739.6
Lower extremities
739.7
Upper extremities
739.8
Rib cage
Table 8.50 identifies the secondary diagnosis codes that chiropractors should bill to the IHCP.
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Table 8.50 – Secondary ICD-9-CM Codes for Chiropractic Services
Diagnosis
Code
8-194
Description
307.81
Tension headache
333.83
Spasmodic torticollis
346.00
Classical migraine without mention of intractable migraine
346.01
Classical migraine with intractable migraine, so stated
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
Common migraine without mention of intractable migraine
346.11
Common migraine with intractable migraine, so stated
346.20
Variants of migraine without mention of intractable migraine
346.21
Variants of migraine with intractable migraine, so stated
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
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
migraine without mention of status migrainosus
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
migraine without mention of status migrainosus
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
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Diagnosis
Code
Description
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
346.81
Other forms of migraine with intractable migraine, so stated
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
346.91
Migraine, unspecified, with intractable migraine, so stated
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
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
Preg compl nos-antepart
648.73
Bone disorder-antepartum
648.93
Oth curr cond-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
Thoracic spondylosis without myelopathy
721.3
Lumbosacral spondylosis without myelopathy
721.6
Anklyosing vertebral hyperostosis
721.7
Traumatic spondylopathy
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Diagnosis
Code
8-196
Description
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
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
724.09
Spinal stenosis of other region
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
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Diagnosis
Code
Description
724.6
Disorders of sacrum
724.70
Unspecified disorders of coccyx
724.79
Other disorders of coccyx, coccygodynia
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, unspecified
729.4
Fascilitis, unspecified
732.0
Juvenile osteochondrosis of spine
737.0
Adolescent postural kyphosis
737.10
Kyphosis (acquired) (postural)
737.12
Kyphosis (acquired), postlaminectomy
737.19
Kyphosis (acquired), other
737.20
Lordosis (acquired) (postural)
737.21
Lordosis (acquired), postlaminectomy
737.22
Lordosis (acquired), other postsurgical lordosis
737.29
Lordosis (acquired), other
737.30
Kyphoscoliosis and scoliosis – scoliosis (and kyphoscoliosis), idiopathic
737.31
Kyphoscoliosis and scoliosis – resolving infantile idiopathic scoliosis
737.32
Kyphoscoliosis and scoliosis – progressive infantile idiopathic scoliosis
737.34
Kyphoscoliosis and scoliosis – 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 extrem
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Diagnosis
Code
8-198
Description
739.7
Nonallopath lesion – upper extrem
739.8
Nonallopath lesion – rib cage
754.1
Congenital torticollis
754.2
Certain congenital musculoskeletal deformities of spine (lordosis, scoliosis)
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 lumbosacral (joint) (ligament)
846.1
Sprains and strains of sacroiliac ligament
846.2
Sprains and strains of sacrospinatus (ligament)
846.3
Sprains and strains of sacrotuberous (ligament)
846.8
Sprains and strains of other specified sites of sacroiliac region
846.9
Sprains and strains of 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 cervical nerve root
953.1
Injury to dorsal nerve root
953.2
Injury to lumbar nerve root
953.3
Injury to sacral nerve root
953.4
Injury to brachial plexus
953.5
Injury to lumbrosacral plexus
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Diagnosis
Code
Description
956.0
Injury to sciatic nerve
956.1
Injury to nerve of pelvic girdle and lower limb – femoral nerve
956.2
Injury to nerve of pelvic girdle and lower limb – posterior tibial nerve
956.3
Injury to nerve of pelvic girdle and lower limb – peroneal nerve
956.4
Injury to nerve of pelvic girdle and lower limb – cutaneous sensory nerve, lower limb
956.5
Injury to nerve of pelvic girdle and lower limb – other specified nerve(s) of pelvic
girdle and lower limb
956.8
Injury to nerve of pelvic girdle and lower limb – multiple nerves of pelvic girdle and
lower limb
956.9
Injury to nerve of pelvic girdle and lower limb – unspecified nerve of pelvic girdle and
lower limb
Diabetes Self-Care Management Training Services
Coverage and Billing Procedures
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:
•
Nutrition
•
Medication counseling
•
Blood glucose self-monitoring
•
Insulin injection
•
Foot, skin, and dental care
The IHCP limits coverage to eight units per member, per rolling calendar year. Providers can prior
authorize additional units. One unit is equal to 30 minutes. The IHCP covers diabetes self-management
training services for Package C members.
Note: For RBMC members, send claims to the appropriate MCO.
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. Eligible practitioners, such as
pharmacists, who work for or own IHCP-enrolled pharmacies should bill for services rendered through
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the enrolled entity where services are provided. MCO contact information is included in Chapter 1,
Section 2.
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
•
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 Surveillance Utilization
Review (SUR) Department.
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, indiv, or G0109 – Diabetes selfmanagement training service, group session. One unit of G0108 or G0109 is equal to 30 minutes of
service. 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
8-200
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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 8.51.
Table 8.51 – 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
blood glucose monitor owned by patient, each
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)
A4253
Blood glucose test or reagent strips, 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
Effective February 1, 2007, a maximum quantity limitation is placed on HCPCS codes A4253 and
A4259. Providers are permitted to bill as many as 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 deny
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unless PA is obtained. Providers are permitted to bill as many as two units of A4259 (200 lancets) per
30 days effective for claims with date of service on or after January 1,2010. Additional units of A4259
deny unless PA is obtained.
The following PA criteria is 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
Drug-Related Medical Supplies and Medical Devices
Some drug-related medical supplies and medical devices are reimbursed on an FFS basis. Table 8.52
lists drug-related medical supplies and medical devices that are paid for by the FFS medical benefit for
all Hoosier Healthwise (HHW) and Healthy Indiana Plan (HIP) health plan members for claims with
dates of service on or after December 31, 2009. These claims should be billed on the CMS-1500 claim
form or an 837P transaction. Services must be provided by an IHCP-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 45 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, HHW, or HIP health plan pharmacy benefits with dates of service on or
after December 31, 2009, will be denied.
Table 8.52 – Drug-Related Medical Supplies and Medical Devices
Procedure Code
8-202
Description
A4210
Needle free injection device
A4211
Supplies for self administered injection
A4245
Alcohol wipes, per box
A4206
Syringe with needle; sterile, 1cc or less, each
A4207
Sterile 2cc, each
A4208
Sterile 3cc, each
A4209
Sterile 5cc or greater, each
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
blood glucose monitor owned by patient, each
A4236
Replacement battery, silver oxide, for use with medically necessary home
blood glucose monitor owned by patient, each
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Procedure Code
Description
A4244
Alcohol or peroxide, per pint
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
Lancet device
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
E2101
Blood glucose monitor with integrated
S8101
Holding Chamber or spacer for use with an inhaler or nebulizer; with
mask
S8100
Holding chamber or spacer for use with an inhaler or nebulizer without
mask
* Not covered by Healthy Indiana Plan
The HHW 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 8.52
•
DME
•
Enteral or oral nutritional supplements
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Durable Medical Equipment and Home Medical Equipment
Coverage and Billing Procedures
405 IAC 5-19-2, IC 25-26-21 defines 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.
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. The benefit limit 407 IAC 3-6-1 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, intermediate care facilities for the mentally retarded (ICFs/MR), 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 long-term 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, refer to 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 in long-term care facilities, receive a
denial with explanation of benefit (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.
The IHCP reimburses for DME or HME equipment, services, and supplies within one of the
classifications listed in Table 8.53.
Table 8.53 – DME/HME Classification Codes
DME Classification
Number
8-204
DME Classification Name
1
Capped rental items
2
Inexpensive or other routinely purchased items
3
Items requiring frequent or substantial
servicing
4
Customized items
5
Prosthetic and orthotic devices
6
Oxygen and oxygen equipment
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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.
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 determines 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 percent above the invoice amount. The IHCP does not accept a
manufacturer’s price list as proof of purchase price for this level of reimbursement.
•
If a provider submits a retail price list from the manufacturer, the IHCP reimburses the claim at 90
percent 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 percent 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).
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.
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
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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 and is covered effective January 1, 2010.
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.
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 8.54 lists the HCPCS codes for DME and HME that do not require PA.
Note: For RBMC members, contact the appropriate MCO for PA.
Table 8.54 – HCPCS Codes – DME/HME That Do Not Require PA
DME/HME
8-206
HCPCS Codes
Surgical/elastic support hose
A4490 – A4510
A6530 – A6544
Battery, heavy duty; replacement for patient-owned
ventilator
A4611
Battery cables; replacement for patient-owned ventilator
A4612
Battery charger; replacement for patient-owned ventilator
A4613
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DME/HME
HCPCS Codes
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 – E0117
Canes
E0100, E0105
Walkers
E0130 – E0159
Commodes
E0163 – E0175
Decubitis Care
E0181 – E0191, E0199
Bilirubin light
E0202
Heat/cold application
E0200 – E0239
Bath and toilet aids
E0240 – E0248
Bedpans
E0275, E0276
Urinals
E0325, E0326
Oximeter for blood oxygen levels
E0445
Humidifiers
E0550 – E0560
Compressors
E0565
Nebulizers
E0570 – 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 – E0673
Belt/harness
E0700
Restraints
E0710
IV Poles
E0776
Parenteral infusion pumps
E0779, E0781 – E0791
Traction
E0840, E0849, E0850,
E0855,E0860, E0870,
E0880,E0890, E0900
Trapeze equipment
E0910 – E0948
Wheelchair accessories
E0950 – E0952,
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DME/HME
Rollabout chair
E1031
Dialysis equipment
E1510 – E1699
Jaw motion rehab system
E1700 – E1702
Repairs and replacement supplies
K0739
Cervical collars
L0120 – L0174
Thoracic-lumbar-sacral orthosis (TLSO)
L0450 – L0492
Lumbar-sacral orthosis
L0621 – L0640
Back supportive devices, such as corsets
L0970 – L0976
Orthotics for scoliosis
L1000 – L1520
Lower limb orthotics
L1600 – L2038
Torsion control orthotics
L2040 – L2090
Fracture orthotics
L2106 – L2397,
Q4001 – Q4051
Knee additions
L2405 – L2550
Pelvic-thoracic control
L2570 – L2680
Abduction bars
L3650 – L3805, L3807
Additions to upper limb
L3810 – L3901
External power orthotics
L3902 – L3904
Wrist/hand orthosis
L3905 – L3954, L3956
Upper limb orthosis
L3960 – L3969
Additions to mobile arm supports
L3970 – L3974, L3978
Upper limb fracture orthosis
L3980 – L3999
Orthotic repairs
L4000 – L4210
Ancillary orthotic services
L4350 – L4380, L4386
Prosthetic procedures
L5000 – L8049
Hernia trusses
L8300 – L8330
Prosthetic socks
L8400 – L8499
Artificial larynx
L8500
Tracheostomy speaking valve
L8501
Prosthetic implants
L8603 – L8670
Medical and Surgical Supplies
8-208
HCPCS Codes
E0959, E0960 –
E0961, E0966, E0970,
E0971, E0978 –
E0980, E0994 , E0995,
E0997, E0998, E2601
HCPCS Codes
Vascular catheters
A4305
Slings
A4565
Supplies for oxygen and related respiratory equipment
A4611 – A4629
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DME/HME
HCPCS Codes
Supplies for other DME
A4630 – A4640
Supplies for ESRD
A4653, A4660,
A4663, A4911,
A4680, A4690
Enteral and parenteral therapy
B9000, B9002, B9004,
B9006
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.
The above procedures are intended to streamline the PA process. The SUR Department evaluates
provider profiles and performs retrospective reviews of services no longer requiring PA.
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/MR, the IHCP reimburses the
items in Table 8.54 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 percent 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
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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 8.55 are subject to the 15-month capped rental period.
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 Indiana Prior Review
and 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 8.55 lists the procedure codes that are subject to the 15-month capped rental period.
Table 8.55 – Procedure Codes – DME/HME Capped Rental Items
B9000*
B9002*
B9004*
B9006*
E0165
E0168
E0170
E0171
E0181*
E0182*
E0186*
E0187*
E0196
E0218*
E0221*
E0231*
E0232*
E0235*
E0236*
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0277
E0290
E0292
E0293
E0294
E0295
E0297
E0296
E0301
E0302
E0303
E0305
E0316
E0371
E0372
E0373
E0445*
E0459
E0462*
E0481
E0482
E0483
E0550*
E0565*
E0571*
E0572*
E0574*
E0585*
E0600*
E0601*
E0603
E0606
E0607*
E0617
E0618*
E0619*
8-210
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E0630
E0635
E0636
E0638
E0641
E0740
E0744
E0745
E0770
E0749
E0779*
E0781*
E0784
E0791*
E0910*
E0920*
E0930*
E0940*
E0941
E0946*
E0955
E0956
E0957
E0958*
E0959
E0960
E0967
E0968
E0969
E0970
E0971
E0973
E0974
E0978
E0980
E0981
E0982
E0983
E0984
E1014
E1015
E1016
E1020
E1028
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
E1228
E1231
E1232
E1233
E1234
E1235
E1236
E1237
E1238
E1240
E1250
E1260
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
E2209
E2210
E2211
E2212
E2213
E2214
E2215
E2216
E2218
E2219
E2220
E2221
E2222
E2223
E2224
E2225
E2226
E2340
E2341
E2343
E2360
E2361
E2362
E2363
E2364
E2365
E2366
E2371
E2372
E2373
E2374
E2376
E2381
K0011
K0010
K0012
K0014
K0606
K0733
K0800
K0801
K0802
K0806
K0807
K0808
K0812
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0829
K0830
K0831
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
K0899
K0890
K0891
K0898
* 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.
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As indicated above, the IHCP makes rental payments through the 15th 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 15th
month and every six months thereafter, for as long as the equipment is medically necessary.
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 8.56 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 8.56 – Procedure Codes Classified as Frequent and Substantial Servicing by the IHCP
Procedure Code
Description
E0450
Volume ventilator, stationary or portable, with backup rate feature, used with
invasive interface (such as 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 (such as 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. The IHCP
includes all medical and nonmedical supplies, routine medical equipment, and therapies in the NF per
diem rate.
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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,
and the provider must submit these on the UB-04 claim form.
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 either an AED (E0617) or a WCD (K0606), based on the physician’s clinical
assessment of the member’s medical needs. Table 8.57 lists examples of factors that providers may
consider when choosing which defibrillator is most appropriate for the member.
Table 8.57– Defibrillator Factors
Factors for Choosing E0617
Inability to wear a WCD vest due to obesity
Skin irritation from wearing electrodes 24 hours per
day
Limited or lack of mobility
Availability of an assistant to operate the AED
Factors for Choosing K0606
Lack of assistant who can operate an AED
Frequency that the member is away from home
Mobility of the member
Frequently unstable heart rhythms
Tables 8.58 and 8.59 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.
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Table 8.58 – Wearable Cardioverter Defibrillator
HCPCS Code
K0607*
Description
Automatic external defibrillator with integrated electrocardiogram analysis,
garment type
Replacement battery for AED, garment type only
K0608
Replacement garment for use with AED garment type only, each
K0609*
Replacement electrodes for use with AED, garment type only
K0606
*Note: These HCPCS codes are used for the automatic external defibrillator and
wearable cardioverter defibrillator.
Table 8.59 – Automatic External Defibrillator
HCPCS Code
E0617
K0607*
K0609*
Description
External defibrillator with integrated electrocardiogram analysis
Replacement battery for AED, garment type only
Replacement electrodes for use with AED, garment type only
*Note: 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.
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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.
When the application of a cast, strap, or splint is an initial service, providers can bill CPT code 99070 –
supplies and materials in combination with the appropriate casting CPT code 29000 through 29799,
and the appropriate CPT E/M code.
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, the billing code is HCPCS code E0935, and providers 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
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•
Brachycephaly documented by a cephalic index 2 standard deviations above or below the mean
(approximately 78 percent)
•
Scaphocephy or dolichochaly in premature or breech infants with a cephalic index significantly
less than 78 percent
•
Further correction or asymmetry for members after surgical treatment of craniosynostosis,
considered on a case-by-case basis
•
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
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. Pharmacies
must bill for compounded prescriptions or any drugs used in parenteral therapy on the
appropriate Compound Prescription Claim Form or National Council for Prescription Drug Programs
(NCPDP) Pharmacy Drug Claim Form or via the NCPDP 5.1 transaction using the appropriate
National Drug Code(s) (NDC). 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.
A home health agency (HHA) that is dually enrolled as a pharmacy provider must submit all
compound drugs and any drugs used in parenteral therapy on a drug claim form or via the NCPDP 5.1
transaction using the appropriate NDC.
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Note: When an HHA that is dually enrolled as a pharmacy bills claims for
parenteral therapy containing drugs on the CMS-1500 or the 837P
transaction, the IHCP may subject those claims to postpayment audit and
recoupment.
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.
Home Infusion – Parenteral and Enteral Nutrition Pumps
Parenteral and enteral pumps (PEN) 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.
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 get 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. 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 percent above the manufacturer’s cost to the provider.
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 (CMN) for all PEN pumps. Providers must submit a copy of the
CMN with the initial, and each subsequent, PA request for enteral nutrition items. The IHCP does not
require PA for HCPCS codes B9002 – Enteral Nutrition Infusion Pump – with Alarm and B9000 –
Enteral Nutrition Infusion Pump – without Alarm.
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 it. 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.
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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
Table 8.60 represents a comprehensive list of the parenteral nutrition solution, kit, and pump HCPCS
codes. View the IHCP fee schedule at http://provider.indianamedicaid.com for a comprehensive list of
covered procedures.
Table 8.60 – 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 8.61 lists HCPCS codes that the IHCP covers for enteral nutrition formula, kit, tubing, and
pump. View the IHCP fee schedule at http://provider.indianamedicaid.com for a comprehensive list of
covered procedures.
Table 8.61 – 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
Nutritional supplements are not considered drugs or biologics. Please report them to the IHCP with the
appropriate HCPCS code on the CMS-1500 paper claim form or using the 837P electronic transaction.
According to the HIPAA, only drugs and biologics may be reported on the pharmacy claim form with
an NDC. The policy for billing changed effective April 3, 2003, and the IHCP discontinued coverage
of nutritional supplements billed with an NDC when billed on a drug claim form. 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 an 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.
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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 claims only and no longer requires a rental trial period before
purchase of nonheated or heated humidifiers.
Incontinence, Ostomy, and Urological Mail Order Supplies
The IHCP contracted with three vendors to provide incontinence, ostomy, urological, and other
supplies including diapers, underpads, ostomy bags, and gloves. The contracted vendors are listed
below:
•
Binson’s Home Health Care Centers
www.binsons.com
Telephone: 1-888-217-9610
•
Healthcare Products Delivery (HPD), Inc.
www.hpdinc.net
Telephone: 1-800-291-8011
•
J&B Medical Supply Company
www.jandbmedical.com
Telephone: 1-866-674-5850
Effective June 1, 2008, 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. Claims for supplies from noncontracted providers
received on or after June 1, 2008, are systematically denied.
Members enrolled in the 590 Program, Medical Review Team (MRT), First Steps, Pre-Admission
Screening and Resident Review (PASRR), Long Term Care (LTC), and RBMC programs are excluded
from this policy change.
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 change.
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 8.62 lists the procedure codes for supplies affected by this change. Claims for these supplies will
be denied if billed by noncontracted providers on and after June 1, 2008.
Table 8.62 – Procedure Codes Covered Under Contract
T4521
T4526
T4531
T4536
T4542
A4313
A4321
A4331
T4522
T4527
T4532
T4537
T4543
A4314
A4322
A4332
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Covered Procedure Codes
T4523
T4528
T4533
T4539
A4310
A4315
A4326
A4333
T4524
T4529
T4534
T4540
A4311
A4316
A4327
A4334
T4525
T4530
T4535
T4541
A4312
A4320
A4328
A4338
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A4340
A4352
A4357
A4366
A4372
A4378
A4383
A4389
A4394
A4399
A4407
A4412
A4417
A4423
A4428
A4433
A5053
A5063
A5082
A5113
A4344
A4353
A4358
A4367
A4373
A4379
A4384
A4390
A4395
A4400
A4408
A4413
A4418
A4424
A4429
A4434
A5054
A5071
A5093
A5114
Covered Procedure Codes
A4346
A4354
A4361
A4368
A4375
A4380
A4385
A4391
A4396
A4404
A4409
A4414
A4419
A4425
A4430
A4458
A5055
A5072
A5102
A5126
A4349
A4355
A4362
A4369
A4376
A4381
A4387
A4392
A4397
A4405
A4410
A4415
A4420
A4426
A4431
A5051
A5061
A5073
A5105
A5131
A4351
A4356
A4363
A4371
A4377
A4382
A4388
A4393
A4398
A4406
A4411
A4416
A4422
A4427
A4432
A5052
A5062
A5081
A5112
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)
•
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 is assigned.
•
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.
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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, 2008, is effective for a maximum of 12 months through February 14, 2009. The supplier
must obtain a new order to cover dates of service starting February 15, 2009, through February 14,
2010. 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
Mentally Retarded, and Long-Term Care Facility Residents
Please note that the IHCP reimburses incontinence supplies for members residing in group homes,
intermediate care facilities for the mentally retarded, 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
•
Cincinnati, Ohio
•
Hamilton, Ohio
•
Harrison, Ohio
•
Oxford, Ohio
•
Chicago, Illinois*
*Note: Effective January 5, 2007, the city of Chicago was added to this list. Chicago
medical providers need to follow the same prior authorization rules as instate providers for all members in the Care Select and Traditional Medicaid
programs. See Chapter 6 for information about the prior authorization
process. This change includes all active providers with locations in the ZIP
Codes of 606XX, 607XX, and 608XX.
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A4927 – Nonsterile Gloves, per 100
One unit of A4927 equals 100 gloves. Partial units of A4927 (less than 100 gloves) must be billed
using the appropriate decimal indicator for the number of gloves. For example, 50 gloves would be
billed as 0.50 units. Billing for more than one unit may result in an incorrect payment amount.
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 either 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.
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.
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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 8.63 are the only codes that providers can use to bill for these
services. Providers should not use these codes in any other circumstances.
Table 8.63 – 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)
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.
Osteogenic Bone Growth Stimulators
The IHCP covers osteogenic bone growth stimulators (OBGS) with prior authorization. The equipment
requires thorough education to the member and his or her caregivers. OBGS are inexpensive and
routinely purchased DME.
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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.
•
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
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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 MCO 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
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
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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 was 56 mm Hg or greater or whose oxygen saturation
was 89 percent 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 percent 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 hypoxiarelated 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 percent,
taken at rest.
•
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 percent taken during sleep, and the patient demonstrates an arterial
PO2 at or above 56mm Hg or an arterial oxygen saturation at or above 89 percent 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
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percent, 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 PO2 at or
below 55mm Hg or an arterial oxygen saturation at or below 88 percent (taken during exercise)
and an arterial PO2 at or above 56mm Hg or an arterial oxygen saturation at or above 89 percent
(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 PO2 of 56
to 59mm Hg or an arterial blood oxygen saturation of 89 percent 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 percent
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 percent. 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 mental retardation 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.
Oxygen – Portable Systems
The IHCP covers a portable oxygen system if the patient is mobile within the home.
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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 8.64 lists billing codes and parameters for nebulizers with compressors.
Table 8.64 – 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 8.65 lists billing codes and parameters for phototherapy.
Table 8.65 – Billing Codes and Parameters – Phototherapy
Procedure Code
E0202
Modifier
RR
Description
Rental
Pneumograms
Providers should bill pneumograms using CPT code 94772 – Circadian respiratory pattern recording
(pediatric pneumogram), 12 to 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 8.66 lists billing codes and
parameters for pneumograms.
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Table 8.66 – Billing Codes and Parameters – Pneumograms
Procedure Code/Modifier
Description
94772
Circadian respiratory pattern recording (pediatric pneumogram), 12
to 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 8.67 shows
current coding options.
Providers should use HCPCS code E0618 when a member requires an apnea monitor without a
recording feature.
Table 8.67 – 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
Patient demands single or multiple event recording with pre-symptom memory loop,
per 30 day period of time; includes transmission, physician review, and
interpretation
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Procedure Code
Description
93270
Recording (includes hook-up, recording, and disconnection)
93271
Monitoring, receipt of transmissions, and analysis
93272
Physician review and interpretation only
Ventricular Assist Devices
Effective May 1, 2006, the IHCP instituted changes in 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 (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 ARBs or ACE inhibitors (if tolerated).
•
Left Ventricular Ejection Fraction (LVEF) must be less than 25 percent.
•
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.
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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 above have 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.
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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 that come standard on the
specific motorized or power wheelchair model provided because the total reimbursement for the
motorized or power wheelchair with programmable electronics (K0011) is all-inclusive under that
code. Effective for claims with dates of service July 18, 2003, or after, 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 them under HCPCS code K0108 with a KA modifier. Providers must bill
the wheelchair base with HCPCS code K0014. For claims submission, providers must attach a cost
invoice or 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 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 that 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 MCO 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
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 MCO 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
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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; E1009 and 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 deleted the HCPCS K codes K0650-K0658 on December 31, 2004, and crosswalked them
to HCPCS codes E2601-E2610. The HCPCS E codes became nonreimbursable after September 30,
2004.
For dates of service on or after September 1, 2006, the following codes are reimbursable for adjustable
seat cushions:
•
K0734 – Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
•
K0735 – Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
•
K0736 – Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22
inches, any depth
•
K0737 – Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or
greater, any depth
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 Statistical Analysis
Durable Medical Equipment Regional Carrier (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 the Indiana Administrative Code (IAC) citation 405 IAC 5-19-1, “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.
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 that 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
•
Frequency of use (for example, change dressing three times per day)
•
Anticipated duration of need
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•
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 that 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. 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
Coverage and Billing Procedures
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 (P.L. 153-1995) 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.
Providers must bill one of the CPT codes listed in Table 8.68, reflecting the appropriate level of
screening exam, on a CMS-1500 or 837P transaction.
Table 8.68 – CPT Codes – Appropriate Level of Screening Exam
CPT Codes
99281
99282
99283
Definitions
Emergency department visit – Level 1
Emergency department visit – Level 2
Emergency department visit – Level 3
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 claim does
not contain the PMP authorization. The authorization consists of the PMP NPI and the two-digit
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certification code. 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 MCO for more specific guidelines.
Evaluation and Management Services
Coverage and Billing Procedures
The purpose of this section of the billing instructions chapter is to provide the most current policy,
billing criteria, and reimbursement information for submitting claims for Evaluation and Management
(E/M) services.
The IHCP offers reimbursement for office visits limited to a maximum of 30 per year, per IHCP
member, without PA, and subject to the restrictions in Section 2 of this rule. The rules set in
405 IAC 5-9-1 apply to E/M services. The E/M codes in Table 8.69 are subject to this limitation.
Table 8.69 – Evaluation and Management Services Codes Subject to Limitation
CPT Code
99201-99215
99241-99245
99381-99397
Per 405 IAC 5-9-2, 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 that 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, or
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
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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. A
consultation implies collaboration between the requesting and the consulting physician. Providers
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.
