PREFACE

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

STATE OF INDIANA

Family and Social Services Administration

Office of Medicaid Policy and Planning

INDIANA MEDICAID MEDICAL ASSISTANCE PROGRAM

MEDICAL POLICY MANUAL

TABLE OF CONTENTS

Page

. PREFACE 6

II. INDIANA HEALTH COVERAGE PROGRAMS OVERSIGHT 7-24

AND DELIVERY SYSTEMS

III. OTHER STATE PROGRAMS 25

V. SERVICES, LIMITATIONS AND EXCLUSIONS 26-29

V. PRIOR AUTHORIZATION 30

VI. MEDICAL POLICIES BY TOPIC

Abortion 31-33

Anesthesia Services 34-44

Bariatric Surgery and Revisions 45-53

Cardiac Rehabilitation 54-60

Case Management—Pregnant Women 61-65

Chiropractic Services

66-78

Clinic Services—FQHC and Rural Health Clinic Services 79-83

Clinical Trials 84-97

Collagen Implants for Stress Urinary Incontinence 98-100

Consultations—Second Opinions

101-106

Dental Services

107-122

Dermatology

123-125

Diabetes Self-Management Training 126-128

01/31/2007 Index

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Diagnostic Studies 129-130

Emergency Medicine—Cardiopulmonary Resuscitation (CPR)

131-132

Emergency Medicine—Emergency Room

133-136

Emergency Medicine—Emergency Services 137-144

EPSDT—HealthWatch 145-156

Evaluation and Management Services 157-162

Family Planning

163-169

Gastroenterology

170-173

Genetic Testing—BRCA1 and BRCA2 for Breast and Ovarian Cancer 174-178

Gynecology Services 179-187

HIV Care Coordination 188-196

Home Health Services 197-226

Hospice 227-243

Hospital Inpatient 244-254

Hospital Inpatient—Readmissions/General/Same Provider 255-256

Hospital Outpatient

257-263

Hyperbaric Oxygen 264-267

Immunizations and Vaccines 268-277

Intermediate Care Facilities for the Mentally Retarded

278-287

Laboratory Services

288-294

Laboratory Services—Group A Beta Hemolytic Streptococcal

Pharyngitis Tests 295-296

Laboratory Services—HER 2/neu Gene Detection Test 297-299

01/31/2007 Index

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Laboratory Services—Human Immunodeficiency Virus

(HIV) Testing 300-302

Laboratory Services—Sweat Chloride Test

303-304

Laboratory Services—Salivary Estriol

305-306

Locum Tenens & Substitute Physician Policy 307-311

Long-Term Acute Care Hospitals 312-318

Medical Supplies and Durable Medical Equipment (DME) Overview 319-332

Medical Supplies and Equipment —Automatic External Defibrillators

333-337

Medical Supplies and Equipment—Beds

338-344

Medical Supplies and Equipment—Gloves 345-348

Medical Supplies and Equipment—Implantable Infusion Pumps 349-354

Medical Supplies and Equipment—Incontinence Supplies 355-358

Medical Supplies and Equipment—Monitoring Devices 359-362

Medical Supplies and Equipment—Negative Pressure Wound Therapy 363-366

Medical Supplies and Equipment—Non-Invasive Respiratory Assist

Devices 367-374

Medical Supplies and Equipment—Patient-Activated Event Recorder—

Implantable Loop Recorder (ILR) 375-379

Medical Supplies and Equipment—Phrenic Nerve Stimulator 380-383

Medical Supplies and Equipment—Power Wheelchairs 384-391

Medical Supplies and Equipment—Programmable Hearing Aids

392-395

Medical Supplies and Equipment—Prothrombin Time

396-399

Medical Supplies and Equipment—Standers

400-406

Medical Supplies and Equipment—Standing Wheelchair

407-408

Medical Supplies and Equipment—ThAIRapy Vest 409-411

01/31/2007 Index

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Medical Supplies and Equipment – Vagus Nerve Stimulator for Epilepsy