Providers may bill a maximum of one unit per patient per day for procedure code 99051 – Service(s)
provided in the office during regularly scheduled evening, weekend, or holiday office hours, in
addition to basic service. Evening hours are defined as routinely scheduled after 5 p.m. in the
prevailing time zone. Providers may only bill for the following holidays, which represent days when
physician offices are generally closed for the day: New Year’s Day, Memorial Day, Independence
Day, Labor Day, Thanksgiving Day, and Christmas Day. When billing for 99051, please document in
the medical chart the time, date, or holiday, as applicable. All other billing requirements will remain
unchanged.
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
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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 an NF admission by the same provider.
Critical Care Services
The IHCP recognizes CPT codes 99291–99296 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.
Family Planning Services
Coverage and Billing Procedures
Family planning services are those 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. Refer to the Qualified Provider Presumptive Eligibility Manual
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, based on the presence of risk factors such as early onset of sexual intercourse and
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multiple sexual partners; 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 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.
See Table 8.70 for family planning ICD-9-CM codes.
Table 8.70 – 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
V2509
Contraceptive management, other
V251
Intrauterine device (IUD) insertion
V253
Menstrual extraction
V2540
Contraceptive surveillance, unspecified
V2541
Contraceptive pill surveillance
V2542
IUD surveillance
V2543
Implantable subdermal contraceptive
V2549
Contraceptive surveillance, other
V255
Insertion of implantable subdermal contraceptive
V258
Other specified contraceptive management
V259
Contraceptive management, unspecified
Providers must bill services and supplies not classified as drugs or biologicals using the CMS-1500 or
837P. Providers should bill these services using 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 using CPT code 99070 for supplies dispensed during a family planning visit should identify
the name of the item dispensed on the CMS-1500 or 837P, below the line item being billed. Identify
the quantity or number of packages dispensed in field 24G. The amount billed should reflect the
appropriate cost of the contraceptive item and should not exceed the NDC packaging price. Do not
substitute CPT code 99070 if an HCPCS code exists for the item dispensed. If billing electronically,
the provider can submit the NDC of the drug administration in the claim notes section of the 837
transaction, and the claim will adjudicate appropriately.
Ensure that 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.
Providers billing for Norplant Systems must use the CPT procedure codes listed in Table 8.71.
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Table 8.71 – CPT Procedure Codes for Norplant Systems
Procedure Code
Description
11975
Insertion, implantable contraceptive capsules
11976
Removal, implantable contraceptive capsules
11977
Removal with reinsertion, implantable contraceptive
capsules
In accordance with CPT Changes, An Insider’s View 2002, published by the American Medical
Association, “CPT Codes 11981–11983 differ from the other implant codes 11975–11977, in that
codes 11975–11977 are also a type of nonbiodegradable capsule, but are specific for contraceptive
use.” Table 8.72 lists CPT codes 11981–11983 and the description for clarification.
Table 8.72 – CPT Codes for Other Contraception Implants
CPT Code
Description
11981
Insertion, nonbiodegradable drug delivery implant
11982
Removal, nonbiodegradable drug delivery implant
11983
Removal with insertion, nonbiodegradable drug delivery
implant
The IHCP covers HCPCS codes J7303 – Contraceptive supply, hormone containing vaginal ring,
each, and J7304 – Contraceptive supply, hormone containing patch, each, effective October 1, 2005.
Providers must bill J7303 and J7304 instead of a miscellaneous supply code because these codes are
more specific to the service being supplied.
Limits and Restrictions for Depo-Provera Contraceptive Injection
HCPCS code J1055-Injection, medroxyprogesterone acetate for contraceptive use, 150 mg. The gender
indicator will be “Female.” The allowable units per date of service (DOS) will be limited to one.
According to the U.S. Food and Drug Administration (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 J1051 – Injection, medroxyprogesterone acetate, 50
mg, 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 MCO to which the member has been assigned.
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 about this process, contact the Indiana Primary Health Care Association at (317)
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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 that
reimbursement remains accurate. In the Care Select network, FQHC provider specialties are not
entitled to receive the monthly administrative fee payment.
Rural Health Clinics
RHCs receive their Medicare designation through CMS. The clinics must contact the 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 Indiana Department of Health, 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.
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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), significant changes
occurred with the IHCP reimbursement methodology for FQHCs and RHCs. Billing procedures and
administrative requirements also changed for fee-for-service billing for each type of facility. Providers
must use the prospective payment system (PPS) methodology for claims submitted with dates of
service (DOS) on or after April 1, 2003. All FQHC and RHC facilities must submit claims using
HCPCS Level III codes, including the current 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 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
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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.
Care Select
Claims submitted for Care Select members require PMP authorization if the service provided to the
member was not provided by the PMP. Refer to 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, 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 third-party liability (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 organization. Do not include the T1015 encounter
code on these claims. Myers and Stauffer, LC reconciles all managed care claims to the providerspecific PPS rate and makes annual settlements at that time. Providers may submit requests for
supplemental payment to Myers and Stauffer, LC. The MCOs 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.
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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 that did not cross
over to the IHCP. These are claims allowed by Medicare that failed to cross over and Medicare-denied
claims.
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 Web sites and documents, go to http://provider.indianamedicaid.com.
Providers that submit claims on paper when 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).
Provider 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 that 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 that 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 that occur within the same 24-hour period to be a single encounter
if they are for the same diagnosis. The IHCP considers them 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.
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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 so that they 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
•
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 encounters, care coordination, and
HealthWatch services. The Care Coordination Services section in this chapter and the
HealthWatch/EPSDT supplemental provider manual provide more information about those services.
HealthWatch/EPSDT Services
Coverage and Billing Procedures
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. Special emphasis is given to early
detection and treatment of health issues because these efforts can reduce the risk of more costly
treatment or hospitalizations that 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. A
copy of the HealthWatch manual is available on the Web site
at http://provider.indianamedicaid.com/general-provider-services/manuals.aspx.
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, refer to the HealthWatch/EPSDT Provider Manual for screening and referral details.
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Table 8.73 – CPT Codes for EPSDT Visits
Visits
CPT® CODES
EPSDT/Well Care
Provide preventive
care following the
EPSDT guidelines and
documenting the
components of the
screening to allow for
a higher level of
reimbursement.
Preventive:
99381-99385
Initial/New Patient
A comprehensive
prenatal visit meets all
of the requirements
for a preventive care
visit.
Sick Visit plus
EPSDT
(two visit codes)
V20.2 – Routine infant or
child health check
Includes:
•
Developmental testing
of infant or child,
Immunizations
appropriate for age
•
Initial and subsequent
routine newborn check
99391-99395
Established Patient
Evaluation and
Management:
99201-99205
New Patient
99211-99215
Established Patient
Preventive/
Well Care
Provide and document
preventive care at any
visit.
Include age
appropriate medical
history, physical
exam, and health
education.
ICD-9 Coding
First 15 months:
99381, 99382
Initial/New Patient
99391, 99392
Established Patient
3rd- 6th years:
99382, 99383
Initial/New Patient
99392, 99393
Established Patient
EPSDT visits must be
billed with V20.2 and
one of the CPT codes
listed. These visits are
eligible for additional
reimbursement.
Initial/New Patient
EPSDT
$75
•
Routine vision and
hearing
Use additional codes to
identify special screening
examinations performed.
Established Patient
EPSDT
$62
V20.2 – Routine infant or
child health check
Only a complete routine
infant/child health
check is provided.
Claim must be billed
with one of the CPT
codes listed and a listed
ICD-9 code.
V70.0 – Routine general
medical examination at a
health care facility
(excludes health checkup of
infant or child)
Initial/New Patient
Well-child $63-69
V70.3 – V70.9 as a
diagnosis
Established Patient
Well-child $50-56
Adolescent years:
99383-99385
Initial/New Patient
99391-99395
Established Patient
Prenatal Care:
59425 and 59426
Preventive visit
code and 9920399215 with
modifier 25
Additional
Reimbursement
V20.2 must be used as the
primary diagnosis for the
appropriate preventive visit
and multiple diagnoses for
presenting problem.
Sick visits depend on
complexity and
doctor/patient
relationship
(new/established)
$19-65
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
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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.
Managed Care Considerations
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 MCO can provide information.
Information on Care Select members can be obtained through the member’s CMO.
Hearing Aids
Coverage and Billing Procedures
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.
•
Reimbursement of the hearing aid includes dispensing fees, which are not separately billable.
•
The IHCP does not reimburse for canal hearing aids.
Maintenance and Repair
The IHCP reimburses for the maintenance and repair of hearing aids as defined in 405 IAC 5-19-14,
Hearing aids; maintenance and repairs, 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 every 12 months. Providers
can obtain PA for repairs more frequently for members under 18 years of age if the provider
documents circumstances justifying the need.
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•
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
CMS-1500 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.
•
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, Hearing
aids; replacement, and under the following conditions:
•
The IHCP reimburses for the replacement of hearing aids, subject to the conditions listed in the
maintenance and repairs 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 18 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. A registered audiology
aide can provide services under the direct on-site supervision of a licensed audiologist under 880
IAC 1-1.
•
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.
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-
-
-
-
The involved professional(s) 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
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 percent 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 percent.
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 an NF, large private
intermediate care facility for the mentally retarded (ICF/MR), or small ICF/MR.
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Augmentative Communication Devices
Coverage and Billing Procedures
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.
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
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•
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.
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 this rule and
405 IAC 5-22, Nursing and Therapy Services.
Pneumatic Artificial Voicing Systems
Coverage and Billing Procedures
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 that the member demonstrates sufficient mental and physical ability
to benefit from the use of the system
•
Documentation to substantiate that 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.
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Home and Community-Based Services Waiver Programs
Coverage and Billing Procedures
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, should continue to bill waiver services on the
CMS-1500 or 837P.
Note: Providers should verify member eligibility on the 1st and 15th of the month, because
member eligibility in managed care is effective on the 1st and 15th calendar days of
the month. If a member is enrolled in Hoosier Healthwise, contact that member’s
MCO immediately. MCO contact information is included in Chapter 1. If the
member is identified as a Care Select member, contact the care management
organization (CMO) to which the member is assigned.
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, either 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 shown on the approved notice of action (NOA). Providers must ensure that 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 addition, the service must be authorized on the
client’s NOA and listed on the member’s prior authorization file.
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 on how electronic signatures will be done, controlled, and verified.
Please see the Electronic Digital Signatures Act (IC 5-24) and the Uniform Electronic Transactions Act
(IC 26-2-8). The State Board of Accounts has promulgated a rule at 20 IAC 3 with additional
regulations. These citations are specific to documents transmitted to the state.
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Injections
Coverage and Billing Procedures
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
maximum allowable reimbursement is equal to Wholesale Acquisition Cost (WAC) plus 5 percent
(WAC+5%) of the benchmark NDC or, if no WAC data is available, CMS’ reimbursement, which is
currently Average Sales Price (ASP) plus 6 percent (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 dose-unspecified.
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 three injections per joint site, per provider, per month. Claims
submitted for more than three injections in a one-month period must have supporting documentation
attached to indicate that the provider administered no more than four injections to a single joint site.
Providers can utilize the claim note section to document that the injections are performed on different
joints and indicate the site of the injection.
The IHCP limits Vitamin B12 injections to one per 30 days per member.
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
immunization procedure 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 National
Drug Code (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.
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The Federal Deficit Reduction Act of 2005 requires that NDCs are submitted on the CMS-1500 in the
shaded area of field 24a beginning August 1, 2007. Because the State may pay up to the 20 percent
Medicare B copayment for dual-eligible individuals, the NDC is required on Medicare crossover
claims for all applicable procedure codes.
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 how drugs are determined to be less than effective is located
at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/12_LTEIRSDrugs.asp.
A list of noncovered, less than effective drugs (DESI) is located
at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/downloads/desi.pdf.
•
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 located
at: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComCon
tactInfo.asp. 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 the Indiana Medicaid Web site. This list
is reviewed and updated on an annual basis, or as determined by the OMPP. The procedure codes
listed in the document located at
http://provider.indianamedicaid.com/media/28002/pg%20154%20codes%20as%20of%205_06_08.pdf
do not guarantee coverage.
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 National Drug Code (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,
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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:
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 be reflective of 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 will 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 will no
longer need to use the KP and KQ modifiers. Providers will 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 change includes crossover claims as well.
Botulinum Toxin Coverage and Billing Procedures
Currently there are three available botulinum toxin products: Botox (J0585), Dysport (J0586), and
Myobloc (J0587). 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 bolulinum toxin products.
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Due to the short life of these products, the IHCP has developed the following policies when providers
administer less than a full vial in a single treatment session.
•
Because botulinium toxin type A is supplied in 100 unit vials, it will be appropriate for the
provider to bill the entire 100 units to Indiana Medicaid when less than 100 units are injected
in a single treatment session and the balance of the product is discarded. If more than 100
units are injected in a single treatment session, and the remainder is not used for another
patient, round the number of units billed on the claim up to the nearest 100 units. Whenever
unused botulinium toxin type A is billed, both the amount of the agent actually administered
and the amount discarded is to be documented in the patient’s medical record.
•
Due to the short shelf life of Myobloc, wastage of the product may be unavoidable. The IHCP
has adopted the following policy for billing unused units of Myobloc. Myobloc is supplied in
2,500 units, 5,000 units, and 10,000 units. When billing for Myobloc, the provider must show
the number of units given on the claim form. If a vial is split between two or more members,
the provider must bill the amount of the Myobloc used for each member and bill the unused
amount as wastage on the claim for the last member injected. If the provider does not split the
vial between two or more members, the provider may bill the discarded portion to the IHCP.
Whenever a provider bills for unused Myobloc, the provider must document the amount of
agent actually administered and the amount discarded in the member’s medical record.
•
Similarly, the IHCP has adopted the following policy for billing unused units of Dysport
(J0586). Dysport is supplied in 300 unit and 500 unit preservative-free, single-use vials. When
billing for Dysport, the provider must show the number of units given on the claim form and
may bill the discarded portion to the IHCP. Whenever a provider bills for unused Dysport, the
provider must document the amount of agent actually administered and the amount discarded
in the member’s medical record.
Providers should bill botulinum toxin injections using the appropriate HCPCS codes.
Table 8.74 – HCPCS Codes for Botulinum Toxin Injections
HCPCS Code
Code Description
J0585
Injection, onabotulinumtoxina, 1 unit
J0586
Injection, abobotulinumtoxina, 5 units
J0587
Injection, rimabotulinumtoxinb, 100 units
IHCP reimbursement for botulinum toxin injections must include one of the following CPT codes
available for billing chemodenervation, listed in Table 8.75.
Table 8.75 – 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 injections, 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
53899
Unlisted procedure, urinary system
64612
Chemodenervation of muscle(s); muscle(s) innervated by facial nerve
(e.g., for blepharospasm, hemifacial spasm)
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CPT Code
Definition
64613
Chemodenervation of muscle(s); cervical spinal muscles(s)
(e.g. for spasmodic torticollis)
64614
Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s)
(e.g., 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)
As of July 1, 2005, the IHCP limits reimbursement for Botox and Myobloc injections to the ICD-9-CM
diagnosis codes listed in Table 8.76.
Table 8.76 – ICD-9-CM Diagnosis Codes for Botox and Myobloc Injections
Diagnosis Codes
333.6
333.89
341.9
343.3
344.03
344.32
378.00
378.07
378.15
378.23
378.35
378.50
378.60
378.81
378.9
596.54
333.71
334.1
342.10
343.4
344.04
344.40
378.01
378.08
378.16
378.24
378.40
378.51
378.61
378.82
478.29
596.55
333.79
340
342.11
343.8
344.09
344.41
378.02
378.10
378.17
378.30
378.41
378.52
378.62
378.83
478.75
705.21
333.81
341.0
342.12
343.9
344.1
344.42
378.03
378.11
378.18
378.31
378.42
378.53
378.63
378.84
478.79
723.5
333.82
341.1
343.0
344.00
344.2
374.03
378.04
378.12
378.20
378.32
378.43
378.54
378.71
378.85
527.7
729.1
333.83
341.22
343.1
344.01
344.30
374.13
378.05
378.13
378.21
378.33
378.44
378.55
378.72
378.86
530.0
754.1
333.84
341.8
343.2
344.02
344.31
351.8
378.06
378.14
378.22
378.34
378.45
378.56
378.73
378.87
565.0
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 IFSSA Drug Claim Form instead of billing
unlisted codes on a CMS-1500 or 837P. Chapter 9 in this manual provides instructions for completing
the IFSSA Drug Claim Form.
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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
Coverage and Billing Procedures
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 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 8.77.
Table 8.77 – 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
Refer to the CMS Web site for information about the procedures that are eligible for reimbursement
under specific CLIA certificates. For more information, go to the Web
site http://www.cms.hhs.gov/clia 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.
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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
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, either in the Medicare Fee Schedule or in the
Medicare Clinical Laboratory Fee Schedule.
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.
Blood or blood products, blood testing, and tests involving physician interpretation are exceptions.
When providers submit codes from the list of codes in Table 8.78 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 8.78 – 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 antiserum
86886
Antihuman globulin test (Coombs test); indirect, titer, each antiserum
86900
Blood typing; ABO
86901
Blood typing; Rh (D)
86903
Blood typing; antigen screening for compatible blood unit using reagent serum, per unit
screened
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
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CPT Code
Description
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
Pretreatment of RBCs for use in RBC antibody detection, identification, and/or
compatibility testing; incubation with enzymes, each
86972
Pretreatment of RBCs for use in RBC antibody detection, identification, and/or
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
Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors,
each
86977
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
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.
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) 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
Providers should use the codes in Table 8.79 to bill HER2 protein over expression tests, HercepTest®,
as an aid in assessment of patients who use trastuzumab, HERCEPTIN®.
Table 8.79 – CPT Codes for HER2 Test
CPT Code
Description
88342
Immunohistochemistry, including tissue immunoperoxidase, each antibody
88365
Tissue in situ hybridization (e.g, 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
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 8.80 to bill it.
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Table 8.80 – CPT Codes for HER-2/neu Gene Detection Test
CPT Code
Description
83892
Molecular diagnostics; enzymatic digestion
88271
Molecular cytogenetics; DNA probe, each, for example, FISH
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
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 8.81 and the appropriate ICD-9-CM diagnosis codes shown in Table 8.82.
The IHCP limits HCPCS codes S3820, S3822, and S3823 to once per lifetime. If the IHCP has
provided reimbursement for HCPCS code S3820, the IHCP will not reimburse S3822 or S3823 for that
member because S3820 represents complete BRCA 1 and BRCA 2 gene sequence analysis.
IHCP reimbursement is not available for BRCA testing reported with the HCPCS codes listed in Table
8.83. However, reimbursement is available for the codes listed in Table 8.83 for genetic testing related
to other types of cancer, such as pancreatic carcinoma.
The IHCP gives PA for genetic testing related to breast and ovarian cancer, using the HCPCS codes
listed in Table 8.81 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
•
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 criteria listed above
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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 8.81 – HCPCS Codes to Report Genetic Testing for Breast and Ovarian Cancer
Diagnoses Only
Code
Description
Comments
S3820
Complete BRCA 1 and BRCA 2
gene sequence analysis for
susceptibility to breast and ovarian
cancer
S3820 encompasses all the testing for all the genetic
variations involving BRCA 1 and BRCA 2. Testing
required is more extensive than required for the
specific gene variations reported by S3822 and S3823.
S3822
Single mutation analysis (in
individual with a known BRCA 1 or
BRCA 2 mutation in the family) for
susceptibility to breast and ovarian
cancer
S3822 designates the test required for detection of
BRCA gene mutation for an individual with a family
member known to have BRCA 1 or BRCA 2
mutation.
S3823
Three-mutation BRCA 1 and BRCA
2 analysis for susceptibility to breast
and ovarian cancer in Ashkenazi
individuals
S3823 reports genetic testing for individuals of
Ashkenazi Jewish descent. Because there are known to
be fewer and more specific changes in this population
group, the amount of testing required is significantly less
than for the general population.
Table 8.82 – ICD-9-CM Codes Supporting Medical Necessity
Code
Description
174.0
Malignant neoplasm of female breast; nipple and areola
174.1
Malignant neoplasm of female breast; central portion
174.2
Malignant neoplasm of female breast; upper-inner quadrant
174.3
Malignant neoplasm of female breast; lower-inner quadrant
174.4
Malignant neoplasm of female breast; upper-outer quadrant
174.5
Malignant neoplasm of female breast; lower quadrant
174.6
Malignant neoplasm of female breast; axillary tail
174.8
Malignant neoplasm of female breast; other specified sites of breast
175.0
Malignant neoplasm of male breast; nipple and areola
175.9
Malignant neoplasm of male breast; other and unspecified sites of male breast
183.0
Malignant neoplasm of ovary and other uterine adnexa; ovary
183.2
Malignant neoplasm of ovary and other uterine adnexa; fallopian tube
183.3
Malignant neoplasm of ovary and other uterine adnexa; broad ligament
183.4
Malignant neoplasm of ovary and other uterine adnexa; parametrium
183.5
Malignant neoplasm of ovary and other uterine adnexa; round ligament
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Code
Description
183.8
Malignant neoplasm of ovary and other uterine adnexa; other specified sites of uterine
adnexa
183.9
Malignant neoplasm of ovary and other uterine adnexa; uterine adnexa, unspecified
V10.3
Personal history of malignant neoplasm; breast
V10.43
Personal history of malignant neoplasm; ovary
V16.3
Family history of malignant neoplasm; breast
V16.41
Family history of malignant neoplasm; ovary
Table 8.83 – CPT/HCPCS Codes to Report Other Genetic Testing Not to be Used for Breast
and Ovarian Cancer Diagnoses
Code
83891
83898
83904
Definition
Molecular diagnostics; isolation or extraction of highly purified nucleic acid
Molecular diagnostics; amplification of patient nucleic acid, each nucleic acid sequence
Molecular diagnostics; mutation identification by sequencing, single segment, each segment
83912
S3818
S3819
Molecular diagnostics; interpretation and report
Complete gene sequence analysis; BRCA 1 gene
Complete gene sequence analysis; BRCA 2 gene
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. The following procedure codes and
modifier combinations are effective December 1, 2007.
Table 8.84 – New Codes for Lead Testing
Procedure Code
Description
83655 U1
Assay of lead, using filter paper
83655 U2
Assay of lead, using handheld testing
device
83655
Assay of lead (venous blood)
Reimbursement
Rate
$10.00
$5.00
$16.72
Medical and Surgical Supplies
Coverage and Billing Procedures
Medical and surgical supplies (medical supplies) are items that are disposable, nonreusable, and must
be replaced on a frequent basis. The IHCP covers some medical supplies and does not cover others.
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 that
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
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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 codes. The IHCP denies all claims submitted on the pharmacy 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, intermediate care facilities for the mentally retarded) 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.
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.
Manually Priced Supplies
For medical supplies that are 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. Providers must submit documentation supporting the cost of the item, including a listing of all
materials. The IHCP uses the following guidelines to determine reimbursement:
•
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 percent above the invoice amount. The IHCP does not accept a
manufacturer’s price list as proof of purchase price for this level of reimbursement.
•
If a provider submits retail price lists from the manufacturer, the IHCP reimburses the claim at 90
percent of the price on the manufacturer’s retail price list but cannot 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 that indicates the price that a provider charges the general public for
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products or supplies, the IHCP reimburses the claim at 90 percent of the invoice or price list, not
to exceed the billed amount.
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
Coverage and Billing Procedures
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/enteral services and therapies to
the IHCP on the UB-04 claim form or 837I transaction.
Refer to 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
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 them crossover claims.
Medicare/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 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 of this
manual provides further information about provider enrollment.
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Mental Health Services
Coverage and Billing Procedures
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 MCO for payment. Services that require PA furnished to
members enrolled in RBMC must be prior-authorized by the MCO in accordance with the MCO
guidelines. Refer to http://provider.indianamedicaid.com/provider-specific-information/managedcare/hoosier-healthwise.aspx.
As stated in 405 IAC 5-20-8, the IHCP also 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)(3), 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
•
Licensed mental health counselor
•
A person holding a master’s degree in social work, marital and family therapy, or mental health
counseling
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
described as stated in 405 IAC 5-20-8 (3) (a) (b)). 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.
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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 5-20-8 (4).
The IHCP requires PA for all units of neuropsychology and psychological testing. This applies to CPT
96101 – psychological testing, 96110 – developmental testing, 96111 – developmental testing
extended, and 96118 – neuropsychological testing battery. According to 405 IAC 5-20-8(5), a
physician or HSPP must provide these services.
According to 405 IAC 5-20-8 (10), reimbursement is available for one unit of psychiatric diagnostic
interview, CPT codes 90801 or 90802, per member, per provider, per rolling 12-month period. All
additional units of psychiatric diagnostic interviews require prior authorization, except 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:
•
90801–90802
•
90804–90815
•
90845–90857
•
96151–96153
The IHCP does not cover the following services:
•
Biofeedback
•
Broken or missed appointments
•
Day care
•
Hypnosis
•
Partial hospitalization, except as set in 405 IAC 5-21
CPT codes 90805, 90807, 90809, 90811, 90813, and 90815 for psychotherapy with medical evaluation
and management, and CPT code 90862 for pharmacological management are medical services.
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
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•
HE – Services provided by any other mid-level practitioner as addressed in the 405 IAC 5-20-8
(10)
•
HW – Medicaid Rehabilitation Option (MRO) services
•
SA – NP/CNS in a nonmental health arena
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 impact reimbursement – the IHCP
reimburses at 75 percent 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 percent 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 above that identify the qualifications or the individual rendering the service. Place the modifiers
in field 24D of the CMS-1500 claim form. Additional information about MRO services is published in
the MRO Provider Manual.
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
Medicaid Rehabilitation Option Services are clinical mental health services that the IHCP covers for
individuals, families, or groups living in the community who need aid intermittently for emotional
disturbances or mental illness. The IHCP reimburses for the following MRO, outpatient mental health
services:
•
Assertive Community Treatment
•
Case management services
•
Conjoint counseling or psychotherapy
•
Crisis intervention
•
Diagnostic assessment and prehospitalization screening
•
Family counseling or psychotherapy
•
Group counseling or psychotherapy
•
Group training in activities of daily living
•
Individual counseling or psychotherapy
•
Medication or somatic treatment
•
Partial hospitalization
•
Prehospitalization screening
•
Training in activities in daily living
As stated in 405 IAC 5-21, 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
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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 must
render these services as outlined in 405 IAC 5-21-1-C-(1-5).
Coverage of Mental Health Codes for Children’s Health Insurance Program
Effective January 1, 2010, for dates of service on or after January 1, 2010, the IHCP will reimburse for
mental health services, including Psychiatric Residential Treatment Facility (PRTF) and Medicaid
Rehabilitation Option (MRO) services under Children’s Health Insurance Plan (CHIP, or Package C).
This change comes as a result of Senate Enrolled Act 102.
Prior authorization (PA) is required for any codes currently requiring PA for fee-for-service
beneficiaries. Providers may submit claims for services that have been rendered on or after January 1,
2010.
Table 8.85 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 8.85 – Codes for Covered Services under CHIP
Code/Modifier
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Description
H0004 HW
Behavioral health counseling and therapy
H0004 HW HQ
Behavioral health counseling and therapy, group setting
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
H0033 HW
Oral medication administration, direct observation
H0035 HW
Mental health partial hospitalization, treatment, less than 24
hours
H0040 HW
Assertive community treatment program, per diem
H2011 HW
Crisis intervention service, per 15 minutes
H2014 HW
Skills training and development, per 15 minutes
T1016 HW
Case management, each 15 minutes
T1016 HW TG
Case management, second case manager
97535
Self-care/home management training
97537
Community/work reintegration training
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
Behavioral health; long-term care residential (nonacute care
in a residential treatment program where stay is typically
longer than 30 days); medical leave days are limited to four
(PRTF)
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Code/Modifier
Description
T2048 U2
Behavioral health; long-term care residential (nonacute care
in a residential treatment program where stay is typically
longer than 30 days); therapeutic leave days are limited to
14 (PRTF)
90801
Psychiatric diagnostic interview examination
90802
Interactive psychiatric diagnostic interview examination
using play equipment, physical devices, language
interpreter, or other mechanisms of communication
90804
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an office or outpatient
facility, approximately 20 to 30 minutes face-to-face with
the patient
90805
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an office or outpatient
facility, approximately 20 to 30 minutes face-to-face with
the patient, with medical evaluation and management
services
90806
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an office or outpatient
facility, approximately 45 to 50 minutes face-to-face with
the patient
90807
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an office or outpatient
facility, approximately 45 to 50 minutes face-to-face with
the patient, with medical evaluation and management
services
90808
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an office or outpatient
facility, approximately 75 to 80 minutes face-to-face with
the patient
90809
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an office or outpatient
facility, approximately 75 to 80 minutes face-to-face with
the patient, with medical evaluation and management
services
90810
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an office or
outpatient facility, approximately 20 to 30 minutes face-toface with the patient
90811
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an office or
outpatient facility, approximately 20 to 30 minutes face-toface with the patient, with medical evaluation and
management services
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Code/Modifier
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Description
90812
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an office or
outpatient facility, approximately 45 to 50 minutes face-toface with the patient
90813
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an office or
outpatient facility, approximately 45 to 50 minutes face-toface with the patient, with medical evaluation and
management services
90814
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an office or
outpatient facility, approximately 75 to 80 minutes face-toface with the patient
90815
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an office or
outpatient facility, approximately 75 to 80 minutes face-toface with the patient, with medical evaluation and
management services
90816
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an inpatient hospital,
partial hospital or residential care setting, approximately 20
to 30 minutes face-to-face with the patient
90817
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an inpatient hospital,
partial hospital or residential care setting, approximately 20
to 30 minutes face-to-face with the patient, with medical
evaluation and management services
90818
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an inpatient hospital,
partial hospital or residential care setting, approximately 45
to 50 minutes face-to-face with the patient
90819
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an inpatient hospital,
partial hospital or residential care setting, approximately 45
to 50 minutes face-to-face with the patient, with medical
evaluation and management
90821
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an inpatient hospital,
partial hospital or residential care setting, approximately 75
to 80 minutes face-to-face with the patient
90822
Individual psychotherapy, insight oriented, behavior
modifying and/or supportive, in an inpatient hospital,
partial hospital or residential care setting, approximately 75
to 80 minutes face-to-face with the patient, with medical
evaluation and management
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Code/Modifier
Description
90823
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an inpatient
hospital, partial hospital or residential care setting,
approximately 20 to 30 minutes face-to-face with the
patient
90824
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an inpatient
hospital, partial hospital or residential care setting,
approximately 20 to 30 minutes face-to-face with the
patient, with medical evaluation and management
90826
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an inpatient
hospital, partial hospital or residential care setting,
approximately 45 to 50 minutes face-to-face with the
patient
90827
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an inpatient
hospital, partial hospital or residential care setting,
approximately 45 to 50 minutes face-to-face with the
patient with medical evaluation and management services
90828
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an inpatient
hospital, partial hospital or residential care setting,
approximately 75 to 80 minutes face-to-face with the
patient
90829
Individual psychotherapy, interactive, using play
equipment, physical devices, language interpreter, or other
mechanisms of nonverbal communication, in an inpatient
hospital, partial hospital or residential care setting,
approximately 75 to 80 minutes face-to-face with the
patient, with medical evaluation and management services
90845
Psychoanalysis
90846
Family psychotherapy (without the patient present)
90847
Family psychotherapy (conjoint psychotherapy) (with
patient present)
90849
Multi-family group psychotherapy
90853
Group psychotherapy (other than of a multi-family group)
90857
Interactive group psychotherapy
90862
Pharmacological management, including prescription, use,
and review of medication with no more than minimal
medical psychotherapy
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Code/Modifier
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Description
90870
Electroconvulsive therapy (includes necessary monitoring)
90899
Unlisted psychiatric service or procedure
96101
Psychological testing (includes psycho diagnostic
assessment of emotionality, intellectual abilities,
personality and psychopathology, e.g, 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
96105
Assessment of aphasia (includes assessment of expressive
and receptive speech and language function, language
comprehension, speech production ability, reading,
spelling, writing, e.g, by Boston Diagnostic Aphasia
Examination) with interpretation and report, per hour
96110
Developmental testing; limited (e.g, Developmental
Screening Test II, Early Language Milestone Screen), with
interpretation and report
96111
Developmental testing; extended (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, e.g, 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 (e.g, 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 (e.g, 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 (e.g, 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 (two or more patients)
96154
Health and behavior intervention, each 15 minutes, face-toface; family (with the patient present)
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Code/Modifier
96155
Description
Health and behavior intervention, each 15 minutes, face-toface; family (without the patient present)
Assertive Community Treatment Service
Assertive community treatment (ACT) is an intensive mental health service for members discharged
from a hospital after multiple or extended stays, or who are difficult to engage in treatment. An
interdisciplinary team provides ACT services as defined under 440 IAC 5.2-2-3, and a physician must
order the services.
Members receiving this intensive level of community support will experience increased community
tenure and decreased frequency or length of hospitalization or crisis services.
The IHCP requires PA for ACT services that it covers. Before admission to an approved ACT team
under 440 IAC 5.2-2-3, the ACT team psychiatrist must document and review an assessment of the
member’s current medical status, psychiatric history, status at time of consideration for ACT services,
and treatment plan goals. Refer to Chapter 6 of this manual for additional information about prior
authorization.
The IHCP requires development of an individual treatment plan that includes: medication
administering and monitoring; self medication monitoring; crisis assessment and intervention;
symptom assessment, management, and individual supportive therapy; substance abuse training and
counseling; psychosocial rehabilitation and skill development; personal, social, and interpersonal skill
training; and coordination with case management, consultation, and psycho-educational support for
individuals and their families provided on behalf of the ACT member.
Services must be available 24 hours a day, seven days a week with emergency response coverage,
including availability of a psychiatrist. Members receiving ACT services must not attend traditional
partial hospitalization programs.
To meet the service standard, the ACT team must meet and discuss the services rendered, scheduled
services, and progress of ACT members on a daily basis during the five-day work week. ACT teams
should have a procedure in place to track daily team meeting attendance and client tracking (for
example, cardex system, minutes, and so forth).
Providers may submit claims for ACT services using the CMS-1500 paper claim or HIPAA-compliant
electronic 837P claim. Providers may bill the IHCP for one unit of ACT service daily per approved
member, provided that the ACT team meets the ACT service standard. Providers must use HCPCS
level II code H0040 – ACT services, per diem and modifier HW – State mental health agency funded
to bill ACT services at 100 percent of the Medicaid allowable amount.
One unit of ACT service equals one 24-hour day. The ACT team psychiatrist or an HSPP who is an
ACT team member must be present at the daily team meeting for the IHCP to reimburse the service
code at 100 percent. When the ACT team psychiatrist or HSPP is not in attendance at the daily team
meeting, the mid-level practitioner is reimbursed at 75 percent. All appropriate modifiers must be used
for correct billing. Follow the billing and modifier guidelines described in this chapter for correct
billing guidelines for mid-level practitioner services.
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Note: The IHCP restricts MRO services to providers enrolled as Community
Mental Health Centers who also meet the requirements for approval by the
Division of Mental Health under IC 12-29 in accordance with 440 IAC 4.
MRO enrolled providers must refer to the separate MRO Provider Manual
for detailed eligibility, billing, and reimbursement information. Chapter 4 of
this manual provides more information.
Psychiatric Residential Treatment Facilities
Coverage Provisions
The IHCP reimburses for medically necessary services provided to children younger than 21 years old
in a psychiatric residential treatment facility (PRTF). The IHCP also reimburses for children younger
than 22 years old who began receiving PRTF services immediately before their 21st birthday. All
services require prior authorization by the appropriate MCO or CMO.
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 of this manual.
Managed Care Considerations
Risk-based Managed Care
The IHCP carves out PRTF services from the risk-based MCOs’ financial responsibility. However,
MCOs 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 1st 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) Care Select. 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 1st and 15th of each
month to confirm the member’s current care management eligibility.
Hoosier Healthwise Package C
Hoosier Healthwise Package C does not cover PRTF services.
Leave Days
The days of care that can be billed to the IHCP for a member admitted to a PRTF shall 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.
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Although it is not mandatory for facilities to reserve beds, Medicaid will reimburse 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 percent. The occupancy rate shall
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.
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 percent. 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 percent. Documentation will be 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 percent. 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 percent. 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
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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.
•
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.
Managed Care Considerations
Risk-based Managed Care
The 2007 Hoosier Healthwise MCO Procurement project carved in most behavioral health services to
the RBMC program. Beginning with dates of service of January 1, 2007, services rendered by
providers enrolled in the IHCP with the following provider specialties are the responsibility of the
MCO:
•
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 listed
above should be billed directly to the applicable Behavioral Health Organization (BHO) subcontracted
by the MCO. Behavioral health services rendered by nonmental health provider specialties should be
billed to the applicable MCO.
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
MCOs retain responsibility for services outside the PRTF, including transportation, pharmacy, and
other related healthcare services. MCOs are also responsible for care coordination of members
receiving PRTF services. PRTF services are not covered for Package C members.
•
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
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disturbances or mental illness. MRO services include outpatient mental health services, partial
hospitalization, case management, and Assertive Community Treatment.
As with other carved-out services, the MCO remains responsible for services that may be related to the
PRTF or MRO services, 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 upon qualification for such services:
•
Services in an ICF/MR
•
Inpatient services in a state psychiatric hospital, which are not Medicaid services, but are provided
under the State’s 590 program
Screening and Brief Intervention Services
Beginning October 1, 2008, the IHCP began reimbursing providers for screening and brief intervention
(SBI) services. SBI identifies and intervenes with individuals who are at risk for substance abuserelated 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 8.86.
Table 8.86 – Screening and Brief Intervention Service Procedure Codes
Code
Description
99408
Alcohol and/or substance abuse structured screening and brief
intervention services, 15-30 minutes
99409
Alcohol and/or substance abuse structured screening and brief
intervention services, greater than 30 minutes
The new 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 does not count toward the number of annual office visits allowed per year for an
individual. Providers can submit claims for services rendered for dates of service beginning October 1,
2008.
Mid-Level Practitioner Services
Coverage and Billing Procedures
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
percent of the rate on file. The nurse practitioner must enter his or her rendering NPI number in
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field 24J of the CMS-1500. The billing NPI must be entered in field 33a on the CMS-1500 claim
form.
•
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 them at 100 percent of the Medicaidallowed amount.
•
Nurse practitioners with an individual LPI and NPI and 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 them at 100 percent 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, bachelors
degree or HO, masters degree modifier applicable to the level of education of the physician
assistant. The physician rendering NPI must be entered in field 24J of the CMS-1500. The
physician billing NPI must be entered in field 33a on the CMS-1500 claim form. The IHCP
reimburses them at 100 percent 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 percent 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
Coverage and Billing Procedures
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.
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.
Pharmacy Providers
The IHCP reimburses pharmacy providers for smoking cessation products when a licensed practitioner
prescribes them within the scope of the practitioner’s license under Indiana law. For the pharmacy to
be reimbursed by the IHCP for over-the-counter smoking cessation products, a licensed practitioner
must prescribe them. The practitioner must prescribe all smoking cessation products for use, along
with counseling, within the 12-week treatment time frame. There is a limit of 84 days of smoking
cessation therapy in 365 calendar days. Pharmacies should bill for reimbursement according to the
normal procedures.
Note: Only patients who agree to participate in smoking cessation counseling may
receive prescriptions for smoking cessation products. The prescribing
practitioner may want to have the patient sign a commitment to establish a
“quit date” and to participate in counseling as the first step in smoking
cessation treatment. A prescription for such products serves as
documentation that the prescribing practitioner has prescribed or obtained
assurance from the patient that counseling occurs concurrently with the
receipt of smoking cessation products.
Smoking Cessation Products
The list of smoking cessation products that the IHCP covers includes, but is not limited to, the
following:
•
Sustained release buproprion products
•
Varenicline tartrate tablets
•
Nicotine replacement drug products, such as a patch, gum, or inhaler
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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
SUR 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.
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.
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 S9075 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.
Newborn Services
Coverage and Billing Procedures
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(c) identifies religious belief exception from this
requirement. The hospital obtains a blood sample from the infant, even if the sample is taken at less
than 48 hours, which is the time needed to obtain valid test results.
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
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) Laboratory.
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The IU Laboratory has a contract with the 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.
Providers must first determine whether IU Laboratory has obtained valid newborn screening test
results for the infant. IU Laboratory results can be verified by calling 1-800-245-9137 or (317) 4916625 or (317) 491-6678. If 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 call the ISDH
at 1-800-761-1271, extension 1250, to work out the best method of accomplishing the rescreening.
Because hospitals are more frequently releasing newborns prior to 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 that 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 number.
Newborn Hearing Screening
Indiana legislation mandates that every infant shall 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 who require
further evaluation should be referred to First Steps. Refer to this Web site for contact
information: http://www.in.gov/fssa/ddrs/2633.htm.
Providers who 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 that results from detection of possible audiological impairment
via the newborn screening process, providers should bill in the same manner that they bill other
audiological testing. Providers should obtain PA if applicable.
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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 will be subsequently
completed by the Division of Family Resources (DFR). Failure on behalf of the patient to cooperate
with DFR to complete the Medicaid application process will result 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.
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 percent 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 Qualified Provider training session provided by the Family and Social Services
Administration (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 MCO as selected by the patient and/or HP
fee-for-service claims. Covered PE services are similar to Package B services, except for the limited
diagnosis listing below. More information about billing for Obstetrical Services and Package B is
found within this chapter. Contact information for the MCOs can be found in Chapter 1 of this manual.
Qualified providers follow general billing directions for completing the CMS-1500 claim form.
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Table 8.87 – Presumptive Eligibility Covered Diagnosis Codes
Diagnosis Code
63300
63301
63311
63321
63381
63391
640
6400
64003
64083
6408
6409
64093
641
6410
64103
64113
64123
6413
64133
6418
64183
6419
64193
64203
64213
64223
64233
64243
64253
64263
64273
64293
643
6430
64303
6431
64313
6432
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Description
ABD PREG W/O INTRAUTER PR
ABD PREG W/INTRAUTER PRG
TUBAL PREG W/INTRAUT PREG
OVAR PREG W/INTRAUT PREG
OTH ECT PREG W/INTRA PREG
ECT PREG NOS W/INTRA PREG
HEMORRHAGE IN EARLY PREG
THREATENED ABORTION
THREATENED ABORTION-ANTEP
HEMORR IN EARLY PREG NECHEMORR IN EARLY PREG NECHEMORR IN EARLY PREG
HEMORR IN EARLY PREG NOSANTEPART HEM & PLAC PREV
PLACENTA PREVIA W/O HEM
PLACENTA PREVIA W/O HEM-A
PLACENTA PREV HEM-ANTEPAR
PREM SEPAR PLAC-ANTEPART
COAG DEF ANTEPART HEMORR
COAG DEF HEMORR-ANTEPART
ANTEPARTUM HEMORR NEC
ANTEPART HEM NEC-ANTEPAR
ANTEPARTUM HEMORR NOS
ANTEPART HEM NOS-ANTEPAR
ESSEN HYPERTEN-ANTEPART
RENAL HYPERTEN-ANTEPART
OLD HYPERTEN NEC-ANTEPAR
TRANS HYPERTEN-ANTEPART
MILD/NOS PREECLAMP-ANTEP
SEV PREECLAMP-ANTEPARTUM
ECLAMPSIA-ANTEPARTUM
TOX W OLD HYPER-ANTEPART
HYPERTENS NOS-ANTEPARTUM
EXCESS VOMITING IN PREG
MILD HYPEREMESIS GRAVIDAR
MILD HYPEREMESIS GRAVID-A
HYPEREM GRAV W METAB DIS
HYPEREM GRAV W METAB DISLATE VOMITING PREGNANCY
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Diagnosis Code
64323
6438
64383
6439
64393
644
6440
64403
6441
64413
645
6451
64513
64523
6453
646
6460
64603
6461
64613
64623
64633
64643
64653
6463
6464
6465
64663
6467
64673
6468
64683
6469
64693
64703
64713
64723
64733
64743
64753
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Description
LATE VOMITING PREGNANCY-A
VOMITING COMPL PREG NEC
VOMITING COMPL PREGNANCYVOMITING PREGNANCY NOS
VOMITING PREGNANCY NOS-AN
EARLY/THREATENED LABOR
THREATEN PREMATURE LABOR
THREAT PREM LABOR-ANTEPAR
THREATENED LABOR NEC
THREAT LABOR NEC-ANTEPAR
LATE PREGNANCY
PROLONGED PREG
POST TERM PREG, ANTEPART)
PROLONG PREG, ANTEPART C/
PROLONGED PREG-ANTEPART
OTHER COMPL OF PREGNANCY
PAPYRACEOUS FETUS
PAPYRACEOUS FET-ANTEPAR
EDEMA IN PREGNANCY
EDEMA IN PREG-ANTEPARTUM
RENAL DIS NOS-ANTEPARTUM
HABITUAL ABORT-ANTEPART
NEURITIS OF PREG-ANTEPAR
ASY BACTERIURIA-ANTEPART
HABITUAL ABORTER
PERIPHERAL NEURITIS PREG
ASYMPT BACTERIURIA PREG
GU INFECTION-ANTEPARTUM
LIVER DISORDER IN PREG
LIVER DISORDER-ANTEPART
PREGNANCY COMPL NEC
PREG COMPL NEC-ANTEPART
PREGNANCY COMPL NOS
PREG COMPL NOS-ANTEPART
SYPHILIS-ANTEPARTUM
GONORRHEA-ANTEPARTUM
OTHER VD-ANTEPARTUM
TUBERCULOSIS-ANTEPARTUM
MALARIA-ANTEPARTUM
RUBELLA-ANTEPARTUM
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Diagnosis Code
64763
64783
64793
64803
64813
64823
64833
64843
64853
64863
64873
6488
64883
64893
65103
65113
65123
65133
65143
65153
65163
65173
65183
65193
65203
65213
65223
65233
65243
65253
65263
65273
65283
65293
65303
65313
65323
65333
65343
65353
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Revision Date: August 26, 2010
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Description
OTH VIRAL DIS-ANTEPARTUM
INFECT DIS NEC-ANTEPART
INFECT NOS-ANTEPARTUM
DIABETES-ANTEPARTUM
THYROID DYSFUNC-ANTEPART
ANEMIA-ANTEPARTUM
DRUG DEPENDENCE-ANTEPART
MENTAL DISORDER-ANTEPART
CONGEN CV DIS-ANTEPARTUM
CV DIS NEC-ANTEPARTUM
BONE DISORDER-ANTEPARTUM
ABN GLUC TOLERAN IN PREG
ABN GLUCOSE-ANTEPARTUM
OTH CURR COND-ANTEPARTUM
TWIN PREGNANCY-ANTEPART
TRIPLET PREG-ANTEPARTUM
QUADRUPLET PREG-ANTEPART
TWIN PREG FET LOSS-ANTEPA
TRIPLET PREG FET LOSS-ANT
QUADRUP PREG FET LOSS-ANT
OTH MULT PREG FET LOSS-AN
MULT GEST POST W/ANTE
MULTI GEST NEC-ANTEPART
MULTI GEST NOS-ANTEPART
UNSTABLE LIE-ANTEPARTUM
CEPHAL VERS NOS-ANTEPART
BREECH PRESENT-ANTEPART
TRANSV/OBLIQ LIE-ANTEPAR
FACE/BROW PRES-ANTEPART
HIGH HEAD TERM-ANTEPART
MULT GEST MALPRES-ANTERPA
PROLAPSED ARM-ANTEPART
MALPOSITION NEC-ANTEPART
MALPOSITION NOS-ANTEPART
PELV DEFORM NOS-ANTEPART
CONTRAC PELV NOS-ANTEPAR
INLET CONTRACT-ANTEPART
OUTLET CONTRACT-ANTEPART
FETOPELV DISPROP-ANTEPART
FETAL DISPROP NOS-ANTEPAR
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Diagnosis Code
65363
65373
65383
65393
65403
65413
65423
65433
65443
65453
65463
65473
65483
65493
655
65503
65513
65523
65533
65543
65553
65563
65573
65583
65593
65603
65613
65623
65633
65653
65663
65673
65683
65693
65703
65803
65843
65883
65893
65943
8-288
Description
HYDROCEPH FETUS-ANTEPART
OTH ABN FET DISPROP-ANTEP
DISPROPOR NEC-ANTEPARTUM
DISPROPOR NOS-ANTEPARTUM
CONGEN ABN UTER-ANTEPART
UTERINE TUMOR-ANTEPARTUM
PREV C-SECT NOS-ANTEPART
RETROVERT UTER-ANTEPART
ABN UTERUS NEC-ANTEPART
CERV INCOMPET-ANTEPARTUM
ABN CERVIX NEC-ANTEPART
ABNORM VAGINA-ANTEPARTUM
ABNORMAL VULVA-ANTEPART
ABN PELV ORG NOS-ANTEPAR
FETAL ABN AFFECT MOTHER
FETAL CNS MALF ORM-ANTEPA
FET CHROMOS ABN-ANTERPART
FAMIL HERED DIS-ANTEPART
FET DAMG D/T VIRUS-ANTEP
FET DAMG D/T DIS-ANTEPAR
FET DAMG D/T DRUG-ANTEP
RADIAT FET DAMAG-ANTEPAR
DECREASED FETAL MOVEMENTS
FETAL ABNORM NEC-ANTEPAR
FETAL ABNORM NOS-ANTEPAR
FETAL-MATERN HEM-ANTEPAR
RH ISOIMMUNIZAT-ANTEPART
ABO ISOIMMUNIZAT-ANTEPAR
FETAL DISTRESS-ANTEPART
POOR FETAL GRTH-ANTEPART
EXCESS FET GRTH-ANTEPART
OTH PLACENT COND-ANTEPAR
FET/PLAC PROB NEC-ANTEP
FET/PLAC PROB NOS-ANTEP
POLYHYDRAMNIOS-ANTEPART
OLIGOHYDRAMNIOS-ANTEPAR
INFECT AMNIOTIC CAVITY-AN
AMNIOTIC CAVITY PROB NECAMNIOTIC CAVITY PROB NOSGRAND MULTIPARITY-ANTEP
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Diagnosis Code
65953
65963
65973
66303
66313
66323
66333
66343
66353
66363
66383
66393
66503
66583
66593
67103
67113
67123
67133
67153
67183
67193
67303
67313
67323
67333
67383
67403
67503
67513
67523
67583
67593
67603
67613
67623
67633
67643
67653
67663
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Revision Date: August 26, 2010
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Description
ELDERLY PRIMIG RAVIDA-ANT
OTHER ADVANCED MATERNAL A
ABNORMALITY IN FETAL HEAR
PROLAPSE OF CORD-ANTEPAR
COMP CORD ROUND NECK-ANTE
CORD ENTANGLE W COMP-ANTE
CORD-ENTANGLE NEC/NOS-ANT
SHORT UMBILICAL CORD-ANTE
VASA PREVIA-ANTEPAR
VASC LESIONS OF CORE-ANTE
UMBILICAL CORD COMP NEC-A
UMBILICAL CORD COMP NOS-A
PRELAB RUPT UTER-ANTEPAR
OB TRAUMA NEC-ANTEPARTUM
OB TRAUMA NOS-ANTEPARTUM
VARIC VEIN LEG-ANTEPART
VARICOSE VULVA-ANTEPART
THROMBOPHLEBIT-ANTEPART
DEEP THROM ANTEPAR-ANTEPA
THROMBOSIS NEC-ANTEPART
VENOUS COMPL NEC-ANTEPAR
VENOUS COMPL NOS-ANTEPAR
OB AIR EMBOLISM-ANTEPART
AMNIOTIC EMBOL-ANTEPART
BLOOD-CLOT EMBOL-ANTEPART
OB PYEMIC EMBOL-ANTEPART
PULMON EMBOL NEC-ANTEPAR
CEREBROVASC DIS-ANTEPART
INFECT NIPPLE-ANTEPARTUM
BREAST ABSCESS-ANTEPART
MASTITIS-ANTEPARTUM
BREAST INF NEC-ANTEPART
BREAST INF NOS-ANTEPART
RETRACT NIPPLE-ANTEPART
CRACKED NIPPLE-ANTEPART
BREAST ENGORGE-ANTEPART
BREAST DIS NEC/NOW-ANTEPA
LACTATION FAIL-ANTEPART
SUPPR LACTATION-ANTEPART
GALACTORRHEA-ANTEPARTUM
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Diagnosis Code
67683
67693
7600
7601
7602
7603
7604
7605
V189
V22
V23
V234
V238
V28
V220
V221
V222
V230
V231
V232
V233
V235
V237
V2381
V2382
V2389
V239
V2631
V2632
V2633
V280
V281
V282
V283
V284
V285
V286
V289
8-290
Description
LACTAT DIS NEC-ANTEPART
LACTAT DIS NOS-ANTEPART
MATERN HYPERTEN AFF NB
MATERN URINE DIS AFF NB
MATERNAL INFEC AFF NB
MATERN CIRULAT/RESPIRAT A
MATERN NUTRIT DIS AFF NB
MATERNAL INJURY AFF NB
FH GENT DIS CARRIER
NORMAL PREGNANCY
SUPERVIS HIGH-RISK PREG
PREG W POOR OBSTETRIC HX
SUPRV HIGH-RISK PREG NEC
ANTENATAL SCREENING
SUPERVIS NORMAL 1ST PREG
SUPERVIS OTH NORMAL PREG
PREG STATE, INCIDENTAL
PREG W HX OF INFERTILITY
PREG W HX-TROPHOBLAS DIS
PREG W HX OF ABORTION
GRAND MULTIPARITY
PREG W POOR REPRODUCT HX
INSUFFICIENT PRENATAL CAR
SUPERVISION OF HIGH RISK
SUPERVISION OF HIGH RISK
SUPERVISION OF OTHER HIGH
SUPRV HIGH-RISK PREG NOS
TEST FEM GENET DIS CAR ST
OTH GENET TESTING OF FEMA
GENETIC COUNSEL
SCREENING-CHROMOSOM ANOM
SCREEN-ALPHAFETOPROTEIN
SCREEN BY AMNIOCENT NEC
SCREEN-FETAL MALFORM
SCREEN-FETAL RETARDATION
SCREEN-ISOIMMUNIZATION
SCREENING STREPTOCOCCUS B
ANTENATAL SCREENING NOS
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Obstetrical Services
Coverage and Billing Procedures
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. Providers must individually list each antepartum visit on the CMS-1500 or 837P.