412-419

Medical Supplies and Equipment—Ventricular Assist Device

(VAD) 420-431

Medical Supplies and Equipment—Wheelchair Accessories

432-448

Mental Health/Behavioral Health—Inpatient Services 449-459

Mental Health/Behavioral Health—Outpatient Services 460-470

Nursing Facilities 471-480

Nursing Services 481-490

Obstetric Care 491-513

Oncology 514-517

Oncology—Breast and Cervical Cancer 518-520

Ophthalmologic Services 521-534

Osteogenic Bone Growth Stimulator 535-539

Out-of-State Services 540-544

Pharmacy 545-566

Pharmacy—Botulinum Toxin Type A (BOTOX)

567-572

Pharmacy—Synagis

® and Respigam® 573-576

Plasmapheresis

577-579

Podiatry

580-586

Radioimmunotherapy

587-595

Radiology

596-607

Radiology-PET Scans

608-614

Screening Services—Newborn Screening 615-618

01/31/2007 Index

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Index

Medical Policy Manual

Smoking Cessation 619-622

Speech and Hearing

623-634

Substance Abuse

635-639

Surgery—Multiple Procedures/Same Operative Session 640-641

Surgery—Office Visits 642-643

Surgery—Plastic Reconstructive Surgery–Genitourinary Breast 644-649

Surgery—Plastic Reconstructive Surgery–Facial and Maxillofacial

650-671

Surgery—Plastic Reconstructive Surgery–Panniculectomy

672-675

Surgery—Removal of Implants 676-678

Surgery—Services Requiring Prior Authorization 679-680

Surgery—Surgeon and Assistant Surgeon, Same Provider 681-682

Surgery— Surgery and Anesthesia by the Same Provider 683-684

Surgery—Surgical Services 685-692

Surgery—Suture of Wounds 693-696

Surgery—Transplants 697-729

Therapy Services

730-740

Transportation Services 741-765

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

I. PREFACE

Health Care Excel, Incorporated, is a private, not-for-profit corporation

established for the purpose of providing clinically-based, objective, and

independent monitoring of the quality, appropriateness, and medical necessity of

health care services. Health Care Excel, in its role as the Indiana Health Coverage

Programs’ (IHCP) Medical Policy and Review Services contractor, is responsible

for the Medical Policy (MP), Prior Authorization (PA), and Surveillance and

Utilization Review (SUR) business functions. The Medical Policy Manual has

been developed to ensure the success of the IHCP. This manual will be used as a

reference handbook for the Family and Social Services Administration’s (FSSA)

Office of Medicaid Policy and Planning (OMPP), Health Care Excel (HCE), and

other State contractors and partners.

Within the Medical Policy and Review Services contract, the formulation of, and

support for, IHCP medical policies will involve an array of individuals and a

complex set of tasks for each policy. The management of medical policy must

involve the careful consideration of the stakeholders–the State, the practitioner

and provider community, and the IHCP member community. It must be

collaborative in nature to promote a positive, effective, and responsive approach

to customer service. By its unique nature, medical policy must strengthen the

foundation of the IHCP, irrespective of the governing agency or health care

delivery system.

This manual addresses the policies of the IHCP. The information regarding prior

authorization, payment methodology, and maximum fees may vary for providers

rendering services to members enrolled in the risk-based managed care (RBMC)

delivery system. Detailed descriptions of all IHCP covered services, as well as

exclusions and limitations, are also included. The objective is to take a proactive

approach in the development of new policy and the review of existing policies to

ensure the manual is reflective of the IHCP. The manual will serve as a living

document, providing flexibility to accommodate change, and promote ease of use.

01/31/2007 Narrative 6

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

II. INDIANA HEALTH COVERAGE PROGRAMS OVERSIGHT

AND DELIVERY SYSTEMS

A. Overview of the Indiana Family and Social Services Administration

The Indiana Family and Social Services Administration (FSSA) is the

umbrella agency responsible for administering Indiana’s public assistance

programs. FSSA includes the offices and divisions listed below.

♦ Office of Medicaid Policy and Planning (OMPP)

♦ Division of Disability and Rehabilitative Services (DDARS)

♦ Division of Family Resources (DFR)

♦ Division of Mental Health and Addiction (DMHA)

♦ Division of Aging (IDA)

The Director of Medicaid and Health Policy is responsible for OMPP.

Other agencies that administer programs that impact IHCP include the

Division of Disability and Rehabilitative Services, Division of Family

Resources, Division of Mental Health and Addiction, and Division of

Aging. These agencies are described below.

♦ Division of Disability and Rehabilitative Services (DADRS)

manages aging and in-home services, guardianship, and adult

protective services, and determines medical eligibility for the

Supplemental Security Income (SSI) and Social Security Disability

(SSD) programs for the Federal government. It provides case

management services for persons with developmental disabilities

including supervision services for four developmental centers for

clients with disabilities, operation of several State institutions,

vocational rehabilitation case management services, independent

living services for the deaf and hard of hearing, and services for the

blind and visually impaired.

♦ Division of Family Resources (DFR), through its county offices, is

responsible for determining eligibility for IHCP services. Following

the eligibility determination, county offices enroll individuals meeting

eligibility standards and maintain eligibility files using the Indiana

Client Eligibility System (ICES) for the IHCP member population.

01/31/2007 Narrative 7

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Division of Mental Health and Addiction (DMHA) ensures the

availability of accessible, acceptable, and effective mental health and

substance abuse related disorder services for Hoosiers. The division is

responsible for providing funding support for mental health and

addictions services to target populations with financial need through a

network of managed care providers, certifying all community mental

health centers and managed care providers (licensing inpatient

psychiatric hospitals and operating State behavioral health hospitals),

and administering Federal funds earmarked for substance abuse

prevention projects.

♦ Division of Aging (IDA) provides in-home and community based

services to older adults and people of all ages with disabilities.

Services focus on areas such as prevention, early intervention,

protection, and advocacy. The IDA collaborates with communities

and local organizations to provide appropriate services to individuals

and their families to ensure community resources are accessible.

In-home services provide assistance to enable independent living,

private homes and community living settings. These services include

attendant care, homemaker, home health services and supplies, respite

care, home delivered meals, adult day care, transportation, CHOICE

(Community and Home Options to Institutional Care for the Elderly

and Disabled), and other appropriate services.

Community based services provide a variety of services. These

services include Adult Guardianship, Title V Senior Employment, Pre-

Admission Screening Annual Resident Review, Indiana Pre-Admission

Screening, Assistance to Residents in County Homes, Room and Board

Assistance, USDA Meals Reimbursement, Title III/VII of the Older

Americans Act, Long Term Care Ombudsman, Money Management

Program, and the Developmental Disabilities Waiver Ombudsman.

Community based services are also accessible to family members of

older and/or disabled people to increase community outreach and

continuity of services.

Adult protective services (APS) address and investigate reports of

abuse, neglect, and exploitation of adults. The state of Indiana

coordinates with Indiana's prosecuting attorneys, law enforcement,

and the Family and Social Services Administration to ensure the safety

of adults in need. Multiple services are available through APS which

is dependent upon the level-of-need of the individual.

01/31/2007 Narrative 8

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

B. Indiana Health Coverage Programs Eligibility

In 2004, the IHCP provided medical assistance to approximately 760,000

eligible members. This estimate includes the categorically needy

population, as well as, those individuals eligible for, or receiving,

federally-aided financial assistance or deemed categorically needy, and

eligible for services under Federally-authorized waiver programs.

Persons in the categorical groups listed below are eligible for the IHCP,

subject to income and asset criteria.

♦ Aged, blind, and disabled people

♦ Families receiving assistance through the Temporary Assistance

for Needy Families (TANF) program

♦ Children under nineteen years of age with family incomes at or

below a designated percent of the Federal poverty level

♦ In addition, limited IHCP benefits are available to certain

population groups, as listed below.