Providers can 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 services within a trimester within 30 days of the end of the trimester.
Providers should bill each antepartum visit separately using CPT procedure codes 59425 or 59426.
Submit visits four through six with the procedure code 59425 at each visit. Submit the seventh, and all
subsequent visits, with procedure code 59426 at each visit. Providers may use a new or established
patient E/M code, 99201–99215, for the first through third antepartum visits to accommodate the
greater amount of work involved with each visit. However, providers should use the appropriate
antepartum care code to bill all subsequent antepartum visits. If providers report an E/M code for the
first visit, they must use the appropriate trimester modifier and expected date of delivery.
To identify antepartum visits in each trimester, providers must bill one of the following modifiers in
conjunction with CPT procedure code 59425, 59426, or 99201-99215 (if used for the first antepartum
visit) with each specific date of service. Place the modifier following the CPT code in field 24D of the
CMS-1500. Table 8.88 lists modifiers for antepartum visits.
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Use the modifiers in Table 8.88, in conjunction with 59425 and 59426, to denote the appropriate
trimester.
Table 8.88 – 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 them 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 within 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.
The trimester schedules in Table 8.89 are uniform with standards established by the ACOG and the
American Academy of Pediatrics (AAP).
Table 8.89 – 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
CMV antibody titer
86694
Herpes simplex test
86701
HIV test (optional)
86777
Toxoplasma antibody titer
88150, 88152-88155
Cervical cytology (Pap smear)
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CPT Code
Procedure
Total obstetrical panel includes:
80055
•
CBC with complete differential
•
Hepatitis B surface antigen
•
Rubella antibody titer
•
Syphilis test
•
Antibody screen, RBC
•
Blood typing (ABO)
• Blood typing (RhD)
Or instead of 80055, use the following:
85025
CBC with complete differential
87340
Hepatitis B surface antigen
86762
Rubella antibody titer
86592
Syphilis test; qualitative such as VDRL, RPR, ART
86850
Antibody screen, RBC
86900
Blood typing (ABO)
86901
Blood typing (RhD)
99354 TH
Notification of Pregnancy (NOP); one NOP per member, per
pregnancy is reimbursed
*Use the appropriate CPT code for the number of antepartum visits:
59425
Antepartum care only; one to six visits
59426
Antepartum care only; seven or more visits
CPT Code
Procedure
Trimester Two (three total visits)
59425*
Second trimester visits = three
59426*
59000
Amniocentesis, 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
82105
Serum alpha-fetoprotein
82947
Diabetic screening
82951
Glucose tolerance test
86644
CMV antibody titer
86694
Herpes simplex test
86777
Toxoplasma antibody titer
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CPT Code
Procedure
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)
Or instead of 80055, use the following:
85025
CBC with complete differential
87340
Hepatitis B surface antigen
86762
Rubella antibody titer
86592
Syphilis test; qualitative such as VDRL, RPR, ART
86850
Antibody screen, RBC
86900
Blood typing (ABO)
86901
Blood typing (RhD)
99354 TH
Notification of Pregnancy; one NOP per member, per
pregnancy is reimbursed
*Use the appropriate CPT code for the number of antepartum visits:
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*
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
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
CMV antibody titer
86694
Herpes simplex test
86777
Toxoplasma antibody titer
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CPT Code
Procedure
Total obstetrical panel includes:
80055
•
CBC with complete differential
•
Hepatitis B surface antigen
•
Rubella antibody titer
•
Syphilis test
•
Antibody screen, RBC
•
Blood typing (ABO)
• Blood typing (RhD)
Or instead of 80055, use the following:
85025
CBC with complete differential
87340
Hepatitis B surface antigen
86762
Rubella antibody titer
86592
Syphilis test; qualitative, such as VDRL, RPR, ART
86850
Antibody screen, RBC
86900
Blood typing (ABO)
86901
Blood typing (RhD)
99354 TH
Notification of Pregnancy; one NOP per member, per
pregnancy is reimbursed. The NOP is not reimbursable when
the risk assessment is performed beyond 29 weeks gestation.
*Use the appropriate CPT code for the number of antepartum visits:
59425
Antepartum care only; one to six visits
59426
Antepartum care only; seven or more visits
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 the Go To NOP button to complete and submit the online
form. Providers may also complete a hard-copy NOP by selecting the Print Blank NOP button.
Only NOPs submitted online are reimbursable.
3. Web interChange will check for potential duplicate NOPs. If a duplicate is identified, the
recognized provider will be asked to provide a reason explaining 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, or (3) member miscarriage. The provider can
continue the process without identifying a reason; however, the duplicate NOP will not be
reimbursed.
4. The NOP can only be submitted and billed for a woman enrolled in Hoosier Healthwise risk-based
managed care.
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5. 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 at http://provider.indianamedicaid.com/providerspecific-information/managed-care/notification-of-pregnancy-(nop).aspx.
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 will 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 prior to 30 weeks of gestation.
Salivary Estriol Test for Preterm Labor Risk Assessment
The salivary estriol test for preterm labor risk assessment gives the provider additional information to
assess the risk for preterm delivery and allows the provider to take steps to treat the patient, even when
the patient does not appear to be a high risk by traditional assessment methods. Patients who may be
currently missed by traditional risk assessment can be identified and treated, decreasing the chance of
premature delivery and the medical impact prematurity entails.
The IHCP does not require PA for the salivary estriol test. Table 8.90 shows the ICD-9-CM diagnosis
codes that support medical necessity of this test.
Table 8.90 – ICD-9-CM Diagnosis Codes for Salivary Estriol Test
Diagnosis Code
Description
V23.2
Pregnancy with history of abortion
V23.4
Pregnancy with other poor obstetric history
V23.8
Other high-risk pregnancy
658.9
Unspecified
640.9
Unspecified hemorrhage in early pregnancy (with V23.8)
644.0
Threatened premature labor
644.03
Threatened premature labor, antepartum condition, or complication
644.13
Other threatened labor, antepartum condition or complication
654.50
Cervical incompetence
654.53
Cervical incompetence, antepartum condition or complication
654.60
Other congenital or acquired abnormality of cervix; unspecified as to episode of
care
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Diagnosis Code
Description
654.63
Other congenital or acquired abnormality of cervix; antepartum condition or
complication
621.0 through 621.9
Disorders of uterus, not elsewhere classified
The ordering physician must have supporting documentation in the patient’s medical record to support
the medical necessity of any tests ordered.
Note: Salivary estriol tests are indicated for use in singleton pregnancies.
Billing Instructions
Providers must bill the salivary estriol test using the code S3652, one unit per test. The test is
appropriate for use between gestational ages 22 to 35 weeks, and providers can use it every one to two
weeks. The physician’s test order and the claim must indicate modifier U2, second trimester, or
Modifier U3, third trimester.
The pregnancy series includes multiple tests during the third trimester of pregnancy. Providers must
not bill the salivary estriol test when providing home tocolytic therapy using codes S9349, 99601, or
99602. The IHCP closely monitors use of the salivary estriol test for appropriateness of use.
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
•
Fetal age determination if necessitated by the following:
- Discrepancy in size versus fetal age
- Lack of fetal growth or suspected fetal death
- Fetal postmaturity syndrome
- Guide for amniocentesis
- Placental localization associated with abnormal bleeding
- Polyhydramnios or oligohydramnios
- Suspected multiple births
- Suspected congenital anomaly
The IHCP reimburses for sonography for fetal age determination prior to therapeutic, 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 16-10-3-3 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
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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:
•
V28.3 – Screening for malformation using ultrasonics
•
V28.4 – Screening for fetal growth retardation using ultrasonics
Obstetrical Delivery and Postpartum Care Billing
Providers 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 providers should identify them by using the codes in the Evaluation
and Management Services section, in addition to codes for maternity care.
Therefore, providers do not bill separately for the hospital inpatient service E/M codes for initial
hospital care (99221, 99222, and 99223), subsequent hospital care (99231, 99232, and 99233), and
hospital discharge services (99238 and 99239), and the IHCP does reimburse for these to the
practitioner billing for the obstetrical delivery. In addition, providers should not bill separately for the
E/M codes for observation or inpatient care services, including admission and discharge services
(99234, 99235, and 99236), and the IHCP does not reimburse to the practitioner billing for the
obstetrical delivery. Any submission of E/M codes by the delivering practitioner should meet the CPT
guidelines.
The IHCP also allows up to two postpartum visits within 60 days postdelivery. The IHCP may
reimburse the provider for up to two inpatient or outpatient postpartum visits using CPT code 59430,
which is for postpartum care only. However, if providers use CPT codes 59410 or 59515 – which
include delivery plus postpartum care – when billing, they can bill one additional postpartum visit
using procedure code 59430.
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 either 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 in this chapter.
Normal Pregnancy
The following diagnosis codes indicate a normal, low-risk pregnancy:
•
V22.0
•
V22.1
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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 percent
of the global fee is reimbursed for the most expensive procedure. The second most expensive
procedure is reimbursed at 50 percent of the global fee, and remaining procedures are reimbursed at 25
percent 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); 59410 –
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care; 59612 –
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps), or
59614 – Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or
forceps); including postpartum care. The second birth and any subsequent births are billed using
procedure codes 59409 or 59612 with modifier 51 – Multiple procedures.
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 or 59515 – Cesarean delivery only;
including postpartum care, 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 birth(s)
are billed on one detail line with one unit of service using procedure code 59514 or 59515. The vaginal
birth(s) are billed as separate details using procedure code 59409 or 59612 with modifier 51.
If all births are cesarean, the cesarean births are billed using the appropriate procedure code 59514,
59515, 59620, or 59622, and one unit of service.
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 percent 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
percent 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 may do one of the following:
•
Use a standardized risk assessment tool (for example, ACOG Obstetric Medical History).
•
Use the Prenatal Risk Assessment Form available on the IHCP Web site at
http://provider.indianamedicaid.com.
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•
Complete and submit the Notification of Pregnancy (NOP) through Web interChange.
Providers are encouraged to use the NOP, which provides a $60 reimbursement per pregnancy
submission. 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 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 complications 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 physicians for medically high-risk pregnancy care.
Providers may refer members identified as having medically high-risk pregnancies only to other
appropriate physicians. The IHCP does not permit referrals to nonphysicians for high-risk pregnancyrelated services. Providers in the Care Select program participating in a Memorandum of Collaboration
agreement may provide care for patients as defined in the agreement.
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.
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 may use a standardized risk assessment tool (for example, ACOG Obstetric
Medical History), use the Prenatal Risk Assessment Form available on the IHCP Web site
at http://provider.indianamedicaid.com, or complete and submit the Notification of Pregnancy (NOP)
through Web interChange to document a high-risk pregnancy. Providers are encouraged to use the
NOP, which provides a $60 reimbursement per pregnancy submissionFor 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 percent 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
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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
•
Major congenital anomaly in previous pregnancy history
•
Malignancy or leukemia in current pregnancy
•
Multiple gestation in current pregnancy
•
Obesity more than 20 percent 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 mental retardation in current pregnancy
•
Pyelonephritis in current pregnancy
•
Renal dialysis status complicating current pregnancy
•
Respirator-dependent status complicating current pregnancy
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•
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 percent 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 8.91 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 use a
standardized risk assessment tool (for example, ACOG Obstetric Medical History), use the Prenatal
Risk Assessment Form available on the IHCP Web site at http://provider.indianamedicaid.com, or
complete and submit the Notification of Pregnancy (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.
Providers should refer patients with risk factors to a prenatal care coordinator. The IHCP provides
higher reimbursement for prenatal office visits only for patients who present with medical high-risk
factors.
Table 8.91 – High-Risk Pregnancy – ICD-9-CM Diagnosis Codes
Medical Factor
Anemias, acquired and
hereditary
Code
282.0 – 282.9, 283.1X –
283.9, 284.0, 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- V85.4,
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
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Medical Factor
Current malignancy or
leukemia
Diabetes
Code
Medical Factor
140.0 – 174.9, 176.0 –
184.9, 188.0 – 214.3, 214.8
Preterm complications, history
– 221.9, 223.0 – 233.3,
233.30, 233.31, 233.32,
of or with current pregnancy
233.39, 233.7 – 236.3,
236.7 – 239.9
Preterm labor in current
362.07, 648.00, 648.03,
pregnancy or previous
648.80, 648.83
pregnancy
Code
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
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,
Potential structural
654.00, 654.03, 654.10, 654.13,
complications of pregnancy or 654.20, 654.23, 654.50, 654.53,
delivery
654.60, 654.63, 657.00, 657.03,
658.00, 658.03, 664.60, 664.61,
664.64, 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
319, V19.5, V21.30 –
congenital anomaly or
V21.35, V23.4
complication to infant
041.02, 042, 079.5X, 090.X
– 099.X, 488.0, 488.1,
Infections affecting
567.2X – 567.8X, 616.10,
pregnancy
647.33, 647.53, 655.33,
795.71, V08, V01.6
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
345.00 – 345.91, 359.21359.29, 414.2, 415.12,
423.3, 426.82, 440.4, 449,
523.0 – 523.9, 646.13,
Maternal diseases or
history affecting
646.70, 646.73, 646.80,
pregnancy
646.83, 648.10, 648.13,
648.50, 648.53, 648.60,
648.63, 656.23, V23.82,
V23.84, V42.0 – V42.9
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Renal complications and
infections
580.0 – 593.9, 599.6X, 639.3,
646.20, 646.23, 646.60, 646.63
Respiratory disease, history of 480.0 – 487.0, 491.0 – 491.9,
or acquired
493.0X – 493.9X, V46.1X
Smoking, more than 10
cigarettes per day
305.11, 648.33, V15.82
Spotting
649.50, 649.51, 649.53
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Medical Factor
Code
Medical Factor
Code
651.00, 651.03, 651.10,
651.13, 651.20, 651.23,
651.30, 651.33, 651.40,
Multiple gestation/grand 651.43, 651.50, 651.53,
multipara
651.60, 651.63, 651.70,
651.71, 651.73, 651.80,
651.83, 651.90, 651.93,
659.40, 659.43, V23.3
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
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.
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. The additional reimbursement is available if the provider identifies
and documents the specific medical high-risk factors in the medical record and indicates the high-risk
diagnosis when submitting claims. Ensure that this information is easily identifiable on the medical
record for audit purposes.
Pregnancy Services Billing Considerations
Providers must indicate the LMP in a MM/YY/DD format in field 14 for paper claim filing and in a
CCYYMMDD format in the Last Menstrual Period Date, Data Element 1251 for electronic claim
filing. 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.
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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 MCO 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.
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. 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.
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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 use the CPT codes listed in Table 8.92
to report the technical component only of the CPT codes noted in Table 8.92 for reporting proton
treatment delivery. Therefore, effective for dates of service on or after December 1, 2006, the IHCP
does not reimburse providers services reported using the CPT codes listed in Table 8.92 and billed
with modifiers 26 – Professional component and TC – Technical component. Providers are advised to
bill CPT codes 77520, 77522, and 77525 for the technical component only. Additionally, providers are
advised to report the professional services using an appropriate CPT procedure code.
Table 8.92 – Proton Treatment Delivery
CPT Code
77520
77522
77525
Description
Proton treatment; simple, without compensation
Proton treatment; simple, with compensation
Proton treatment delivery; complex
Ophthalmological Services
Coverage and Billing Procedures
The IHCP provides reimbursement for ophthalmology services, subject to the following restrictions:
•
One routine vision care examination and refraction for members 18 years old and younger, per
rolling calendar year
•
One routine vision care examination and refraction for members 19 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
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.
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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 them only for services listed on the code set. IHCP provider code sets are available
on the IHCP Web site at http://provider.indianamedicaid.com.
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
Vision Procedures Limited to One Unit
IHCP providers may only bill one unit, per member, per day for the procedures listed in Table 8.93.
Claims that have more than one unit per day for these codes will automatically cut back and pay for
one unit. Providers that have been reimbursed for more than one unit may be subject to post-payment
review and possible recoupment.
Table 8.93 – Eye Exams and Other Ophthalmological Services
CPT
Code
92002
92004
92012
92014
92018
92019
92020
92060
92065
92081
Definition
Ophthalmological services: medical examination and evaluation with initiation of diagnostic
and treatment program; intermediate, new patient
Ophthalmological services: medical examination and evaluation with initiation of diagnostic
and treatment program; comprehensive, new patient, one or more visits
Ophthalmological services: medical examination and evaluation, with initiation or
continuation of diagnostic and treatment program; intermediate, established patient
Ophthalmological services: medical examination and evaluation, with initiation or
continuation of diagnostic and treatment program; comprehensive, established patient, one or
more visits
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
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
Gonioscopy (separate procedure)
Sensorimotor examination with multiple measurements of ocular deviation (such as
restrictive or paretic muscle with diplopia) with interpretation and report (separate
procedure)
Orthoptic and/or pleoptic training, with continuing medical direction and evaluation
Visual field examination, unilateral or bilateral, with interpretation and report; limited
examination (such as tangent screen, Autoplot, arc perimeter, or single stimulus level
automated test, such as Octopus 3 or 7 equivalent)
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CPT
Code
Definition
92130
Visual field examination, unilateral or bilateral, with interpretation and report; intermediate
examination (such as at least two isopters on Goldmann perimeter, or semiquantitative,
automated suprathreshold screening program, Humphrey suprathreshold automatic
diagnostic test, Octopus program 33)
Visual field examination, unilateral or bilateral, with interpretation and report; extended
examination (such as Goldmann visual fields with at least three 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)
Serial tonometry (separate procedure) with multiple measurements of intraocular pressure
over an extended time period with interpretation and report, same day (such as diurnal curve
or medical treatment of acute elevation of intraocular pressure)
Tonography with interpretation and report, recording indentation tonometer method or
perilimbal suction method
Tonography with water provocation
92140
Provocative tests for glaucoma, with interpretation and report, without tonography
92250
Fundus photography with interpretation and report
92260
Ophthalmodynanometry
92265
92270
Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with
interpretation and report
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 (such as close-up photography, slit lamp photography, goniophotography, stereophotography)
Special anterior segment photography with interpretation and report; with specular
endothelial microscopy and cell count
Special anterior segment photography with interpretation and report; with fluorescein
angiography
Prescription of optical and physical characteristics of and fitting of contact lens, with medical
supervision of adaptation; corneal lens for aphakia, one eye
Prescription of optical and physical characteristics of and fitting of contact lens, with medical
supervision of adaptation; corneal lens for aphakia, both eyes
Prescription of optical and physical characteristics of and fitting of contact lens, with medical
supervision of adaptation; corneoscleral lens
Prescription of optical and physical characteristics of contact lens, with medical supervision
of adaptation and direction of fitting by independent technician; corneal lens for aphakia, one
eye
Prescription of optical and physical characteristics of contact lens, with medical supervision
of adaptation and direction of fitting by independent technician; corneal lens for aphakia,
both eyes
92082
92083
92100
92120
92286
92287
92311
92312
92313
92315
92316
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Eye Examinations
Providers should use the CPT code that best describes the examination to report eye examinations.
Table 8.94 lists CPT codes for eye examinations.
Table 8.94 – Eye Examination
CPT Codes
99201 – 99215
99241 – 99245
99251 – 99255
92002 – 92014
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 8.95 lists CPT codes for eye examinations including
counseling and coordination.
Table 8.95 – Eye Examination including Counseling and Coordination
99201 – 99215
99251 – 99255
CPT Codes
99241 – 99245
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
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Orthoptic or Pleoptic Training, Vision Training, and Therapies Coverage Criteria
CPT code 92065 – Orthoptic or pleoptic training, with continuing medical direction and evaluation
covers all vision training therapies. Providers should be sure to 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 that 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 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.
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 8.96.
Table 8.96 – Procedure Codes Not Covered by the IHCP
Procedure Code
8-310
Description
V2702
Deluxe lens feature
V2744
Tint, photochromic, per lens
V2750
Antireflective coating, per lens
V2760
Scratch resistant coating, per lens
V2781
Progressive lenses, 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 multi-focal lens, per lens
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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 8.97 – Covered Codes for Tints
Code with Modifier
Description
V2745 U1
Tint, plastic, rose 1 or 2, per lens
V2745 U2
Tint, 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 that require additional ocular protection for members. HCPCS
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 has had eye surgery and still requires the use of a corrective lens.
•
Member has retinal detachment or is post-surgery 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 post-cataract 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 is 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.
The IHCP does not reimburse for more than one unit for eye exams and other ophthalmologic
procedures. (See Table 8.97 for codes applying to eye exams and other ophthalmological services.)
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IHCP providers may only bill one unit, per member, per day for the codes listed in the table below.
Claims that have more than one unit per day for these codes will automatically cutback and pay for one
unit.
Table 8.97 – Eye Exams and Other Ophthalmological Services
CPT Codes
92002
92004
92012
92014
92018
92019
92020
92060
92065
92081
92082
92083
92100
92120
92130
92140
92250
92260
92265
92270
92275
92284
92285
92286
92287
92311
92312
92313
92315
92316
Frames
The IHCP reimburses for frames including, but not limited to, plastic or metal. Providers should bill
for frames using V2020. Providers who 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 percent 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 and/or frames can be repaired.
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Members younger than 19 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 19 years of age and older who have met the medical necessity for
replacement eyeglasses may be eligible for a new pair of eyeglasses two 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 prior to the
established frequency limitations, providers must use the RP modifier for dates of service on or before
December 31, 2008, and U8 modifier for dates of service on or after January 1, 2009, to bill for the
replacement lenses and/or frames. Providers must include documentation in the member’s medical
record to substantiate the 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 and prior to the established frequency limitations, providers must use modifier SC when billing
lenses and/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 needed on claims for replacement of
frames or lenses within the one- or two-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 of this manual provides
additional information.
When providers use the Indiana Medicaid Inquiry Form, it assists the HP Provider Written
Correspondence Unit in providing 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
Indianapolis, IN 46207-7263
Note: For RBMC members, contact the appropriate MCO.
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Download copies of the Indiana Medicaid Inquiry Form from the http://provider.indianamedicaid.com
Web site or request copies from the following address:
HP Forms Request
P.O. Box 7263
Indianapolis, IN 46207-7263
Note: For RBMC members, contact the appropriate MCO to obtain PA.
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 that 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 that the
service will not be covered because benefits have been exhausted.
•
If the EVS does not show that benefits have been exhausted, the provider may ask the member or
their guardian to attest in writing that they have not received Medicaid covered glasses within the
past one or two 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’ MCO for payment. Surgeries furnished
to patients enrolled in the RBMC must be prior authorized by the MCO in accordance with the MCO
guidelines.
Podiatric Services
Coverage and Billing Procedures
Routine foot care includes the following:
•
Cutting or removal of corns, calluses, or warts, including plantar warts
•
Trimming of nails, including mycotic nails
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•
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.
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 prior to 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 referred 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
•
Has had severe circulatory impairment as a result of the systemic condition or has had areas of
desensitization in the legs or feet
•
The following is a list of the ICD-9-CM diagnosis codes that represent those systemic conditions
that would 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 20 years old and younger.
•
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
Refer to 405 IAC 5-8 for documentation about second opinions.
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Office Visits
The IHCP reimburses for podiatric office visits, subject to the following restrictions:
•
The IHCP limits reimbursement to one office visit, using procedure codes 99211, 99212, and
99213, per member, per 12 months, without obtaining PA.
•
The IHCP reimburses 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.
•
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 with the 25 modifier. The provider needs to send documentation
indicating why the subsequent visit was required.
Note: The SUR Department identified utilization issues related to podiatrists inappropriately
billing multiple units of CPT® codes 99201-99203 for new patient visits and CPT
codes 99211-99213 for established patient visits.
The SUR Department advises all providers to carefully review claims submitted to the
IHCP to ensure proper billing of units for these services. The SUR 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 SUR Department to arrange for
repayment.
Surgical Services
The IHCP reimburses for the following surgical procedures without PA:
•
Drainage of skin abscesses of the foot
•
Drainage or injections of a joint or bursa of the foot
•
Surgical cleansing of the skin
•
Trimming of skin lesions of the foot, other than those identified as included in routine foot care
services
The IHCP reimburses for surgical procedures other than those mentioned above, performed within the
scope of the podiatrist’s license, subject to PA, as specified in 405 IAC 5-26, Podiatric Services. For
all surgical procedures on one or both feet performed on the same date, the IHCP pays 100 percent of
the IHCP allowance for the major procedure and 50 percent of the IHCP allowance for subsequent
procedures.
If providers perform surgery on both feet, and if the surgery on the second foot is performed at least
five days after surgery on the first foot, 100 percent allowance is payable for the second surgery.
If providers perform the major surgical procedure on one toe, a time period of five days must elapse
before the IHCP would again pay 100 percent of the IHCP-allowable reimbursement for subsequent
surgery on the same foot. For surgery performed sooner than five days, the IHCP pays 50 percent of
the IHCP-allowable reimbursement.
If providers perform the major surgical procedure on one toe, a period of 30 days must elapse before
the IHCP would again pay at 100 percent of IHCP-allowable reimbursement for a subsequent surgery
on the same toe. For surgery performed sooner than 30 days, the IHCP reimburses 50 percent of the
IHCP-allowable reimbursement.
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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 reimburses a podiatrist 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 directly to the IHCP. 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.
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 a member younger than
20 years old
•
Orthopedic shoes for members with severe diabetic foot disease, subject to the restrictions and
limitations outlined in 405 IAC 5-19-10
•
Palliative or hygienic care for the removal or trimming of corns, calluses, and nails covered for
members with painful keratosis, diseased nails, or deformed nails (authorization covers six
treatments per year)
•
Routine foot care in excess of six services per year for patients with diabetes mellitus, peripheral
vascular disease, or peripheral neuropathy
Podiatric Services and Managed Care
Providers furnishing podiatric services to members enrolled in Care Select must follow existing PA
guidelines. Podiatric services are available to Care Select and Hoosier Healthwise patients on a selfreferral basis. Providers should submit RBMC member claims to the member’s MCO for payment. For
services that require PA furnished to members enrolled in RBMC, providers must obtain prior
authorization from the MCO in accordance with the MCO guidelines.
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Radiology Services
Coverage and Billing Procedures
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 MCO for
payment. Services that require PA furnished to members enrolled in RBMC must be prior authorized
by the MCO in accordance with the MCO 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.
•
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
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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/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
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).
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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.
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 they are expressly the responsibility of
the hospice provider.
Renal Dialysis Physician Services
Coverage and Billing Procedures
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 8.98 lists the HCPCS codes for
ESRD.
Table 8.98 – HCPCS Codes for ESRD
Code
90951
8-320
Description
End-stage renal disease (ESRD)-related services during the course of treatment, 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 four or more face-to-face physician
visits per month
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Code
Description
09052
ESRD-related services during the course of treatment, 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 two or three face-to-face physician visits per month
90953
ESRD-related services during the course of treatment, 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 one face-to-face physician visit per month
90954
ESRD-related services during the course of treatment, 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 four or more face-to-face physician visits per month
90955
ESRD-related services during the course of treatment, 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 two or three face-to-face physician visits per month
90956
ESRD-related services during the course of treatment, 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 one face-to-face physician visit per month
90957
ESRD-related services during the course of treatment, 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 four or more face-to-face physician visits per month
90958
ESRD-related services during the course of treatment, 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 two or three face-to-face physician visits per month
90959
ESRD-related services during the course of treatment, 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 one face-to-face physician visit per month
90960
ESRD-related services during the course of treatment, for patients 20 years of age and older; with
four or more face-to-face physician visits per month
90961
ESRD-related services during the course of treatment, for patients 20 years of age and older; with
two or three face-to-face physician visits per month
90962
ESRD-related services during the course of treatment, for patients 20 years of age and over; with
one face-to-face physician visit per month
90963
ESRD-related services for home dialysis patients per full month; for patients younger than 2 years
of age to include monitoring for adequacy of nutrition, assessment of growth and development,
and counseling of parents
90964
ESRD-related services for home dialysis patients per full month; for patients 2-11 years of age to
include monitoring for adequacy of nutrition, assessment of growth and development, and
counseling of parents
90965
ESRD-related services for home dialysis patients per full month; for patients 12-19 years of age to
include monitoring for adequacy of nutrition, assessment of growth and development, and
counseling of parents
90966
ESRD-related services for home dialysis patients per full month; for patients 20 years of age and
older
90967
ESRD-related services for home dialysis (less than full month), per day; for patients younger than
2 years of age
90968
ESRD-related services for home dialysis (less than full month), per day; for patients 2-11 years of
age
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Code
Description
90969
ESRD-related services for home dialysis (less than full month), per day; for patients 12-19 years
of age
90970
ESRD-related services for home dialysis (less than full month), per day; for patients 20 years of
age and over
School Corporation Services
Coverage and Billing Procedures
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. Effective for dates of service on or after August
1, 1998, school corporations enrolled as IHCP providers are exempt from requirements to obtain PA
and the PMP Certification Code to bill for IEP services furnished to a student in Special Education.
Submit claims for IEP services provided to special education students enrolled in the Care Select on
the CMS-1500 to the following address:
HP CMS-1500 Claims
P.O. Box 7269
Indianapolis, IN 46207-7269
If the student is enrolled in an RBMC MCO, school corporation providers must submit claims for IEP
services to HP and not to the student’s MCO.
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 for each
student.
Surgical Services
Coverage and Billing Procedures
Providers furnishing surgical services to members enrolled in Care Select must follow existing PA
guidelines. RBMC member claims are submitted to the patients’ MCO for payment. Services that
require PA furnished to patients enrolled in RBMC must be prior authorized by the MCO in
accordance with the MCO 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.
•
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Modifier 57 – Decision for Surgery must be submitted on the CMS-1500 or 837P with the E/M
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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, prior
to 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
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.
•
Agreement must become part of the patient’s file.
•
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 who 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
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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 8.99.
Table 8.99 – Procedure Code 43030
Description
Percentage
Preoperative
Modifier
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 8.100.
Table 8.100 – 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 percent preoperative percentage + 81 percent
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 8.101, Physician B performs the balance of the postoperative care for 30 days.
Table 8.101 – Billing Physician B
Physician B
Detail 1
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From Date of
Service
12/01/2008
To Date of
Service
12/30/2008
Procedure
Code
43030
Modifier
55
Units Billed
30
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Calculations are made as follows:
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 percent of the RBRVS fee. 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 8.102.
Table 8.102 – 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
Calculations are made as follows:
The global fee for procedure code 43030 is $460.48. Therefore, reimbursement for this service should
be made at $460.48.
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
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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 percent of the rate on file.
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 percent of the global fee for the most expensive procedure
•
50 percent of the global fee for the second most expensive procedure
•
25 percent 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 percent 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 of this manual provides additional information on PA for this service.
Note: For RBMC members, contact the appropriate MCO for PA instructions.
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Therapy Services
Coverage and Billing Procedures
This section outlines IAC criteria for therapy services.
405 IAC 5-22-6 states that 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 an NF or large private or small ICF/MR, 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
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.
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•
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. The IHCP does not authorize therapy services when they duplicate nursing services required
under 410 IAC 16.2-3-4.
405 IAC 5-22-8 states that physical therapy services are subject to the following restrictions:
•
A licensed physical therapist or certified therapist assistant under the direct, on-site 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 on-site 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
- 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 an NF or large private or
small ICF/MR, which are included in the facility’s per diem rate. The IHCP does not reimburse
these services separately.
405 IAC 1-11.5-2 was amended to allow 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.
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Covered Procedures for Physical Therapist Assistants
Effective April 1, 2006, 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 will reimburse at 75 percent of the reimbursement level
for a physical therapist. Table 8.103 lists the physical therapy services that PTAs may perform.
Note: This information does not apply to First Steps services.
Table 8.103 – Physical Therapy Services that May Be Performed by a PTA
CPT Code
Description
29200
Strapping; thorax
29220
Strapping; low back
29240
Strapping; shoulder
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
29590
Denis-Browne splint strapping
97010
Application of a modality to one or more areas; hot or cold compacts
97012
Application of a modality to one or more areas; traction, mechanical
97014
Application of a modality to one or more areas; electrical stimulation (unattended)
97016
Application of a modality to one or more areas; vasopneumatic devices
97018
Application of a modality to one or more areas; paraffin bath
97022
Application of a modality to one or more areas; whirlpool
97024
Application of a modality to one or more areas; diathermy
97026
Application of a modality to one or more areas; infrared
97028
Application of a modality to one or more areas; ultraviolet
97032
Application of a modality to one or more areas; electrical stimulation (manual), each 15
minutes
97033
Application of a modality to one or more areas; iontophoresis, each 15 minutes
97034
Application of a modality to one or more areas; contrast baths, each 15 minutes
97035
Application of a modality to one or more areas; ultrasound, each 15 minutes
97036
Application of a modality to one or more areas; Hubbard tank, each 15 minutes
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CPT Code
Description
97110
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to
develop strength and endurance, range of motion and flexibility
97112
Therapeutic procedure, one 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, one or more areas, each 15 minutes; aquatic therapy with
therapeutic exercise
97116
Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair
climbing)
97124
Therapeutic procedure, one or more areas, each 15 minutes; massage, including
effleurage, petrissage, and/or tapotement (stroking, compression, percussion)
97140
Manual therapy techniques (such as mobilization/manipulation, manual lymphatic
drainage, manual traction), one or more regions, each 15 minutes
97150
Therapeutic procedure(s), group (two or more individuals)
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
97530
Therapeutic activities, direct (one-on-one) patient contact by the provider (use of
dynamic activities to improve functional performance), 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 to be part of the
provider’s capital equipment.
•
The IHCP does not require PA for oxygen provided in an 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 an NF or large private or small ICF/MR, 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:
•
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A registered occupational therapist or a certified occupational therapy assistant under the direct
on-site 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.
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•
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.
•
The IHCP does not require PA for occupational therapy services provided by an NF or large
private or small ICF/MR, which are included in the facility’s established per diem rate.
Note: For RBMC members, contact the appropriate MCO for billing and PA
instructions.
The IHCP reimburses for therapy services provided outside Indiana, subject to PA as defined in 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 manual 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 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, effective April 1, 2005. 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 exercises to develop strength and endurance, range of motion, and flexibility
•
97112 – Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense,
posture, or proprioception for sitting and standing activities
•
97530 – Therapeutic activities to improve functional performance
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•
97533 – Sensory integrative techniques to enhance sensory processing and promote adaptive
responses to environmental demands. 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), effective January 1, 2005, 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.
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 listed in
Table 8.104.
Table 8.104 – Traumatic Brain Injury ICD-9-CM Codes
ICD-9-CM Codes
348.1
800.01
800.02
800.03
800.04
800.05
800.06
800.09
800.10
800.11
800.12
800.13
800.14
800.15
800.16
800.19
800.20
800.21
800.22
800.23
800.24
800.25
800.26
800.29
800.30
800.31
800.32
800.33
800.34
800.35
800.36
800.39
800.40
800.41
800.42
800.43
800.44
800.45
800.46
800.49
800.50
800.51
800.52
800.53
800.54
800.55
800.56
800.59
800.60
800.61
800.62
800.63
800.64
800.65
800.66
800.69
800.70
800.71
800.72
800.73
800.74
800.75
800.76
800.79
800.80
800.81
800.82
800.83
800.84
800.85
800.86
800.89
800.90
800.91
800.92
800.93
800.94
800.95
800.96
800.99
801.00
801.01
801.02
801.03
801.04
801.05
801.06
801.09
801.10
801.11
801.12
801.13
801.14
801.15
801.16
801.19
801.20
801.21
801.22
801.23
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ICD-9-CM Codes
801.24
801.25
801.26
801.29
801.30
801.31
801.32
801.33
801.34
801.35
801.36
801.39
801.40
801.41
801.42
801.43
801.44
801.45
801.46
801.49
801.50
801.51
801.52
801.53
801.54
801.55
801.56
801.59
801.60
801.61
801.62
801.63
801.64
801.65
801.66
801.69
801.70
801.71
801.72
801.73
801.74
801.75
801.76
801.79
801.80
801.81
801.82
801.83
801.84
801.85
801.86
801.89
801.90
801.91
801.92
801.93
801.94
801.95
801.96
801.99
803.00
803.01
803.02
803.03
803.04
803.05
803.06
803.09
803.10
803.11
803.12
803.13
803.14
803.15
803.16
803.19
803.20
803.21
803.22
803.23
803.24
803.25
803.26
803.29
803.30
803.31
803.32
803.33
803.34
803.35
803.36
803.39
803.40
803.41
803.42
803.43
803.44
803.45
803.46
803.49
803.50
803.51
803.52
803.53
803.54
803.55
803.56
803.59
803.60
803.61
803.62
803.63
803.64
803.65
803.66
803.69
803.70
803.71
803.72
803.73
803.74
803.75
803.76
803.79
803.80
803.81
803.82
803.83
803.84
803.85
803.86
803.89
803.90
803.91
803.92
803.93
803.94
803.95
803.96
803.99
804.00
804.01
804.02
804.03
804.04
804.05
804.06
804.09
804.10
804.11
804.12
804.13
804.14
804.15
804.16
804.19
804.20
804.21
804.22
804.23
804.24
804.25
804.26
804.29
804.30
804.31
804.32
804.33
804.34
804.35
804.36
804.39
804.40
804.41
804.42
804.43
804.44
804.45
804.46
804.49
804.50
804.51
804.52
804.53
804.54
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ICD-9-CM Codes
804.55
804.56
804.59
804.60
804.61
804.62
804.63
804.64
804.65
804.66
804.69
804.70
804.71
804.72
804.73
804.74
804.75
804.76
804.79
804.80
804.81
804.82
804.83
804.84
804.85
804.86
804.89
804.90
804.91
804.92
804.93
804.94
804.95
804.96
804.99
851.00
851.01
851. 02
851.03
851.04
851.05
851.06
851.09
851.10
851.11
851.12
851.13
851.14
851.15
851.16
851.19
851.20
851.21
851.22
851.23
851.24
851.25
851.26
851.29
851.30
851.31
851.32
851.33
851.34
851.35
851.36
851.39
851.40
851.41
851.42
851.43
851.44
851.45
851.46
851.49
851.50
851.51
851.52
851.53
851.54
851.55
851.56
851.59
851.60
851.61
851.62
851.63
851.64
851.65
851.66
851.69
851.70
851.71
851.72
851.73
851.74
851.75
851.76
851.79
851.80
851.81
851.82
851.83
851.84
851.85
851.86
851.89
851.90
851.91
851.92
851.93
851.94
851.95
851.96
851.99
852.00
852.01
852.02
852.03
852.04
852.05
852.06
852.09
852.10
852.11
852.12
852.13
852.14
852.15
852.16
852.19
852.20
852.21
852.22
852.23
852.24
852.25
852.26
852.29
852.30
852.31
852.32
852.33
852.34
852.35
852.36
852.39
852.40
852.41
852.42
852.43
852.44
852.45
852.46
852.49
852.50
852.51
852.52
852.53
852.54
852.55
852.56
852.59
853.00
853.01
853.02
853.03
853.04
853.05
853.06
853.09
853.10
853.11
853.12
853.13
853.14
853.15
853.16
853.19
854.00
854.01
854.02
854.03
854.04
854.05
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ICD-9-CM Codes
854.06
854.09
854.10
854.11
854.12
854.13
854.14
854.15
854.16
854.19
907.0
994.1
997.01
Transportation Services
Advanced Life Support – ALS
The Indiana Emergency Medical Services Commission (EMSC), Title 836 of the Indiana
Administrative Code (IAC), defines advanced life support (ALS) 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 Indiana Code (IC)16-1-31, 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
The EMSC 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
•
An emergency medical technician-basic advanced may perform the following:
- Electrocardiogram interpretation
- Manual external defibrillation
- 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
Effective for dates of service on or after December 25, 2009, the IHCP provides reimbursement for a
base rate and mileage. The base rate and mileage will be 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 8.105 – Rotary Air Ambulance Codes Effective December 25, 2009
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/attendant in
a rotary air ambulance.
Prior Authorization
Providers are reminded that prior authorization is required for air ambulance services. The IHCP
acknowledges that 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 that 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 only established 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 list below 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
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.
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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 general instructions above, additional information concerning coverage and billing is
included below for three identified 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 patient transported from one hospital to another hospital is covered only if the
hospital to which the patient is transferred is the nearest one with appropriate facilities. Reimbursement
is not available for transport from a hospital capable of treating the patient because the patient and/or
family prefer a specific hospital or physician.
Patient Expiration
When the member expires, the IHCP payment amount depends on the time at which the member is
pronounced dead by an individual authorized by the State to make such pronouncements. If the time of
death pronouncement is prior to takeoff to point of pickup, with notice to the dispatcher and time to
abort the flight, no payment is made. This includes scenarios in which the air ambulance has taxied to
the runway and/or has been cleared for takeoff but has not actually taken off. If the member is
pronounced dead after takeoff to point of pickup, but before the member is loaded, the appropriate air
base rate (A0431) with no mileage is reimbursed. The provider should use the QL modifier when
submitting such a claim (A0431 QL). If the provider bills a mileage code in conjunction with a base
rate and QL modifier, the mileage code will be denied with the following audit 6194 explanation:
Mileage is not payable with this service. When the member is pronounced dead after being loaded
onboard but prior to or upon arrival at the receiving facility, the provider may bill for the air
ambulance base rate and mileage as if the member had not expired.
Table 8.106 – Billing Upon Beneficiary Death After Takeoff but Before Loading
Provider Specialty 261: Air Ambulance
HCPCS Code
A0431 QL
Description
Ambulance service, conventional air service, transport, one way (rotary wing)
Bad Weather
Providers should note that if the flight is aborted due to bad weather or other circumstance beyond the
pilot’s control any time before the beneficiary is loaded onboard, that is, prior to or after takeoff to
point of pickup, the IHCP will not reimburse for the flight. If the flight is aborted due to bad weather
after the beneficiary is loaded, the appropriate base and mileage codes may be reimbursed.
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Retroactive Eligibility
If a member becomes retroactively eligible for IHCP coverage and notifies the provider of retroactive
eligibility, the provider must follow guidelines outlined in Chapter 2 of this manual. When notified of
member eligibility, the provider must refund any payments by the member for covered services (other
than the IHCP Package C copayments) rendered on or after the eligibility effective date.
Definition of a Trip
For billing purposes, the IHCP defines a trip as transporting a member from the initial point of pickup
to the drop-off point at the final destination. Transportation must be the least expensive type of
transportation available that meets the medical needs of the member. Providers must bill trips
according to the level of service rendered and not according to the vehicle type. Providers must bill for
all transportation services provided to the same member on the same date of service on one claim form.
If the provider makes a round trip for the same member, same date of service, and same level of base
code, the provider should submit both runs on the same detail with two units of service to indicate a
round trip. Additionally, the provider must bill all mileage for the trip on the one detail with the total
number of miles associated for the round trip.
If the provider transports a member on the same date of service but with different trip levels (for
example, the to trip was a CAS trip, and the return trip was a NAS trip with mileage for each base), the
provider must bill these base trips on two different claim forms with the corresponding mileage for
each base.
Note: In the Units field on the CMS-1500 or Service Unit Count field on the 837P,
the provider must use a 1 with the base unit code to indicate a one-way trip
and a 2 to indicate a two-way trip. The provider must use the transportation
modifiers to indicate the place of origin and destination for each service.
Multiple Destinations
If the provider transports a member to multiple points in succession, the provider cannot bill for a trip
between each point of the destination. The following examples explain this concept:
•
Example 1: A vehicle picks up a member at home and transports the member to the physician’s
office. This is a one-way trip.
•
Example 2: A vehicle picks up a member from home and transports the member to the physician’s
office. The provider leaves, and later the same vehicle picks up the member from the physician’s
office and transports the member back to the member’s home. This is considered two one-way
trips.
•
Example 3: A vehicle picks up the member from the physician’s office and transports the member
to the laboratory for a blood draw, waits outside the laboratory for the member, and then transports
the member home. This is a one-way trip, even though there was a stop along the way. A stop
along the way is not considered a separate trip.
•
Example 4: A vehicle picks up Member A at the member’s home and begins to transport Member
A to the dialysis center. Along the way, the vehicle stops to pick up Member B at a nursing home
and transports Member A and Member B to the dialysis center. The stop at the nursing home is not
considered a separate trip, and the transportation of Member A from home to the dialysis center is
considered a one-way trip.
Note:
Table 8.110 includes information about the policy for multiple passengers.
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Modifiers
Use single-character modifiers for ambulance transportation in combination to report services to CMS.
The first character indicates the transport’s place of origin, and the second character indicates the
destination. Table 8.107 lists the modifiers used for ambulance transports.
Table 8.107 – Modifiers – Ambulance Transport
Modifier
Description
D
Diagnostic or therapeutic site, other than P or H
E
Residential, domiciliary, or custodial facility (nursing home, not SNF)
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
Non hospital-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)
Prior Authorization
The IHCP requires PA for the following transportation services:
•
Trips exceeding 20 one-way trips per member, per rolling 12-month period, with certain
exceptions as described in this billing guide
•
Trips of 50 miles or more one way, including all codes associated with the trip (wait time, parent
or attendant, additional attendant, and mileage)
•
Interstate transportation or transportation services rendered by a provider located out-of-state in a
nondesignated area
•
Train or bus services
•
Airline or air ambulance services
With their PA requests, providers must include a brief description of the anticipated care and a
description of the clinical circumstances necessitating the transportation. The appropriate MCO or
CMO reviews the PA requests and sends copies of the decisions to the members and the rendering
providers. Transportation providers may request authorization for members that exceed 20 one-way
trips. Examples of situations that require frequent medical intervention include, but are not limited to,
prenatal care, chemotherapy, and certain other therapy services. The IHCP does not approve additional
trips for routine medical services. The IHCP may grant PA up to one year following the date of
service.
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Twenty One-Way Trip Limitation and Exemptions
The IHCP limits transportation to 20 one-way trips per member, per rolling 12-month period.
Providers must request PA for members who exceed 20 one-way trips if the member requires frequent
medical intervention. However, some services are exempt from the 20 one-way trip limitation. The
following sections include information about those services.
Emergency Transportation Services
Emergency ambulance transportation is exempt from the 20 one-way trip limitation. Providers must
indicate that the transportation was an emergency by using the Y indicator in field 24c on the CMS1500 or in the Emergency Indicator on the 837P.
Hospital Admission or Discharge
Transportation services for transporting a member to a hospital for admission or for transporting the
member home following discharge from the hospital are exempt from the 20 one-way trip limitation.
This includes interhospital transportation when the member is discharged from one hospital for the
purpose of admission to another hospital. Providers must use the transportation modifiers to indicate
the place of origin and destination for each service.
Note: Transporting an IHCP member to or from a hospital for any reason
unrelated to an admission or discharge is not exempt from the 20-trip
limitation.
Members on Renal Dialysis or Members Residing in Nursing Homes
Members on renal dialysis and members residing in nursing homes are exempt from the 20 one-way
trip limitation. Providers must file claims for members undergoing dialysis or members in nursing
homes with one of the diagnosis codes listed in Table 8.108. Enter the diagnosis code on the CMS1500 or 837P, and place a 1 in field 24E of the CMS-1500 claim form or the Diagnosis Code Pointer
on the 837P to indicate that the first diagnosis code applies.
Note: The IHCP requires transportation providers to complete field 24E on the
claim form only for claims being submitted for dialysis or nursing home
patients. Failure to complete this field correctly may result in the IHCP
denying the claim when the member meets the 20 one-way trip limitation.
The aforementioned renal dialysis and nursing facility diagnosis codes must
only be used when appropriate and medically necessary. These diagnosis
codes should not be used to circumvent the prior authorization process
required for trips exceeding the 20 one-way trip limitation.
Table 8.108 – Diagnosis Codes for Transportation of Renal Dialysis Patients and Patients
Residing in Nursing Homes
Diagnosis Code
Usage
V56.0, V56.1, or V56.8
Patient undergoing renal dialysis
V70.5
Patient residing in nursing facility
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Mileage
The IHCP expects transportation providers to transport members along the shortest, most efficient
route to and from a destination. All transportation providers must document mileage on the driver’s
ticket using odometer readings or mapping software programs. The IHCP reimburses for mileage, in
addition to the base rate, under the following circumstances:
•
The IHCP reimburses ambulance providers for loaded mileage for each mile of the trip regardless
of the type or level of service being billed.
•
The IHCP reimburses CAS and NAS providers for loaded mileage when they transport a member
more than 10 miles one way.
•
The IHCP does not reimburse taxi providers for mileage and does not require them to submit
mileage with their claim. However, providers must document mileage on the driver’s ticket using
odometer readings or mapping software, as outlined in the Documentation Requirements For
Transportation Services section.
•
Although the IHCP automatically deducts the first 10 miles of a CAS or NAS trip from each oneway trip, CAS and NAS providers must bill for all mileage (including the first 10 miles) to ensure
proper reimbursement. For trips less than 10 miles, the IHCP does not require the provider to bill
mileage; however, if the provider does bill mileage, the IHCP processes the mileage as a denied
line item.
•
For trips and associated mileage in excess of 50 miles one way, the IHCP requires PA. If the
provider has not obtained PA, the IHCP denies reimbursement for mileage, the base rate, and any
other transportation services related to the trip. Providers must bill for all transportation services
provided to the same member on the same date of service on one claim form.
•
Providers must use procedure code A0425 and the appropriate U modifier for transportation
services in conjunction with ALS, BLS, CAS, or NAS base rates to report mileage. Providers must
not fragment mileage. Providers must submit mileage for round trips on one detail line using the
appropriate code listed in Table 8.109.
•
IHCP made procedure code S0215 – Nonemergency transportation; mileage, per mile,
nonreimbursable. Providers must bill the appropriate mileage code listed in Table 8.109.
In addition, providers must not report procedure code S0215 with the codes listed in Table 8.109 to
avoid IHCP reimbursing them incorrectly.
Table 8.109 – Mileage Codes and Descriptions
Code
Description
A0425 U1
ALS ground mileage, per statute mile
A0425 U2
BLS ground mileage, per statute mile
A0425 U3
CAS ground mileage, per statute mile
A0425 U5
NAS ground mileage, per statute mile
Mileage Units and Rounding
Providers must bill the IHCP for whole units only. For partial mileage units, round 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.
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Multiple Passengers
When providers transport two or more members simultaneously from the same county to the same
vicinity for medical services, the IHCP reimburses for the second and subsequent member transported
for medical services in a single CAS or NAS vehicle at one-half the base rate. The IHCP reimburses
the full base code, mileage, and waiting time for the first member only. For example, providers should
bill no mileage in conjunction with T2004 – Nonemergency transport; commercial carrier, multi-pass,
individualized service provided to more than one patient in the same setting.
The IHCP does not provide reimbursement for multiple passengers in ambulances or family member
vehicles. The IHCP does not provide additional reimbursement for multiple passengers when the
billing provider does not bill non-IHCP customers for these services. Table 8.110 shows the correct
coding methods for multiple passengers.
Table 8.110 – Coding Transportation for Multiple Passengers
Type of Transportation
First Member
Second and Subsequent Members
Commercial Ambulatory
Services
T2003 for base rate. A0425 U3 for
mileage. T2007 U3 for waiting time, if
applicable.
T2004 for base rate. No reimbursement
for mileage. No reimbursement for
waiting time.
Nonambulatory Services
A0130 for base rate. A0425 U5 for
mileage. T2007 U5 for waiting time, if
applicable.
A0130 TT for base rate. No
reimbursement for mileage. No
reimbursement for waiting time.
Taxi, nonregulated, 0-5
miles
A0100 UA (no mileage).
A0100 UA TT (no mileage).
Taxi, nonregulated, 6-10
miles
A0100 UB (no mileage).
A0100 UB TT (no mileage).
Taxi, nonregulated, 11 or
more miles
A0100 UC (no mileage).
A0100 UC TT (no mileage).
Note: PA for a base code includes the base code and the multiple passenger code
that corresponds to the approved base code. When last minute changes in
scheduling modify the service from a single passenger to a multiple
passenger, the provider must use the appropriate code.
Accompanying Parent or Attendant
When members younger than 18 years of age need an adult to accompany them to a medical service,
the provider should bill the appropriate accompanying parent or attendant code.
When adult members need an attendant to travel or stay with them for a medical service, the provider
should bill the appropriate accompanying parent or attendant code.
The following are guidelines for billing the accompanying parent or attendant codes:
•
Bill the procedure code for the base rate and the accompanying parent or attendant under the IHCP
member’s identification number (RID).
•
The IHCP does not provide additional reimbursement for accompanying parent or attendant when
the billing provider does not bill non-IHCP customers for like services.
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•
The provider must maintain documentation on the driver’s ticket to support that the accompanying
parent or attendant was transported with the IHCP member. This documentation must include the
name, signature, and relation of the accompanying parent or attendant.
Table 8.111 lists the base rates and the applicable accompanying parent or attendant code. The
provider must bill the base code and the accompanying parent or attendant code using the member’s
information.
The IHCP does not apply procedure codes for accompanying parent or attendant to the member’s 20
one-way trip limitation. The IHCP requires prior authorization for an accompanying parent or
attendant only when the trip exceeds 50 miles one way.
Table 8.111 – Procedure Codes for Accompanying Parent or Attendant
Type of Transportation
Base Code
Accompanying
Parent/Attendant
Commercial Ambulatory Services
T2003
T2001
Nonambulatory Services
A0130
A0130 TK
Taxi, nonregulated, 0-5 miles
A0100 UA
A0100 UA TK
Taxi, nonregulated, 6-10 miles
A0100 UB
A0100 UB TK
Taxi, nonregulated, 11 or more miles
A0100 UC
A0100 UC TK
Additional Attendant
Transportation providers sometimes need an additional attendant to help load a member. In situations
where the driver cannot load the member without help, such as when a wheelchair-bound member lives
upstairs and the residence has no wheelchair ramp, the provider needs an additional attendant. This
code is not subject to the 20-trip limit; however, if the trip exceeds 50 miles one way, the IHCP
requires prior authorization for all procedure codes, including additional attendant codes. The
additional attendant who assists must be an employee of the billing provider and is not required to
remain for the trip.
Providers must document the need for an additional attendant on the driver’s ticket. The IHCP may
subject the documentation to postpayment review. The IHCP limits the number of additional attendants
to a maximum of two extra units, although usually one attendant is sufficient. The IHCP limits
reimbursement for an additional attendant to NAS or wheelchair van and ambulance transportation.
For ambulance providers, the additional attendant is the third or fourth attendant, because the IHCP
requires ambulances to have two attendants.
The IHCP does not apply procedure codes A0424 – Extra ambulance attendant, ground (ALS or BLS)
or air (rotary or fixed wing) and A0130 U6 – Nonemergency transportation; wheelchair van,
additional attendant to the member’s 20 one-way trip limitation. The IHCP requires prior authorization
for procedure codes A0424 and A0130 U6 when the trip exceeds 50 miles one way.
Table 8.112 – Procedure Codes for an Additional Attendant
Type of Transportation
Nonambulatory or wheelchair van
transportation
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Procedure
Code
A0130 U6
Description
Nonambulatory transportation; wheelchair van, U6
= additional attendant
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Type of Transportation
Ambulance transportation (ALS and
BLS)
Procedure
Code
A0424
Description
Extra ambulance attendant, ground (ALS or BLS)
or air (fixed or rotary winged); (requires medical
review)
Waiting Time
The IHCP reimburses for waiting time in excess of 30 minutes only when the provider parks the
vehicle outside the medical service provider, awaiting the return of the member to the vehicle, and if
the member is transported 50 miles or more one way. The provider must obtain PA for all codes
associated with trips of 50 miles or more one way, including waiting time. The IHCP does not cover
the first 30 minutes of waiting time; however, the provider must include the total waiting time or else
the IHCP cannot pay the claim appropriately.
For all procedure codes that providers use to bill waiting time, providers should use one unit of service
for every 30 minutes of waiting time. When providers wait between 15 to 30 minutes, they should
round up the partial 30-minute increments to the next unit. For example, if providers wait 45 minutes,
they would bill the units of service as two, or 2.0. For partial 30-minute increments of less than 15
minutes, providers must round down. For example, if providers wait one hour and 10 minutes,
providers must bill the units of service for waiting time as two, or 2.0. Providers must maintain
documentation, including start and stop times, on the driver’s ticket to support the waiting time billed.
Ambulance Transportation Services
The IHCP covers emergency and nonemergency ALS and BLS ambulance transport services. The
IHCP exempts emergency ambulance services from the 20 one-way trip limit and does not require PA.
In addition, the IHCP exempts emergency ambulance services from the copayment requirement. To
indicate that the service rendered was an emergency, providers must use the Y indicator in field 24c on
the CMS-1500 or the Emergency Indicator on the 837P to bill emergency services. Remember that
transportation must be the least expensive type of transportation available that meets the medical needs
of the member.
Note: The IHCP requires PA for air ambulance and interstate transportation
services. In addition, the IHCP requires PA for any transportation services
provided by a provider located in an out-of-state, nondesignated area.
Level of Service Rendered Versus Level of Response
Providers must bill all transportation services according to the level of service rendered and not
according to the provider’s level of response or vehicle type. The IHCP provides reimbursement for
emergency and nonemergency ambulance services; however, the IHCP covers ALS services only
when the level of service is medically necessary and BLS services are not appropriate due to the
medical conditions of the member being transported. Ambulance providers should refer to the Indiana
EMSC definitions of ALS and BLS services listed in Title 836 of the IAC. Ambulance providers must
bill the IHCP according to the level of service rendered. The following examples explain the level of
service policy:
•
Example 1: ALS personnel and ambulance respond to a call. On arrival, the personnel find the
member to need emergency medical transport but no ALS services. In this case, the provider must
use the BLS emergency transport code. Subsequently, if no emergency is present, providers must
use the nonemergency BLS ambulance transport code to transport the member.
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•
Example 2: An ambulance responds to a call to transport a member to a scheduled appointment.
Upon arrival, the ambulance personnel discover that a CAS service or wheelchair van can
transport the member. The ambulance provider can either call for the appropriate vehicle or
transport the patient in the ambulance. If the ambulance provider transports the member, the
provider must bill the IHCP for the appropriate CAS or NAS transportation code(s).
Table 8.113 includes a complete listing of ambulance transportation codes. The procedure codes listed
in Tables 8.113 and 8.114 are valid for ambulance providers to bill for CAS or NAS level of service.
The IHCP no longer reimburses for procedure codes A0426 U3, A0428 U3, A0426 U5, and A0428
U5. Ambulance providers must bill the most appropriate CAS or NAS code listed in Tables 8.113 and
8.114 if the level of service does not meet the EMSC definition of ALS or BLS services. The IHCP
still permits ambulance providers to bill A0425 U1 or A0425 U2 to be reimbursed for mileage.
Table 8.113 – Valid CAS Codes for Ambulance Providers
Procedure Code
Description
T2003
Nonemergency transportation, encounter/trip
T2007 U3
Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2)
hour increments; CAS
Table 8.114 – Valid NAS Codes for Ambulance Providers
Procedure Code
Description
A0130
Nonemergency transportation, wheelchair van base rate
A0130 U6
Nonemergency transportation, wheelchair van base rate; additional attendant
T2007 U5
Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour
increments; NAS
Note: Ambulance providers must bill procedure codes T2003 and T2007 U3 when
the level of service rendered is that of a CAS provider. Ambulance providers
must bill procedure codes A0130, A0130 U6, and T2007 U5 when the level
of service rendered is that of a NAS or wheelchair van provider. The IHCP
still permits ambulance providers to bill A0425 U1 or A0425 U2 to be
reimbursed for mileage.
Ambulance Mileage
The IHCP reimburses for each mile of the trip only for loaded ambulance mileage. The provider’s
documentation must contain mileage from mapping software or odometer readings indicating starting
and ending trip mileage. Providers must use A0425 U1 – Ground mileage, per statute mile; ALS or
A0425 U2 – Ground mileage, per statute mile; BLS to bill ambulance mileage. The IHCP uses U1 and
U2 modifiers to differentiate between ALS and BLS mileage. The IHCP denies claims billed without
the U1 or U2 modifier and requires providers to resubmit the claim with the appropriate modifier.
Neonatal Ambulance Transportation
The IHCP makes reimbursement available for specialized neonatal ambulance services especially
equipped for interhospital transfers of high-risk or premature infants only when the member has been
discharged from one hospital for admission to another hospital. Providers must use procedure code
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A0225 – Ambulance service, neonatal transport, base rate, emergency transport, one way only for
neonatal ambulance transport.
Oxygen and Oxygen Supplies
Providers must not bill procedure code A0422 – Ambulance (ALS or BLS) oxygen, and oxygen
supplies, life sustaining situation with ALS codes A0426, A0427, and A0433. These base codes for
ALS transport include the reimbursement for supplies and oxygen in an ALS situation.
Providers can bill procedure code A0422 with BLS codes A0428 or A0429, if medically necessary.
Emergency medical technicians (EMTs) and paramedics must document the medical necessity for
oxygen use in the medical record maintained by the provider.
Member Copayments
The IHCP requires a copayment for transportation services. Providers should review 405 IAC 5-30-2
for complete copayment narratives.
The IHCP determines the member’s copayment amount based on the reimbursement for the base rate
or loading fee only. The IHCP does not require a copayment for an accompanying parent or attendant.
Transportation providers may collect a copayment amount from the IHCP member equal to those listed
in Table 8.115.
Table 8.115 – Transportation Copayments
Transportation Service
Member Copayment
Transportation services that pay $10.00 or less
$0.50 each one way trip
Transportation services that pay $10.01 to $50.00
$1.00 each one way trip
Transportation services that pay $50.01 or more
$2.00 each one way trip
Exemptions to Copayments for Transportation Services
The IHCP exempts the following services from the copayment requirement:
•
Emergency ambulance services
•
Services furnished to members younger than 18 years old
•
Services furnished to pregnant women
•
Services furnished to members who are in hospitals, NFs, ICFs/MR, or other medical institutions
- This includes instances where a provider transports a member for the purpose of admission or
discharge.
•
Transportation services provided under an MCO to its Hoosier Healthwise enrollees
Federal Guidelines for Copayment Policy
According to 42 CFR 447.15, providers may not deny services to any member due to the member’s
inability to pay the copayment amount on the date of service. Pursuant to this federal requirement, this
service guarantee does not apply to a member who is able to pay, nor does a member’s inability to pay
eliminate his or her liability for the copayment. It is the member’s responsibility to inform the provider
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that he or she cannot afford to pay the copayment on the date of service. The provider may bill the
member for copayments not paid on the date of service.
Package C Transportation Services
Hoosier Healthwise Package C members are eligible to receive emergency ambulance services, subject
to the prudent layperson definition of emergency in 407 IAC 1-1-6. The IHCP covers nonemergency
ambulance transportation between medical facilities when ordered by the treating physician.
Risk-Based Managed Care Hoosier Healthwise Services
The MCO is responsible for transportation services for risk-based managed care (RBMC) members.
Providers must contact the appropriate MCO for more information about transportation guidelines for
RBMC members.
Noncovered Transportation Services
The IHCP does not reimburse for the following transportation services:
•
One-way trips exceeding 20 per member, per rolling 12-month period, except when the provider
documents medically necessity for additional trips through the PA process
•
Trips of 50 miles or more one way, unless the provider obtains PA
•
First 30 minutes of waiting time for any type of conveyance, including ambulance
•
Nonemergency transportation provided by any of the following:
- A volunteer with no vested or personal interest in the member
- An interested individual or neighbor of the member
- A caseworker or social worker
•
Ancillary, nonemergency transportation charges including, but not limited to, the following:
- Parking fees
- Tolls
- Member meals or lodging
- Escort meals or lodging
•
Disposable medical supplies, other than oxygen, provided by a transportation provider
•
Transfer of durable medical equipment, either from the member’s residence to place of storage, or
from the place of storage to the member’s residence
•
Use of red lights and siren for an emergency ambulance call
•
All interhospital transportation services, except when the member has been discharged from one
hospital for admission to another hospital
•
Delivery services for prescribed drugs, including transporting a member to or from a pharmacy to
pick up a prescribed drug
Documentation Requirements for Transportation Services
Providers must support each claim with the following documentation on the driver’s ticket or run
sheet:
•
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•
Complete member name and address of pickup, including street address, city, county, state, and
ZIP Code
•
Member identification number
•
Member signature, and if the member is unable to sign, the driver should document that “the
patient was unable to sign” and list the reason for the inability
•
Waiting time; including the actual start and stop time of the waiting period, such as wait time from
1 p.m. to 3:20 p.m.
•
Complete service provider name and address, including street address, city, county, state, and ZIP
Code
Note: If the service provider’s name is abbreviated on the driver’s ticket, the
provider must document the complete provider name or maintain a facility
abbreviation listing. This helps to expedite the postpayment review process.
•
Name of the driver who provided transportation service
•
Vehicle odometer reading at the beginning and end of each trip or mileage from mapping
software, including the date that the provider performed the transportation service and the specific
starting and destination address
- If the provider used mapping software, it must indicate the shortest route.
Note: All providers, including taxi providers, must document mileage using either
odometer readings or mapping software. Taxi providers must document the
distance traveled to support the metered or zoned rate or mileage code
billed.
•
Indication of a one-way or round trip
•
Indication of CAS or NAS transportation
•
Name and relationship of any accompanying parent or attendant to support the accompanying
parent or attendant code billed, if applicable
Note: When providers bill an attendant or parent as part of the transport, the
parent or attendant must also sign the driver’s ticket.
Providers are responsible to verify that they are transporting the member to or from a covered service.
Providers are responsible to maintain documentation that supports each transport and/or service
provided. Transportation providers put themselves at risk of recoupment of payment if they do not
maintain the required documentation or cannot verify covered services.
Registration Requirements
Commercial or Common Ambulatory and Nonambulatory Providers
•
The IHCP requires all for profit-only CAS and NAS providers to certify annually through the
Indiana Motor Carrier Services (MCS) and obtain a Motor Carrier Certification.
•
Providers must keep a copy of the certification for their records.
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Taxi Providers
•
Providers must have documentation showing operating authority from a local governing body
(city taxi or livery license), if applicable.
•
Providers must keep a copy of the documentation for their records.
Ambulance
•
Providers must have an Emergency Medical Services (EMS) Commission certification.
•
Providers must keep a copy of the certification for their records.
•
Vehicles and staff that provide ambulance services must be certified by the EMS Commission to
be eligible for reimbursement for transports involving either advanced life support or basic life
support services. Providers who fail to maintain the EMS Commission certification on all vehicles
involved in transporting members risk termination of the IHCP Provider Agreement.
Bus
•
Providers must have an MCS certificate from the Indiana Department of Revenue.
•
Providers must keep a copy of the certification for their records.
Family Member
•
Providers must have an authorization letter from the local Office of Family and Children (OFC)
(contact caseworker).
•
Providers must keep a copy of the authorization letter for their records.
Air Ambulance
•
Providers must have EMS Commission Air Ambulance certification.
•
Providers must keep a copy of the certification for their records.
Chapter 4 of this manual includes detailed information about enrollment requirements and
responsibilities. The IHCP may refer providers who fail to maintain the required registration
documentation to the appropriate governing agencies.
Transportation Code Sets
The IHCP limits transportation providers to specific codes based on the provider specialty listed on the
provider enrollment file. Tables 8.116 through 8.122 list the procedures codes allowed for each
transportation provider specialty. Each table lists the national code(s), and the procedure code
description for each provider specialty.
Table 8.116 – CAS Provider Code Set
264 Commercial Ambulatory Service (CAS) Provider
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HCPCS Code
Description
A0425 U3
Ground mileage, per statute mile; CAS
T2003
Nonemergency transportation, encounter/trip (CAS)
T2004
Nonemergency transportation, commercial carrier, multi-pass (CAS)
T2001
Nonemergency transportation, patient attendant/escort (CAS)
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Table 8.116 – CAS Provider Code Set
264 Commercial Ambulatory Service (CAS) Provider
HCPCS Code
Description
T2007 U3
Transportation waiting time, air ambulance and nonemergency
vehicle, one-half hour increments; CAS
Note: Providers must indicate the origin and destination modifiers with the base
rate and mileage procedure codes.
Nonambulatory Service Provider
Note: For ambulatory members transported in a vehicle equipped to transport
nonambulatory members, providers must bill according to the CAS level of
service and rate, and not bill according to the vehicle type. The NAS
provider code set and Table 8.116 list the CAS codes.
Table 8.117 – NAS Provider Code Set
265 Nonambulatory Service (NAS) Provider
HCPCS Code
Description
A0425 U5
Ground mileage, per statute mile; NAS
A0130
Nonemergency transportation, wheelchair van base rate
A0130 TK
Nonemergency transportation, wheelchair van base rate; extra patient or
passenger, nonambulance
A0130 TT
Nonemergency transportation, wheelchair van base rate; individualized
service provided to more than one patient in same setting
A0130 U6
Nonemergency transportation, wheelchair van base rate; additional
attendant
T2007 U5
Transportation waiting time, air ambulance and nonemergency vehicle,
one-half hour increments; NAS
A0425 U3
Ground mileage, per statute mile; CAS
T2003
Nonemergency transportation, encounter/trip (CAS)
T2004
Nonemergency transportation, commercial carrier, multi-pass (CAS)
T2001
Nonemergency transportation, patient attendant/escort (CAS)
T2007 U3
Transportation waiting time, air ambulance and nonemergency vehicle,
one-half hour increments; CAS
Note: For ambulatory members transported in a vehicle equipped to transport
nonambulatory members, providers must bill according to the CAS level of
service and rate, and not bill according to the vehicle type. The NAS
provider code set and Table 8.116 include the CAS codes.
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Ambulance (ALS and BLS) Provider
Note: Providers must bill transportation according to the level of service rendered.
Therefore, the Ambulance (ALS and BLS) provider code set and Table 8.118
list the CAS and NAS codes.
Table 8.118 – Ambulance Provider Code Set
260 Ambulance (ALS and BLS) Provider
HCPCS Code
Description
A0422
Ambulance (ALS and BLS) oxygen and oxygen supplies, life-sustaining
situation
A0425 U1
Ground mileage, per statute mile; ALS
A0425 U2
Ground mileage, per statute mile; BLS
A0420 U1
Ambulance waiting time ALS, one-half hour increments
A0420 U2
Ambulance waiting time BLS, one-half hour increments
A0426
Ambulance service, advanced life support, nonemergency transport, level 1
(ALS1)
A0427
Ambulance service, advanced life support, emergency, level 1 (ALS1emergency)
A0428
Ambulance service, basic life support, nonemergency transport (BLS)
A0429
Ambulance service, basic life support, emergency transport, one way (BLSemergency)
A0433
Advanced ALS (Level 2)
A0225
Ambulance service, advanced life support, nonneonatal transport, base rate,
emergency transport, one way
A0999
Unlisted ambulance service (Manual price)
A0424
Extra ambulance attendant, ground (ALS or BLS) or air (rotary and fixed
wing)
T2003
Nonemergency transport wheelchair van base rate (level 1) (ALS1); CAS
A0130
Ambulance service, advanced life support, nonemergency transport, level 1
(ALS1); NAS
T2003
Nonemergency transportation, encounter/trip (CAS) (NAS)
A0130
Nonemergency transportation, wheelchair van base rate (NAS)
T2007 U3
(Use this code for waiting
time when the transport is
a CAS level of service.)
Transportation waiting time, air ambulance and nonemergency vehicle, onehalf hour increments; CAS
A0130 U6
Nonemergency transportation, wheelchair van base rate; additional attendant
T2007 U5 (Use this code
for waiting time when the
transport is a NAS level of
service.)
Transportation waiting time, air ambulance and nonemergency vehicle, onehalf hour increments; NAS
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Note: Providers must bill transportation according to the level of service rendered.
Therefore, the Ambulance (ALS and BLS) provider code set and Table 8.116
list CAS and NAS codes.
Air Ambulance
Table 8.119 – Air Ambulance Code Set
261 Air Ambulance
HCPCS Code
Description
Nonemergency transportation and air travel (private or commercial), intrastate
or interstate
Ambulance service, conventional air service transport, one way (fixed wing)
Ambulance service, conventional air service, transport, one way (rotary wing)
Ambulance service, conventional air service, transport, one way (rotary wing);
if the member is pronounced dead after takeoff to point of pickup, but before
the member is loaded
Rotary wing air mileage, per statute mile
Unlisted ambulance service
A0140
A0430
A0431
A0431 QL
A0436
A0999
Taxi Provider
Table 8.120 – Taxi Code Set
263 Taxi Provider
HCPCS Code
Description
A0100 UA
A0100 UB
A0100 UC
A0100 TK UA
A0100 TK UB
A0100 TK UC
A0100 TT UA
A0100 TT UB
A0100 TT UC
A0100 U4
Taxi, rates nonregulated, 0-5 miles
Taxi, rates nonregulated, 6-10 miles
Taxi, rates nonregulated, 11 or more miles
Taxi, rates nonregulated, 0-5 miles for accompanying parent/attendant
Taxi, rates nonregulated, 6-10 miles for accompanying parent/attendant
Taxi, rates nonregulated, 11 or more miles for accompanying parent/attendant
Taxi, rates nonregulated, 0-5 miles for multiple passengers
Taxi, rates nonregulated, 6-10 miles for multiple passengers
Taxi, rates nonregulated, 11 or more miles for multiple passengers
Nonemergency transportation; taxi, suburban territory
Family Member Transportation Provider
Table 8.121 – Family Member Transportation Provider Code Set
266 Family Member Provider
HCPCS Code
A0090
Description
Nonemergency transportation, per mile – vehicle provided by individual (family
member, self, neighbor) with vested interest
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Bus Provider
Table 8.122 – Bus Provider Code Set
262 Bus Provider
HCPCS Code
A0110
Description
Nonemergency transportation and bus, intrastate or interstate carrier
Vaccines for Children
The Indiana Immunization Program, ISDH, administers the federal Vaccines for Children (VFC)
Program.
Eligible Members
The goal of the VFC Program is to help raise childhood immunization levels in the United States by
supplying healthcare providers with free vaccine to administer to children 18 years old and under who
meet one or more of the following criteria:
•
Enrolled in Medicaid*
•
Without health insurance
•
Identified by parent or guardian as American Indian or Alaskan native
•
Underinsured, for example, children with health insurance that does not cover immunizations
- Underinsured patients who have health insurance that does not cover immunizations are
eligible to receive VFC vaccines only at an FQHC or RHC.
*Note: Through a special arrangement with the Indiana Children’s Health
Insurance Program (CHIP or Hoosier Healthwise Package C), VFC
vaccines are also available for immunizing children enrolled in Hoosier
Healthwise Package C. Additional information about VFC vaccine
administration follows in this section.
Provider Enrollment in the VFC Program
The Indiana Immunization Program, ISDH, handles VFC provider enrollment and education as well as
VFC vaccine orders and distribution. To participate in the VFC Program, providers should complete
the following steps:
•
Contact the ISDH and request VFC provider enrollment forms
•
Complete and mail the provider enrollment forms
•
Receive appropriate training and technical assistance
•
Order vaccines periodically, as needed, and maintain appropriate vaccine supply records
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Providers may contact the ISDH about the VFC at the following address:
Indiana Immunization Program
Indiana State Department of Health
2 North Meridian Street
Indianapolis, IN 46204
Telephone: (317) 233-7704 or 1-800-701-0704
Fax: (317) 233-3719
Vaccines for Children Forms
To screen patients for VFC eligibility, providers may use the Patient Eligibility Screening Record
form, available from the ISDH. This form includes a box to indicate Hoosier Healthwise Package C
eligible children, as well as a box to indicate Hoosier Healthwise Package A (Medicaid) eligible
children. Providers may use this form or may incorporate it into existing clinical forms.
Because different funding sources provide the free vaccines, the ISDH must separately track the
number of doses administered to Package A (Medicaid) enrolled children from those administered to
children enrolled in Hoosier Healthwise Package C. The Patient Eligibility Screening Record and the
Vaccine Accountability Tally Sheet forms available from ISDH incorporate tracking for vaccines
administered to children enrolled in Hoosier Healthwise Package A and Package C.
Vaccine Storage
The IHCP does not require providers to physically separate vaccine stock for children in the VFC
Program from vaccine stock for Hoosier Healthwise Package C children. No additional storage rules
are necessary.
VFC Vaccine Coverage and Billing Procedures
Currently, the VFC Program offers free vaccines against the following diseases:
•
Diphtheria
•
Hemophilus influenza type B
•
Hepatitis A
•
Hepatitis B
•
Human Papilloma virus
•
Influenza
•
Measles
•
Meningococcal disease
•
Mumps
•
Rubella
•
Pertussis
•
Pneumococcal disease
•
Polio
•
Rotavirus
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•
Tetanus
•
Varicella
All Hoosier Healthwise members 18 years old or younger are eligible for the VFC Program. For
vaccines available through the VFC Program and provided to members age 18 years old and younger,
the IHCP limits reimbursement to the fee for vaccine administration only. IHCP providers may bill the
IHCP up to $8 for administering VFC vaccine to any IHCP-eligible child age 18 years old or younger.
IHCP reimbursement for VFC vaccine administration is the lesser of the provider’s submitted charge
for VFC vaccine administration or $8.
To address the need for immunizations and deal with potential shortage of available influenza
vaccines, the IHCP is not limiting reimbursement for any influenza vaccines, regardless of their
availability from the VFC Program.
This policy, effective October 1, 2008, allows providers to obtain reimbursement for privately
purchased influenza vaccines for eligible VFC members when VFC vaccines are not available and
supplies are delayed. For administering a free VFC vaccine, providers should bill the appropriate CPT
procedure code but not charge more than the $8 VFC vaccine administration fee. Do not bill the
separate administration CPT code.
When administering a privately purchased influenza vaccine, providers may bill for the cost and
administration of the vaccine. The IHCP-allowable reimbursement is based on 105 percent of the
wholesale ascquisition cost (WAC) of the vaccine. Providers may separately bill an appropriate CPT
administration code (96372, 96373, 96374) in addition to the CPT vaccine procedure code. If an
evaluation and management (E/M) service code is billed with the same date of service as an officeadministered immunization, do not bill the vaccine 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 for an
administration fee for each injection using 96372, 96373, or 96374, as appropriate.
Remember – bill no more than the $8 VFC administration fee for free VFC influenza vaccine; or bill
the usual and customary rate for the influenza vaccine CPT plus the appropriate administration CPT
for provider-purchased influenza vaccine when the immunization is provided without the E/M service.
Providers must continue to submit claims to the appropriate delivery system (HP or the member’s
managed care organization) for each member, regardless of the source of the vaccine stock. Claims are
eligible for postpayment review, and providers must maintain documentation and invoices related to
private stock when substituting for VFC vaccine. Rates for rural health clinics (RHCs) and Federally
Qualified Health Centers (FQHCs) include payment for the vaccine and administration fee.
Table 8.123 lists the procedure codes for vaccines available through the VFC Program.
Providers should direct questions about the Medicaid fee-for-service reimbursement for VFC vaccines
to Customer Assistance at (317) 655-3240 in the Indianapolis local area or 1-800-577-1278. In
addition, providers can refer to http://www.in.gov/isdh/17203.htm with questions regarding vaccine
availability and general program information.
For members enrolled in an MCO, the provider should contact the MCO for answers to questions
about the VFC vaccine administration and reimbursement.
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Table 8.123 – Procedure Codes – VFC-Available Vaccines
Procedure Code
Description
90633
Hepatitis A Vaccine, Pediatric/adolescent dosage (2 dose schedule), for
intramuscular use per 720 unit single dose vial (effective 7/17/2006)
90634
Hepatitis A Vaccine, Pediatric/adolescent dosage (3 dose schedule) for
intramuscular use per 360 unit single dose vial (effective 7/17/2006)
90647
Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for
intramuscular use
90648
Hemophilus influenza b vaccine (Hib), PRR-T conjugate (4 dose schedule), for
intramuscular use
90649
Human Papilloma Virus (HPV) Vaccine for members 9 to 18 years of age
90650
Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule,
for intramuscular use
90655
Influenza virus vaccine, split virus, preservative free, for children 6-35 months
dosage, for intramuscular use
90656
Influenza virus vaccine, split virus, preservative free, for individuals 3 years and
above, for intramuscular use
90657
Influenza virus vaccine, split virus, for children 6-35 months of age, for
intramuscular use
90658
Influenza virus vaccine, split virus, for use in individuals 3 years of age and
above, for intramuscular use
90660
Influenza virus vaccine, live, for intranasal use for members 2 to 49 years of age
90669
Pneumoccocal conjugate vaccine, polyvalent, for children under 5 years, for
intramuscular use NOTE: Removed from VFC program March 2010.
90670
Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
90700
Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in
individuals younger than 7 years, for intramuscular use
90702
Diphtheria and tetanus toxoids (DTP) absorbed for use in individuals younger
than 7 years, for intramuscular use
90707
Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use
90713
Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
90715
Tetanus, diphtheria toxoids and acellular pertussis vaccine(Tdap) for use in
individuals 7 years or older, for intramuscular use (Boostrix and Adacel)
90716
Varicella virus vaccine, live, for subcutaneous use
90718
Tetanus and diphtheria toxoids (Td) absorbed for use in individuals 7 years old or
older, for intramuscular use
90721
Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus
influenza
B vaccine (DtaP-Hib), for intramuscular use
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Procedure Code
Description
90723
Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus
vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use
90734
Meningococcal conjugate vaccine, Serogroups A, C, Y, 4-135, IM
90744
Hepatitis B vaccine, pediatric/adolescent dosage (three-dose schedule), for
intramuscular use
90748
Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular
use
Reporting Individual Cases of Varicella (Chickenpox)
As of December 12, 2008, all primary cases of varicella (chickenpox) are reportable to the local health
department under 410 IAC 1-2.3-47. Healthcare providers should report all individual cases of
chickenpox to the local health department within 72 hours for investigation by department staff. Cases
of varicella should be reported to the local health department using the Report of Confidential
Communicable Diseases Form available at http://www.in.gov/isdh/files/43823.pdf.
The complete revised Communicable Disease Control Rule is available
at http://www.in.gov/legislative/iac/T04100/A00010.PDF?\.
VFC and HealthWatch
If a HealthWatch provider chooses not to participate in the VFC Program, the provider must document
the IHCP-enrolled patient’s immunization history. If a Care Select PMP chooses not to participate in
the VFC Program, the PMP must have a procedure in place, such as a Memorandum of Collaboration
(MOC), to ensure that children are adequately and appropriately immunized.
Provider-Purchased Vaccine
To address an initial shortage of available meningococcal vaccines under VFC, the IHCP does not
limit reimbursement for MCV4 or Menactra vaccine, regardless of availability from the VFC program.
This allows providers to obtain reimbursement for using privately purchased meningococcal vaccine if
they cannot obtain VFC vaccine. When administering privately purchased meningococcal vaccine,
providers may bill for the cost of the vaccine plus its administration, and the IHCP-allowable
reimbursement includes payment for both.
Note: If a provider administers a free VFC vaccine, the provider should bill the
appropriate meningococcal vaccine procedure code but must not charge
more than the $8 VFC vaccine administration fee and not bill the separate
administration CPT code.
Use CPT code 90734 – Meningococcal conjugate vaccine, serogroups A, C, Y and W-135
(tetravalent), for intramuscular use. One unit of 90734 equals 0.5ml of the vaccine.
Administration Fee
For vaccines that are part of the VFC program and are received free by the provider as part of VF C
program, the provider may bill the appropriate CPT vaccine procedure code and the lesser of the usual
and customary administration fee or $8. A separate CPT administration code should not be billed for a
VFC-administered vaccine.
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For vaccines that are typically part of the VFC program but have been purchased or supplied out of
private stock, providers may bill for both the vaccine and its administration (using CPT code 96372,
96373, or 96374). However, if an evaluation and management (E/M) service code is billed with the
same date of service as an office-administered immunization, providers should not bill the vaccine
administration code separately. Reimbursement for the administration is included in the E/M codeallowed amount. Separate reimbursement is allowed only when the administration of the drug is the
only service billed by the practitioner.
For vaccines that are not part of the VFC program, providers may bill for both the vaccine and its
administration (using CPT code 96372, 96373, or 96374). However, if an E/M service code is billed
with the same date of service as an office-administered immunization, providers should not bill the
vaccine administration code separately. Reimbursement for the 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 vaccine is administered on the
same date of service and no E/M code is billed, providers may bill an administration fee for each
injection.
The Indiana Medicaid maximum fee information may be found on
the http://provider.indianamedicaid.com/ihcp/Publications/MaxFee/fee_schedule.asp Web site. Be
aware of the member’s primary medical provider assignment, managed care delivery system
assignment, and third-party liability resource(s).
RHCs and FQHCs
Note: RHC- and FQHC-specific encounter rates already include payment for
immunizations.
When providers submit RHC and FQHC claims to track encounters – claims that the IHCP denies –
providers should bill no more than the $8 VFC administration fee for use of VFC influenza vaccine or
bill the usual and customary rate for the influenza vaccine CPT plus the administration CPT 90782 for
use of provider-purchased meningococcal vaccine.
Third Party Liability
For vaccines administered to VFC-eligible children, providers can bill directly to the appropriate
delivery system (HP or the MCO) when the primary diagnosis is V20.2. Providers need not bill these
vaccines to the primary insurance company prior to billing the IHCP. Providers should not experience
TPL claim denials for children enrolled in Hoosier Healthwise Package C. If providers obtain
information that identifies a primary insurance for children enrolled in Hoosier Healthwise Package C,
they should contact the HP TPL Unit at (317) 488-5046 in the Indianapolis local area or 1-800-4574510.
Package C
The VFC Program is for uninsured children. Although the IHCP considers Hoosier Healthwise
Package C an insurance program, the OMPP, the Children’s Health Insurance Program (CHIP), and
the ISDH have worked together to open the VFC Program to children in all the Hoosier Healthwise
benefit packages, including Hoosier Healthwise Package C.
The Vaccine Accountability Tally Sheet contains an additional column for reporting vaccines
administered to children enrolled in Hoosier Healthwise Package C. This allows for accurate tracking
of the amount of vaccine used for children in each group. Providers must check the appropriate column
on the Patient Eligibility Screening Record and the Vaccine Accountability Tally Sheet. Providers no
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longer need to submit the Vaccine Accountability Tally Sheet when ordering vaccines. Instead,
providers should submit the form to the ISDH monthly, by the 10th of the month following the month
in which the provider administered the vaccines. This change standardizes the reporting period for all
providers. Providers who use the Children and Hoosiers Immunization Registry Program (CHIRP)
immunization registry do not have to submit the Doses Administered Form (Vaccine Accountability
Tally Sheet) to the ISDH. The ISDH generates Doses Administered Reports from CHIRP on the 10th of
each month.
Send forms to the following address:
Indiana Immunization Program
Indiana State Department of Health
2 North Meridian Street
Indianapolis, IN 46204
The telephone numbers are as follows:
(317) 233-7704 or
1-800-701-0704
Children and Hoosiers Immunization Registry Program
The ISDH has a statewide, Internet-based immunization registry that contains immunization data for
Children and Hoosiers Immunization Registry Program (CHIRP) members. Enrolled users can request
View-Only Access to see whether a patient is present in the database and obtain that person’s data, or
users can request Full-Access, which includes entry of immunization data into the database directly
from an office or clinic, or through an export file from the healthcare provider’s billing vendor.
Scientific Technologies Corporation (STC) is the vendor for ISDH development of CHIRP.
The ISDH’s goal is to enroll other public facilities – such as community health centers, physicians in
private practice, and hospitals, including emergency and clinics – and to expand to schools, Headstart
centers, and childcare facilities. Physicians already enrolled as VFC providers were contacted by the
ISDH to provide CHIRP information and enrollment packs for consideration. A 2003 change in state
law allows for including patient immunization data in CHIRP without specific patient consent and
affords provider liability protection for good-faith participation in CHIRP. Patients who choose not to
participate can “opt out” by signing a form designed for that purpose.
CHIRP has built-in algorithms to recommend the appropriate immunization schedule for each person.
It maintains a vaccine inventory and reports vaccine usage. The system also provides reminder or
recall capabilities to contact parents through printed mailing labels for postcards and letters. In
addition, CHIRP can generate a variety of reports to help a healthcare provider assess the vaccine
coverage rates for a practice. It also produces electronic reports for managed care plans and Health
Plan Employer Data and Information Set (HEDIS) assessments.
Continued development and implementation of CHIRP will ensure that a sustainable system exists to
monitor the percent of children who are adequately immunized and to assist in the attainment of the
national goal of 90 percent or more of 2-year-old children being appropriately immunized. Obtain
more information about CHIRP from the CHIRP Web site at https://chirp.isdh.state.in.us or by calling
the ISDH at 1-888-227-4439.
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Medical Review Team Billing Procedures
This section provides billing and claim processing guidelines for Medical Review Team (MRT)
providers. MRT claims use IHCP claim processing billing procedures, although there may be minor
differences, as follows:
•
Providers must submit MRT claims via a paper CMS-1500 claim form, Web interChange, or the
837P transaction within one year of the date of service. Providers must properly identify and
itemize all services rendered.
•
Claims that providers submit on paper should be submitted on standard CMS-approved paper
CMS-1500 claim forms. For information on purchasing CMS-1500 claim forms, refer
to http://www.cms.hhs.gov/ElectronicBillingEDITrans/16_1500.asp.
•
All providers must be valid participants in the MRT program.
•
Providers should submit paper CMS-1500 claim forms to the following address:
HP CMS-1500 Claims
P.O. Box 7269
Indianapolis, IN 46207-7269
•
Providers submitting claims via Web interChange must meet the technical requirements for Web
interChange access, and have a valid Web interChange account and password. Providers should
allow five business days to process each new Web account. Providers that currently have a Web
interChange account and password do not need an additional account and password to submit
claims for MRT.
•
New providers wanting to use the 837P transaction must complete, submit, and obtain prior
approval of their vendor’s software, trading partner ID, logon ID, and password. Providers should
allow one week to process vendor and account information. Providers may obtain instructions for
account setup by obtaining a copy of the Companion Guide – 837 Professional Claims and
Encounters Transaction from the IHCP Web site at http://provider.indianamedicaid.com.
Note: Providers that are currently transmitting claims using the 837P transaction
are not required to submit a second application.
•
Providers cannot submit MRT claims for payment with a claim for Medicaid or services for any
other IHCP program. Providers must submit MRT claims with the unique MRT member
identification number.
•
MRT claims are subject to all edits and audits not excluded by MRT program requirements.
•
Providers can bill for partial units of service.
•
MRT financial information is available in the electronic 835 RA transaction.
•
MRT claims processing information is reflected on the 276/277 Claim Status Request and
Response Transactions. Providers can inquire on the claims status request and response using Web
interChange.
•
At no time will an applicant bear financial responsibility for an MRT claim if the services were
requested by the MRT or county caseworker. MRT claims are paid even if the disability
application is denied.
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MRT Reimbursement for Transportation
The MRT program reimburses for transportation services in cases of financial hardship when no
transportation is available for medically necessary examinations or tests; however, the provider must
contact the MRT to obtain approval prior to rendering the service.
Only the following codes will be authorized and billed for most trips:
•
T2003 SE – Nonemergency transportation, encounter, trip; $10 each way, regardless of vehicle
type
•
T2007SE – Transportation waiting time, air ambulance and nonemergency vehicles, one-half hour
increments; $4.50
•
A0425 SE – Ground mileage, per statute mile; $1.25
Note: These codes are different from transportation codes used in the IHCP.
For billing purposes, a trip is defined as the act of transporting a member from the initial point of
pickup to the drop-off point at the final destination.
Transportation providers are expected to transport the member along the shortest and most efficient
route to and from the destination.
MRT Procedure Codes
The following tables provide information to help providers select the procedure code that best
describes the services rendered. When providers have questions about procedure codes used for billing
MRT services or the RBRVS/Maximum Fee Schedule, or when they require clarification about a
specific code, they should follow the appropriate avenue of resolution listed in Chapter 1 of this
manual. The complete fee schedule is available on the IHCP Web site
at http://provider.indianamedicaid.com.
Table 8.124 – MRT CPT® Procedure Codes and Fee Schedule
Procedure
Code
8-362
Modifier
Procedure Code Description
Modifier Description
36415
Collection of venous blood by venipuncture
70210
Radiologic examination, sinuses, paranasal;
less than three views
70220
Radiologic examination, sinuses, paranasal;
complete, minimum of three views
70250
Radiologic examination, skull; less than 4
views
70260
Radiologic examination skull; minimum of 4
views
71010
Radiologic examination, chest; single view,
frontal
71020
Radiologic examination, chest; two views,
frontal and lateral
71100
Radiologic examination, ribs, unilateral; two
views
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Procedure
Code
Modifier
Procedure Code Description
71250
Computed tomography, thorax; without
contrast material
71260
Computerized tomography, thorax; with
contrast material(s)
72040
Radiologic examination, spine, cervical; two
or three views
72050
Radiologic examination, spine, cervical;
minimum of four views
72052
Radiologic examination, spine, cervical;
complete, including oblique and flexion
and/or extension studies
72069
Radiologic examination, spine,
thoracolumbar, standing (scoliosis)
72070
Radiologic examination, spine; thoracic; two
views
72072
Radiologic examination, spine; thoracic; three
views
72074
Radiologic examination, spine; thoracic;
minimum of four views
72080
Radiologic examination, spine;
thoracolumbar; two views
72100
Radiologic examination, spine, lumbosacral;
two or three views
72110
Radiologic examination, spine, lumbosacral;
minimum of four views
72114
Radiologic examination, spine, lumbosacral;
complete, including bending views
72170
Radiologic examination, pelvis; one or two
views
72200
Radiologic examination, sacroiliac joints; less
than three views
72202
Radiologic examination, sacroiliac joints;
three or more views
72220
Radiologic examination, sacrum and coccyx;
minimum of two views
73020
Radiologic examination, shoulder; one view
73030
Radiologic examination, shoulder; complete,
minimum of two views
73060
Radiologic examination, humerus; minimum
of two views
73070
Radiologic examination, elbow; two views
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Procedure
Code
8-364
Modifier
Procedure Code Description
Modifier Description
73080
Radiologic examination, elbow, complete;
minimum of three views
73090
Radiologic examination, forearm; two views
73100
Radiologic examination, wrist; two views
73110
Radiologic examination, wrist; complete,
minimum of three views
73120
Radiologic examination, hand; two views
73130
Radiologic examination, hand; minimum of
three views
73500
Radiologic examination, hip; unilateral, one
view
73510
Radiologic examination, hip; complete,
minimum of two views
73520
Radiologic examination, hips, bilateral;
minimum of two views of each hip, including
anteroposterior view of pelvis
73550
Radiologic examination, femur; two views
73560
Radiologic examination, knee; one or two
views
73562
Radiologic examination, knee; three views
73564
Radiologic examination, knee; complete, four
or more views
73565
Radiologic examination, knee; both knees,
standing, anteroposterior
73590
Radiologic examination, tibia and fibula; two
views
73600
Radiologic examination, ankle; two views
73610
Radiologic examination, ankle; complete,
minimum of three views
73620
Radiologic examination, foot; two views
73630
Radiologic examination, foot; complete,
minimum of three views
74000
Radiologic examination, abdomen; single
anteroposterior view
74020
Radiologic examination, abdomen; complete,
including decubitus and/or erect views
74022
Radiologic examination, abdomen; complete
acute abdomen series, including supine, erect,
and/or decubitus views; single view chest
80048
Basic metabolic panel
80053
Comprehensive metabolic panel
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Procedure
Code
Modifier
Procedure Code Description
80061
Lipid profile
80076
Hepatic function panel
80100
Drug screen, qualitative; multiple drug
classes, chromatographic method; each
procedure
80164
Dircpylacetic acid (valproic acid)
82150
Amylase
82465
Cholesterol, serum or whole blood; total
82565
Creatinine; blood
82575
Creatinine; clearance
82947
Glucose; quantitative, blood (except reagent
strip)
83036
Hemoglobin; glycosylated (AIC)
83690
Lipase
83718
Lipoprotein, direct measurement; high
density cholesterol (HDL cholesterol)
84436
Thyroxine, total
84443
Thyroid stimulating hormone (TSH)
84450
Transferase; aspartate amino (AST) (SGOT)
84460
Transferase; alanine amino (ALT) (SGPT)
84478
Triglycerides
84479
Thyroid hormone (T3 or T4) uptake or
thyroid hormone binding ratio (THBR)
84550
Uric acid; blood
85018
Blood count; hemoglobin (Hgb)
85025
Blood count; complete (CBC), automated
(Hgb, Hct, RBC, WBC, and platelet count)
and automated differential WBC count
85651
Sedimentation rate, erythrocyte;
nonautomated
85652
Sedimentation rate, erythrocyte; automated,
Westergren test
86361
T cells; absolute CD4 count
86430
Rheumatoid factor; qualitative
86707
Hepatitis Be antibody (HBeAB)
86708
Hepatitis A antibody (HAAB); total
86803
Hepatitis C antibody
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Modifier Description
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Procedure
Code
8-366
Modifier
Procedure Code Description
Modifier Description
90801
SE
Psychiatric diagnostic interview examination
State and/or federally
funded programs/
service
92002
SE
New: Ophthalmological services: medical
examination and evaluation with initiation of
diagnostic and treatment program;
intermediate, new patient
State and/or federally
funded programs/
services
92012
SE
Established: Ophthalmological services:
medical examination and evaluation, with
initiation or continuation of diagnostic and
treatment program; intermediate, established
patient
State and/or federally
funded programs/
services
92015
Determination of refractive state
92083
Visual field extended examination (e.g.,
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 30-2,
24-2, or 30/60-2)
92551
Screening test; pure tone, air only
92552
Pure tone audiometry (threshold); air only
92553
Pure tone audiometry (threshold); air and
bone
92557
Comprehensive audiometry threshold
evaluation and speech recognition (92553 and
92556 combined)
93000
Electrocardiogram, routine ECG with at least
12 leads; with interpretation and report
93010
Electrocardiogram, routine ECG with at least
12 leads; interpretation and report only
94010
Spirometry, including graphic record, total
and timed vital capacity, expiratory flow rate
measurement(s) with or without maximal
voluntary ventilation
94060
Bronchodilation responsiveness, spirometry
as in 94010, pre- and post-bronchodilator
administration
95816
Electroencephalogram (EEG); including
recording awake and drowsy
95819
Electroencephalogram (EEG); including
recording awake and asleep
95860
Needle electromyography; one extremity with
or without related paraspinal areas
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Procedure
Code
Modifier
Procedure Code Description
95861
Needle electromyography; two extremities
with or without related paraspinal areas
95863
Three extremities with or without related
paraspinal areas
95864
Four extremities with or without related
paraspinal areas
95900
Nerve conduction, amplitude and
latency/velocity study; each nerve, motor,
without F-wave study
95903
Nerve conduction, amplitude and
latency/velocity study; each nerve, motor,
with F-wave study
95904
Sensory
Modifier Description
96100
SE
Psychological testing – includes
psychodiagnostic assessment of personality,
psychopathology, emotionality, intellectual
abilities, such as Wechsler Adult Intelligence
Scale – Revised (WAIS R), Rorschach,
Minnesota Multiphasic Personality Inventory
(MMPI) – with interpretation and report, per
hour
State and/or federally
funded programs/
services
96101
SE
Psychological testing (includes
psychodiagnostic assessment of emotionality,
intellectual abilities, personality and
psychopathology, such as MMPI, Rorschach,
WAIS) 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
State and/or federally
funded programs/
services
99080
Special reports as insurance forms, more than
the information conveyed in the usual
medical communications or standard
reporting form
99199
Unlisted special service, procedure or report
99244
Office consultation for a new or established
patient
99245
Office consultation for a new or established
patient
99274
Confirmatory consultation for a new or
established patient
99275
Confirmatory consultation for a new or
established patient
99450
Basic life and/or disability examination
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Procedure
Code
A0425
Modifier
SE
Procedure Code Description
Modifier Description
SE – State and/or
federally funded
programs/service
Ground mileage, per statute mile
S9981
Medical records copying fee, administrative
T1023
Screening to determine the appropriateness of
consideration of an individual for
participation in a specified program, project
or treatment protocol, per encounter
T2003
SE
Nonemergency transportation; encounter/trip
State and/or federally
funded
programs/services
T2007
SE
Transportation waiting time, air ambulance
and nonemergency vehicle, one-half hour
increments
State and/or federally
funded programs/
services
Pre-Admission Screening and Resident Review Billing Procedures
This section provides billing and claim processing guidelines for Pre-Admission Screening and
Resident Review (PASRR) providers. PASRR claims use normal claim processing billing procedures
and payment logic, although there may be minor differences.
For Provider Enrollment, new Diagnostic and Evaluation (D&E) Teams and CMHCs are only
approved to conduct PASRR Level II assessments through contractual arrangements with the Division
of Disability, Rehabilitative Services (DDRS), and the Division of Mental Health and Addiction
(DMHA). The OMPP refers the names of new entities to the HP Provider Enrollment Unit for further
enrollment processing. PASRR providers that are currently enrolled as IHCP providers do not need to
re-enroll. The current IHCP provider ID number that has been assigned for Medicaid or other
nonwaiver IHCP programs will be the provider’s PASRR provider ID number. If a current provider ID
does not exist, the provider must enroll as a PASRR provider.
To enroll as a PASRR provider and to obtain a valid provider ID to submit PASRR claims, providers
should visit the IHCP Web site at http://provider.indianamedicaid.com to obtain and complete
enrollment applications.
Providers should submit completed applications to the following address:
HP Provider Enrollment
P.O. Box 7263
Indianapolis, IN 46207-7263
PASRR applicants or members may be dually eligible in the IHCP. When providers submit claims for
PASRR, the provider must use the PASRR member ID that consists of 800 and the applicant’s Social
Security number, or the applicant’s PASRR identification number (for example, 800999999999). At no
time shall a member bear financial responsibility for a PASRR Level II assessment.
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PASRR claims must be submitted via a paper CMS-1500 claim form, Web interChange, or the 837P
transaction within one year of the date of service. The provider must properly identify and itemize all
services rendered. Providers should submit paper claims on standard CMS-approved paper CMS-1500
claim forms to the following address:
HP CMS-1500 Claims
P.O. Box 7269
Indianapolis, IN 46207-7269
Providers submitting claims using the Web interChange must meet the technical requirements for Web
interChange access, and have a valid Web interChange account and password. Providers should allow
five business days to process each new Web account. Providers that currently have a Web interChange
account and password do not need an additional account and password.
New providers wanting to use the 837P transaction must complete, submit, and obtain prior approval
of their vendor’s software, trading partner ID, logon ID, and password. Providers should allow one
week to process vendor and account information. Providers may obtain instructions for account setup
by obtaining a copy of the Companion Guide – 837 Professional Claims and Encounters Transaction
on the IHCP Web site at http://provider.indianamedicaid.com. Providers who currently send claims
using the 837P transaction are not required to make a second application.
Providers must submit a claim for each service instance. Services cannot be combined with other nonPASRR service types, even if the services are rendered on the same day or same visit. For example, a
claim for PASRR services cannot be combined with a claim for Medicaid services.
PASRR claims are subject to all edits and audits not excluded by PASRR program requirements. If a
claim encounters an edit or audit for missing or invalid information, the claim suspends or denies.
Provider reimbursement for rendered services is determined by the procedure codes, modifiers, and
associated maximum (max) fee rate. Procedure codes, modifiers, and max fee rates must accompany
all PASRR claim submissions. Providers are responsible for entering billable charges per the published
procedure code and max fee rate.
Procedure codes and modifiers must accompany all claim submissions. IndianaAIM will capture as
many as four modifiers for all PASRR claims with MI or MR segments. If the procedure code or
applicable modifier is missing or invalid, edits will deny or suspend claims.
Providers may void or replace PASRR claims. PASRR financial information is available on the 835
RA transaction. PASRR claims processing information is reflected on the 276/277 Claim Status
Request Response Transactions. Providers can inquire on the claims status request and response using
Web interChange.
Table 8.125 lists the procedure codes and modifiers for PASRR.
Table 8.125 – Procedure Codes for PASRR
Procedure
Code
T2011 U1 UA
Code
Description
Level II
PAS-MR
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Revision Date: August 26, 2010
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Procedure Code and Modifiers
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U1: PAS (Preadmission Screening)
UA: Mental Retardation / Developmental Disability
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Procedure
Code
Code
Description
Procedure Code and Modifiers
T2011 U1 UA
H1
Level II
PAS-MR
Psych Exam
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U1: PAS (Preadmission Screening)
UA: Mental Retardation / Developmental Disability
HI: Integrated Mental Health and Mental Retardation /
Developmental Disabilities Program
T2011 U2 UA
Level II
RR-MR
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U2: RR (Resident Review)
UA: Mental Retardation / Developmental Disability
T2011 U2 UA
H1
Level II
RR-MR
Psych Exam
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U2: RR (Resident Review)
UA: Mental Retardation / Developmental Disability
HI: Integrated Mental Health and Mental Retardation /
Developmental Disabilities Program
T2011 U1 UB
Level II
PAS-MI
Initial
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U1: PAS (Preadmission Screening)
UB: Mental Illness
T2011 U1 UB
TS
Level II
PAS-MI
Initial Update
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U1: PAS (Preadmission Screening)
UB: Mental Illness
TS: Follow-up service
T2011 U2 UB
Level II
RR-MI
T2011: Preadmission Screening and Resident Review (PASRR)
Level II Evaluation, per Evaluation
U2: RR (Resident Review)
UB: Mental Illness
Notes:
1. U1, U2, UA, and UB modifiers would be assigned by the Medicaid
Program.
2. HI and TS modifiers are existing national modifiers.
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Chapter 8
Section 5: Dental Claim Form Billing Instructions
Introduction
The Indiana Health Coverage Programs (IHCP) accepts only the American Dental Association (ADA)
2006 Dental Claim Form for paper claim submissions, which this section refers to as the ADA 2006
claim form or Dental Claim Form. The 837 Health Care Claim: Dental Health Insurance Portability
and Accountability Act (HIPAA) transaction is the HIPAA-compliant electronic dental transaction.
This section refers to this transaction as the 837 Dental or 837D transaction.
HP does not supply dental claim forms, and they are not available on the IHCP Web site. Providers can
obtain dental claim forms from several sources, including the American Dental Association at
1-800-947-4746. The IHCP returns claims submitted on any other claim form to the provider.
Providers Using the Dental Claim Form
The following types of providers use the Dental Claim Form or the 837D transaction to bill services to
the IHCP:
•
Endodontists
•
General dentistry providers
•
Orthodontists
•
Oral surgeons
•
Pediatric dentists
•
Periodontists
•
Prosthodontists
ADA 2006 Paper Claim Form Changes and Requirements
This section provides a brief overview of the requirements for completion of the ADA 2006 claim
form. The ADA 2006 claim form replaced the ADA 1999, Version 2000 claim form on March 1, 2008.
The instructions outlined in this manual are effective for the new ADA 2006 paper claim submissions
starting April 15, 2007. All ADA 2006 paper claims received on and after March 1, 2008, must meet
the new ADA 2006 claim form requirements. Noncompliant paper claims submitted for processing are
returned to the provider. During the transition period of April 1, 2007, to March 1, 2008, the IHCP
accepted the old and the new claim forms. As of March 1, 2008, providers are required to report their
National Provider Identifier (NPI) to the IHCP and may include their IHCP Legacy Provider Identifier
(LPI) on the paper claim form. After March 1, 2008, only the NPI is required to process claims. For
more instructions about NPI requirements, see the National Provider Identifier and One-to-One Match
section.
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Rendering NPI Required
All dental group providers must use their rendering and billing provider NPIs on the new ADA 2006
dental claim form. To expedite claims, providers should follow the claim form completion guidelines
as listed in Table 8.126 when submitting claims.
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.
ADA 2006 Dental Claim Form Fields
This section includes instructions for completing the dental claim form. Table 8.126 describes each
field of the ADA 2006 Dental Claim Form. The field chart uses bold to indicate fields that are required
or required, if applicable. The instructions describe each field, or data element, by referring to the
number found in the left corner of each box on the dental claim form. Several fields are not numbered.
These fields are listed as unlabeled. The narrative sequence moves from left to right, top to bottom,
across the claim form.
Note: Each claim form must have all required fields completed, including a total
dollar amount. Providers can list only one procedure code per service line. If
the number of service lines exceeds the number of service lines allowed on
the form, providers must complete an additional claim form.
All dental providers are required to include dental rendering provider NPI. This requirement is for
claims received on or after April 15, 2007. This requirement includes submission of noncheck- and
check-related adjustments submitted by paper or replacements that are performed on Web interChange.
If the claim or adjustment submitted does not include the appropriate rendering provider NPI, the claim
will be denied.
In the event that your claim or adjustment request was denied, your claim or adjustment request must
be resubmitted with the necessary corrections. In the event that a mass adjustment (claims that begin
with region 56) is initiated by HP for erroneously denied claims and the claim was originally paid
based on a date of receipt prior to April 15, 2007, and the claim suspends for a rendering NPI edit, the
claim will be forced. If the mass adjustment is processed and the original date of receipt is after April
15, 2007, the claim will be denied appropriately.
Providers who have administrator access in Web interChange can view their provider profiles to access
a list of the rendering providers linked to the group. Providers can contact the Provider Enrollment
Helpline at 1-877-707-5750 to discuss any updates that need to be made to the provider group
information.
Description of Fields on the ADA 2006 Dental Claim Form
This section explains completion of the ADA 2006 claim form. Some information is required to
complete the claim form, while other information is optional. All dental providers must use their
rendering and group NPI numbers. When two or more dentists are rendering services for a member, the
providers must use separate claims to expedite claims processing. Providers should follow the
guidelines in Table 8.126 when submitting claims.
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Section 5: Dental Claim Form Billing Instructions
The ADA 2006 Claim Form Field Descriptions table uses bold type to indicate 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 noted as well. The instructions
describe each form locator by referring to the number found in the left corner of each box on the ADA
2006 claim form. These boxes contain the data elements.
Figure 8.3 – American Dental Association (ADA) 2006 Dental Claim Form
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Table 8.126 – ADA 2006 Dental Claim Form Field Descriptions
Form Field
Narrative Description/Explanation
1
Type of Transaction (mark all applicable boxes) – Mark the box stating, Dentist’s
statement of actual services and/or EPSDT. Optional.
2
Predetermination/Preauthorization Number – Prior Authorization #:
If it is an emergency situation, include the word Emergency in this field. Required if
applicable.
3
INSURANCE COMPANY/DENTAL BENEFIT PLAN INFORMATION – Company
Plan Name, Address, City, State, ZIP Code – Enter primary insurance information with
name and address, ZIP Code+4. Optional. Only required if member has other
insurance. This field is not to be used for Indiana Medicaid information.
4
OTHER DENTAL OR MEDICAL COVERAGE? – Mark yes or no. Optional.
5
OTHER SUBSCRIBER NAME – If another insurance is available and the policyholder is
other than the member indicated in field 20, provide the policyholder’s name. Optional.
6
DATE OF BIRTH: MM/DD/CCYY – If another insurance is available and the
policyholder is other than the member indicated in field 20, provide the policyholder’s
birth date in MMDDCCYY format. Optional.
7
GENDER – M, F – Mark the appropriate box. Optional.
8
POLICYHOLDER/SUBSCRIBER ID (SSN OR ID#) – Required, if applicable.
9
PLAN/GROUP NUMBER – Required, if applicable.
10
PATIENT’S RELATIONSHIP TO PERSON NAMED IN #5 – Required, if
applicable.
11
OTHER INSURANCE COMPANY/DENTAL BENEFIT PLAN NAME, ADDRESS,
CITY, STATE, ZIP CODE – Required, if applicable.
12
POLICYHOLDER/SUBSCRIBER INFORMATION (FOR INSURANCE
COMPANY NAMED IN #3) – Enter the member’s last name, first name, and middle
initial as found on the member’s IHCP identification card. Required for field 12 or field
20.
13
DATE OF BIRTH (MM/DD/CCYY) – Optional.
14
GENDER – Optional.
15
POLICYHOLDER/SUBSCRIBER ID (SSN OR ID#) – This field accommodates the
12 numeric characters. Required for either field 15 or field 23.
16
PLAN/GROUP NUMBER – Required, if applicable.
17
EMPLOYER NAME – Required, if applicable.
PATIENT INFORMATION
18
RELATIONSHIP TO POLICYHOLDER/SUBSCRIBER IN #12 ABOVE – Enter an ‘X’
in the appropriate box. Optional.
19
STUDENT STATUS – Optional.
20
PATIENT NAME (LAST, FIRST, MIDDLE INITIAL, SUFFIX), ADDRESS,
CITY, STATE, ZIP CODE – Enter the member’s last name, first name, and middle
initial as found on the member’s IHCP identification card. Required for field 12 or field
20.
21
DATE OF BIRTH – Optional.
22
GENDER – Optional.
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Form Field
Chapter 8
Section 5: Dental Claim Form Billing Instructions
Narrative Description/Explanation
23
PATIENT ID/ACCOUNT # (ASSIGNED BY DENTIST) – Enter the IHCP member’s
identification (RID) number. This field accommodates the 12 numeric characters.
Required for field 15 or field 23.
24
PROCEDURE DATE – Enter the date the service was rendered in MM/DD/CCYY
format. Required. Date of service is the date the specific services were actually supplied,
dispensed, or rendered to the patient. For example, this date will reflect the date the
denture or space maintainer is delivered to the patient.
25
AREA OF ORAL CAVITY – Optional.
26
TOOTH SYSTEM – Optional.
27
TOOTH NUMBER(S) OR LETTER(S) – Enter the tooth number or letter for the
service rendered. Required for any procedure performed on an individual tooth.
Required, if applicable.
28
TOOTH SURFACE – Enter the tooth surface for the service rendered. Required, if
applicable.
29
PROCEDURE CODE – Enter the appropriate ADA Current Dental Terminology (CDT)
procedure code. Required.
30
DESCRIPTION – Optional.
31
FEE – Enter the amount charged for the procedure code. Eight digits are allowed,
including two decimal places. Required.
32
OTHER – Not used.
33
TOTAL FEE – Enter the total of all the individual service line charges. Eight digits are
allowed, including two decimal places. Required.
34
MISSING TEETH INFORMATION – (PLACE AN ‘X’ ON EACH MISSING TOOTH)
Mark the diagram as directed. Optional.
35
REMARKS – Enter only the amount paid by prior payer. All commercial payments are
required in this field. Required, if applicable.
36
AUTHORIZATIONS – PATIENT/GUARDIAN SIGNATURE AND DATE – Optional.
37
AUTHORIZATIONS – SUBSCRIBER SIGNATURE AND DATE – Optional.
ANCILLARY CLAIM/TREATMENT INFORMATION
38
PLACE OF TREATMENT – Indicate the type of facility where treatment was rendered
by marking an ‘X’ in the appropriate box. Required.
39
NUMBER OF ENCLOSURES (00 TO 99) – Not applicable.
40
IS TREATMENT FOR ORTHODONTICS? – If Yes is marked, provide the additional
information requested. Optional.
41
DATE APPLIANCE PLACED (MM/DD/CCYY) – Enter date. Optional.
42
MONTHS OF TREATMENT REMAINING – Optional.
43
REPLACEMENT OF PROSTHESIS? – If Yes is marked, provide the additional
information requested. Optional.
44
DATE PRIOR PLACEMENT (MM/DD/CCYY) – Enter date. Optional.
45
TREATMENT RESULTING FROM – Mark the appropriate box. Required, if
applicable.
46
DATE OF ACCIDENT (MM/DD/CCYY) – Enter date. Required, if applicable.
47
AUTO ACCIDENT STATE – Enter state of accident. Required, if applicable.
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Form Field
Indiana Health Coverage Programs Provider Manual
Narrative Description/Explanation
BILLING DENTIST OR DENTAL ENTITY
48
NAME, ADDRESS, CITY, STATE, ZIP CODE – Enter the billing provider office
location name, address, city, state, and nine-digit ZIP Code +4. Required.
49
NPI – Enter the 10-digit numeric NPI of the billing or group provider. Required.
50
LICENSE NUMBER – Leave field blank. Effective October 1, 2009, healthcare
providers will no longer enter the LPI in this field.
51
SSN OR TIN – Optional.
52
PHONE NUMBER – Optional.
52A
ADDITIONAL PROVIDER ID – Enter the taxonomy code for the billing provider NPI.
Required if needed to establish one-to-one NPI/LPI match if the provider has
multiple locations.
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
53
TREATING DENTIST AND TREATMENT LOCATION INFORMATION –
SIGNED (TREATING DENTIST) – An authorized person, someone designated by the
provider, or the dentist must sign and date the claim. A signature stamp is acceptable;
however, a typed signature is not acceptable. Required, unless the Signature on File
form has been completed and is included in the provider enrollment file.
DATE – Provide the date the claim was submitted in a MMDDYYYY format. Required.
Note: If two or more physicians perform services on the same patient on
the same date of service, these services must be filed on separate
claims.
54
NPI – Enter the rendering provider NPI. Required.
55
LICENSE NUMBER – Optional.
56
ADDRESS, CITY, STATE, ZIP CODE – Enter rendering provider address. Optional.
56A
PROVIDER SPECIALTY CODE – Enter the rendering provider taxonomy code for
the NPI. Required if needed to establish a one-to-one NPI/LPI match if the provider
has multiple locations.
57
PHONE NUMBER – Optional.
58
ADDITIONAL PROVIDER ID – Leave field blank. Effective October 1, 2009,
healthcare providers will no longer enter the LPI in this field.
837D Electronic Transaction
Providers must use the standard 837D format to submit electronic institutional claims. These standards
are published in the 837D 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 Web site at http://wpc-edi.com.
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
Companion Guides are never intended to modify, contradict, or reinterpret the rules established by the
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Section 5: Dental Claim Form Billing Instructions
IGs. The Companion Guides are located on the IHCP Web site at http://provider.indianamedicaid.com
in the EDI Solutions section.
Some data elements that providers submit may not be used in processing the 837I or 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 add these data elements may result in claim suspension or claim denial.
Billing Procedures
Current Dental Terminology Procedure Codes
The IHCP end-dated in IndianaAIM all IHCP dental codes not listed as Current Dental Terminology
(CDT) procedure codes.
As updates to the CDT occur, the IHCP notifies providers of the changes through the Healthcare
Common Procedure Coding System (HCPCS) updates in IHCP provider bulletins, newsletters, and
banner page articles.
Dental Extractions
The following billing requirements and reimbursement policies apply to tooth extractions. The IHCP
allows only one tooth number per service line for dental extractions.
A provider submitting a claim for D7140 – Extraction, erupted tooth or exposed root (elevation and/or
forceps removal) must indicate the tooth number for each tooth extracted on a separate service line in
field 27 on the ADA 2006 Dental Claim Form. The IHCP pays 100 percent of the maximum allowed
amount or the billed amount, whichever is less, for the initial extraction. This dental service is not
applied toward the IHCP member’s $600 Dental Cap services. For multiple extractions within the
same quadrant on the same date of service, the IHCP pays 90 percent of the maximum allowed amount
for procedure code D7140 or the billed amount, whichever is less.
Package E Billing
With the assistance of the Dental Advisory Panel (DAP), the IHCP created a table of the CDT codes
that are allowed for reimbursement of emergency services provided to Package E members. These
codes are shown in Table 8.127. The listing of a code in Table 8.127 does not eliminate the need for
providers to document the emergency medical condition that required treatment.
The Omnibus Budget Reconciliation Act of 1990 (OBRA) defines an emergency medical condition as
follows:
A medical condition of sufficient severity (including severe pain) that the absence of medical attention
could result in placing the member’s health in serious jeopardy, serious impairment of bodily
functions, or serious dysfunction of an organ or part.
Radiographs must be billed only when the member presents with symptoms that warrant the diagnostic
service.
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Table 8.127 – CDT Codes Allowed for Package E Members
CDT Code
Description
D0140
Limited oral evaluation – problem focused
D0210
Intraoral – complete series (including bitewings)
D0220
Intraoral – periapical – first film
D0230
Intraoral – periapical – each additional film
D0240
Intraoral – occlusal film
D0270
Bitewing – single film
D0272
Bitewings – two films
D0273
Bitewings – three films
D0274
Bitewings – four films
D0330
Panoramic film
D7111
Extraction, coronal remnants – deciduous tooth
D7140
Extraction, erupted tooth or exposed root
D7210
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal
of bone and/or section of tooth
D7220
Removal of impacted tooth – soft tissue
D7230
Removal of impacted tooth – partially bony
D7240
Removal of impacted tooth – completely bony
D7241
Removal of impacted tooth – completely bony, with unusual surgical complications
D7250
Surgical removal of residual tooth roots (cutting procedure)
D7260
Oroantral fistula closure
D7261
Primary closure of sinus perforation
D7270
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7280
Surgical access of unerupted tooth (impacted tooth not intended for extraction)
D7282
Mobilization of erupted or malpositioned tooth to aid eruption
D7285
Biopsy of oral tissue – hard
D7286
Biopsy of oral tissue – soft
D7288
Brush biopsy – transepithelial sample collection
D7510
Incision and drainage of abscess – intraoral soft tissue
D7511
Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage
of multiple fascial spaces)
D7520
Incision and drainage of abscess – extraoral soft tissue
D7521
Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage
of multiple fascial spaces)
D7560
Maxillary sinusotomy for removal of tooth fragment or foreign body
D7610
Maxilla – open reduction (simple fracture)
D7620
Maxilla – closed reduction (simple fracture)
D7630
Mandible – open reduction (simple fracture)
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CDT Code
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Description
D7640
Mandible – closed reduction (simple fracture)
D7650
Malar and/or zygomatic arch – open reduction (simple fracture)
D7660
Malar and/or zygomatic arch – closed reduction (simple fracture)
D7670
Alveolus – closed reduction, may include stabilization of teeth (simple fracture)
D7671
Alveolus – open reduction, may include stabilization of teeth (simple fracture)
D7680
Facial bones – complicated reduction with fixation and multiple surgical approaches
(simple fracture)
D7710
Mandible Maxilla – open reduction (compound fracture)
D7720
Mandible Maxilla – closed reduction (compound fracture)
D7730
Mandible – open reduction (compound fracture)
D7740
Mandible – closed reduction (compound fracture)
D7750
Malar and/or zygomatic arch – open reduction (compound fracture)
D7760
Malar and/or zygomatic arch – closed reduction (compound fracture)
D7770
Alveolus – open reduction, may include stabilization of teeth (compound fracture)
D7771
Alveolus – closed reduction, may include stabilization of teeth (compound fracture)
D7780
Facial bones – complicated reduction with fixation and multiple surgical approaches
(compound fracture)
D7910
Suture of small wounds up to 5cm (excludes surgical incisions)
D7911
Complicated suture – up to 5cm (excludes surgical incisions)
D7912
Complicated suture – greater than 5cm (excludes surgical incisions)
D7999
Unspecified oral surgery procedure – by report
D9220
General anesthesia – first 30 minutes. (Covered only if medically necessary. Only
covered in the office setting for members less than 21 years of age. Only covered for
members 21 years of age and older in the hospital (inpatient or outpatient) or ASC
setting.)
D9221
General anesthesia – each additional 15 minutes. (See D9220.)
D9230
Analgesia, anioxlysis, inhalation of nitrous oxide. (Covered only for members 20 years
of age and younger and limited to one unit per visit.)
D9241
Intravenous conscious sedation/analgesia – first 30 minutes. (Covered for oral surgical
procedures only.)
D9242
Intravenous conscious sedation/analgesia – each additional 15 minutes. (Covered for oral
surgical procedures only.)
D9248
Nonintravenous conscious sedation
D9920
Behavior management
Attachments
In the past, the IHCP allowed attachments only with paper claim submissions. However, HIPAA
allows attachments to be submitted with paper and electronic claims. Attachment control numbers
(ACNs) are only for electronic claim submission. Providers must submit attachments for electronic
claims by mail for processing. Providers must use the attachment transmission code BM (by mail)
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– when submitting all attachments for electronic claims. Providers must submit all attachments at
the same time. Each time a claim that has attachments is submitted electronically, the ACN must be a
unique number. Providers must mail the attachment and cover sheet to the IHCP at the following
address:
HP
P.O. Box 7259
Indianapolis, IN 46207
If HP does not receive an attachment within 45 days of claim submission, the IHCP automatically
denies the claim. If HP receives an incorrect attachment, the IHCP automatically denies the claim.
Attachment Control Number
Attachments must contain an ACN. This code identifies each attachment. The ACN allows the IHCP
to match the attachment to the submitted claim and must be written at the top of each page of the
attachment. The provider must create the ACN, which can be numbers, letters, or a combination of
letters and numbers. ACNs can be up to 30 characters in length. The numbers must be unique to each
attachment for each claim. The provider must indicate the number of pages on the Claims Attachment
Cover Sheet (not including the cover sheet) and on each page of a multiple-page document. The
Claims Attachment Cover Sheet is available on the Forms page of the IHCP Web site at
http://provider.indianamedicaid.com/general-provider-services/forms.aspx.
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:
•
B4 – Referral Form – Used by Surveillance and Utilization Review (SUR) for the Right Choices
Program
•
DA – Dental Models – Used by SUR and submitted only upon request
•
DG – Diagnostic Report – Used by prior authorization (PA) and SUR
•
EB – Explanation of Benefits – Used by Third Party Liability (TPL), Resolutions, and SUR
•
OB – Operative Note – Used by PA, Resolutions, Medical Policy, and SUR
•
P6 – Periodontal Charts – Used for specific periodontal procedures
•
RR – Radiology Reports – Used by PA, Medical Policy, and SUR
•
RB – Radiology Films – Used by PA and SUR
•
OZ – Support Data for Claim – The following are uses for progress notes:
- Invoices (Manual Pricing)
- Durable Medical Equipment delivery tickets
- Transportation run tickets
- Sterilization/Hysterectomy consent forms
- Spend-down Form 8A
- Past filing limit documentation
- PA request/response copies
- Environmental modification service requests
- Consultation reports
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Return to Provider Letter
Providers receive a return to provider (RTP) letter when the number of attachments behind the
attachment cover letter does not match the number the provider listed on the Claims Attachment Cover
Sheet. HP matches the attachments received with the parent claim electronically. When providers
correctly submit attachments with all numbers matching, Claim Support, Resolutions, and the
appropriate MCO or CMO processes the claim.
When an ACN that is not unique is submitted on a claim, an error message prompts the provider to
change the ACN; the claim cannot be submitted without a unique ACN.
Paper Claims with Attachments
HIPAA implementation did not change the process for paper claim attachments. Providers should
continue to follow current procedures for submitting paper claims with attachments as outlined
in Chapter 10 of this manual.
Managed Care Considerations
Hoosier Healthwise risk-based managed care (RBMC) is the delivery system for the mandatory
managed care program for parents and children who receive Temporary Assistance for Needy Families
(TANF) and for children and pregnant women at or just above the federal poverty limit.
Care Select enrolls most aged, blind, and disabled Medicaid enrollees. Care Select excludes enrollees
with a nursing facility or waiver Level of Care, or those who have spend-down.
The IHCP pays dental claims for Hoosier Healthwise and Care Select members the same way it pays
traditional IHCP fee-for-service (FFS) claims. Providers must submit dental claims to HP for payment.
Providers do not need primary medical provider (PMP) authorization or program authorization for
members to access dental services, except for dental surgery provided in an inpatient, outpatient, or
ambulatory surgical center (ASC) setting.
Note: For RBMC members, contact the appropriate MCO for instructions
regarding surgery. MCO contact information can be found in Chapter 1.
Care Select
Dental claims using the CDT codes for services provided to Care Select members do not require
certification from the PMP. However, for services rendered in an inpatient, outpatient, or ASC setting
to a Care Select member, the provider must have the services authorized by the PMP; the
anesthesiologist’s services also must be authorized by the PMP. For claims billed on the CMS-1500 or
UB-04 claim form for Care Select members, providers must have the claim authorized by the PMP to
be reimbursed. Providers can submit these claims to HP for payment.
Risk-Based Managed Care
In RBMC, the State contracts with managed care organizations (MCOs) to provide covered services,
including dental services provided in an inpatient, outpatient, or ASC setting to enrolled IHCP
members. The MCOs prefer prenotification by dentists using other service providers for delivery of
dental services. The IHCP carves out dental provider services billed on a dental claim form from
RBMC and MCO services. Providers must submit dental claims incurred by RBMC members to HP
for adjudication.
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When providers perform dental services in an inpatient, outpatient, or ASC setting, they bill their
services with the Healthcare Common Procedure Coding System (HCPCS) codes on a CMS-1500
claim form. The IHCP does not carve out ancillary services, such as anesthesia, and providers must bill
these services to the MCO.
Services Associated with Dental Services for Hoosier Healthwise RBMC Networks
For dental services that providers submit with CDT codes included in the IHCP Dental Fee Schedule
and bill on a dental claim form (paper or electronically), the IHCP carves out these services from
Hoosier Healthwise RBMC managed care. Providers must submit claims for these services to HP.
Providers can find a copy of the Dental Fee Schedule on the IHCP Web site
at http://provider.indianamedicaid.com. Information on how to obtain a paper copy of the fee schedule
is presented in the Healthcare Common Procedure Coding System Codes section.
Dental services, which are performed by the following dental specialists and billed on the ADA 2006
or the 837 Health Care Claim: Dental (837D) electronic transaction, are carved out or excluded from
the responsibility of Hoosier Healthwise RBMC:
•
Endodontists
•
General Dentistry Practitioners
•
Oral Surgeons
•
Orthodontists
•
Pediatric Dentists
•
Periodontists
•
Mobile Dentists
•
Prosthodontists
•
Dental Clinics
All dental services billed using CDT procedure codes must be submitted to HP using the ADA 2006
claim form or the 837D transaction.
Prior to dental services being provided in an inpatient or outpatient hospital setting or an ASC for an
RBMC member, the dental providers must first contact the member’s MCO before rendering services
to determine whether PA is required. When the provider obtains MCO authorization and provides
services, the services must then be billed as follows:
•
Dental-related facility charges must be billed on a UB-04 claim form.
•
Dental services provided in an inpatient, outpatient, or ASC setting can be billed with CDT codes
on a dental claim form. These services are carved out of RBMC, and must be billed to HP using
the ADA 2006 claim form or the 837D transaction.
•
All other associated professional services, such as oral surgery, radiology, and anesthesia, as well
as ancillary services related to the dental services, must be billed to the MCO on the CMS-1500
claim form or the 837P transaction, along with appropriate authorization information.
Note: If a member is enrolled in Care Select, the PMP must authorize services
rendered in an inpatient, outpatient, or ASC setting for providers to receive
reimbursement.
The MCOs and CMOs are responsible for determining which services require PA for their members.
The MCOs’ and CMOs’ decisions to authorize, modify, or deny a given request are based on medical
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necessity, reasonableness, and other criteria. A provider must make requests for reviews and appeals
by contacting the appropriate MCO and CMO.
Member Eligibility Verification and Billing for Dental Services
As in the traditional FFS IHCP, providers must verify eligibility at the time a member makes an
appointment and again prior to rendering the service on the day the appointment is scheduled.
Providers can verify eligibility through the Automated Voice Response (AVR) system, Omni swipe
card device (Omni), and the Web interChange. These methods are the same whether the member is in
Hoosier Healthwise, Care Select, or the Traditional Medicaid network.
Dental Cap
The IHCP places a $600 cap on dental services per calendar year, per member, for members 21 years
of age and older. This includes members who reach 21 years of age during the year and new members
who are 21 years of age or older on the date the member is eligible for dental services. The $600 cap
includes services provided on or after the date a member reaches 21 years old. Dental services
provided in a hospital do not apply to the cap. If the provider does not indicate the place of service on
the claim form, the IHCP assumes the service was delivered in a dental office. If services were
rendered in a hospital, providers should indicate a hospital place of service in field 38 of the ADA 2006
claim form.
Table 8.128 identifies codes for services included in the $600 dental cap when provided in a dentist’s
office.
Table 8.128 – CDT Codes Included in the $600 Dental Cap
CDT Code
Description
D0120
Periodic oral evaluation
D0140
Limited oral evaluation – problem focused
D0145
Oral evaluation for a patient under 3 years of age and counseling with primary
caregiver
D0150
Comprehensive oral evaluation
D0160
Detailed and extensive oral evaluation – problem focused, by report
D0170
Reevaluation – limited, problem focused (established patient; not postoperative visit)
D0210
Intraoral – complete series (including bitewings)
D0220
Intraoral – periapical – first film
D0230
Intraoral – periapical – each additional film
D0240
Intraoral – occlusal film
D0250
Extraoral – first film
D0260
Extraoral – each additional film
D0270
Bitewing – single film
D0272
Bitewings – two films
D0274
Bitewings – four films
D0290
Posterior-anterior or lateral skull and facial bone survey film
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CDT Code
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Description
D0310
Sialography
D0330
Panoramic film
D0340
Cephalometric film
D1110
Prophylaxis-adult
D2140
Amalgam – one surface, permanent
D2150
Amalgam – two surfaces, permanent
D2160
Amalgam – three surfaces, permanent
D2161
Amalgam – four or more surfaces, permanent
D2330
Resin-based composite – one surface, anterior
D2331
Resin-based composite – two surfaces, anterior
D2332
Resin-based composite – th