♦ Qualified Medicare Beneficiaries (QMB)

♦ Pregnant women whose family income exceeds TANF program

limits, but is at or below a designated percent of the Federal

poverty level

♦ Qualified Disabled Working Individuals (QDWI) who lost

Medicare Part A due to employment status

♦ Specified Low Income Medicare Beneficiaries (SLIMB)

♦ Undocumented or unqualified aliens

C. Medicaid Waiver Programs

1. Overview of CMS’ Medicaid Waivers

States may apply to the Centers for Medicare and Medicaid Services

(CMS) for waivers of certain Federal regulations. There are three

major types of waivers; 1115, 1915(b), and 1915(c). Of these, Indiana

has no 1115 waivers, but does have one 1915(b) waiver, and several

waivers under 1915(c). States have the flexibility to design each

waiver program and select the mix of waiver services to best meet the

needs of the population they wish to serve. Waiver services may be

provided statewide or may be limited to specific geographic

01/31/2007 Narrative 9

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

subdivisions. The following Waiver services are provided statewide in

Indiana.

♦ CMS’ Home and Community-Based Waivers

♦ CMS’ Freedom of Choice Waivers

♦ CMS’ Research and Demonstration Waivers

2. Indiana Waiver Program Overview

The eight home-and community-based waivers currently offered

through the Indiana Medicaid program are listed below.

♦ Aged and Disabled

♦ Assisted Living

♦ Autism

♦ Traumatic Brain Injury

♦ Developmental Disability

♦ Medically Fragile Children

♦ Support Services

♦ Severely Emotionally Disturbed (SED) Children

FSSA’s DDARS administers the Home and Community Based

Services (HCBS) waiver program with assistance from, and oversight

by, OMPP. The HCBS waivers provide services to eligible recipients

to address special health care needs for persons who would be

institutionalized in the absence of community-based services.

The IHCP Medical Policy Manual will no longer contain policies

specific to Medicaid Waiver Programs. Clarification of policies for

Medicaid Waiver Programs can be found by contacting the Medicaid

Waiver Unit by phone at 1-800-545-7763, or in writing at the

following.

Medicaid Waiver Unit

Bureau of Aging and In-Home Services

Division of Disability, Rehabilitative Services

402 West Washington Street, W-454

Post Office Box 7083, MS-21

Indianapolis, IN 46207-7083

01/31/2007 Narrative 10

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

D. Traditional Medicaid

1. Overview

The Traditional Medicaid program provides coverage for health care

services rendered to the following eligibility groups.

♦ Wards and foster children who do not voluntarily enroll in a

managed care program

♦ Persons in nursing homes and other institutions, such as ICF/MR

facilities

♦ Undocumented aliens

♦ Waiver or hospice services

♦ Spenddown recipients

Eligible members receive health care services from enrolled IHCP

providers. Providers bill services rendered to members enrolled in

Traditional Medicaid subject to fee-for-service (FFS) directly to the

IHCP claims processing contractor, EDS. Providers are required to sign

a Medicaid Provider Agreement.

2. Delivery System

Traditional Medicaid is part of the FFS delivery system and

includes four benefit packages.

♦ Standard Plan–Members enrolled in the Traditional Medicaid are

eligible for full coverage.

♦ Spenddown–Some members with income in excess of the

Traditional Medicaid threshold can be enrolled under the

spenddown provision. These members are enrolled in Traditional

Medicaid with a spenddown. Spenddown is similar to a deductible

in that members must incur medical expenses in the amount of their

excess income each month before becoming eligible for Traditional

Medicaid. It is the member’s responsibility to provide verification

of incurred medical expenses to the county Division of Family

Resources (DFR) office. When spenddown is met, the member

becomes eligible for the remainder of the month. Members eligible

for assistance under the spenddown provision are listed below.

o Aged 65 and over

o Blind

01/31/2007 Narrative 11

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

o Disabled

o QMB-Also in combination with another aid category

o Those who spenddown their income to the correct

percentage of the federal poverty level in any given month

according to Hayes versus Paine

♦ Waiver–Waiver programs cover a variety of Home and

Community-Based Services (HCBS) not otherwise reimbursed by

the IHCP. Waiver programs are available to those IHCP-eligible

members who require the level-of-care (LOC) provided in a nursing

facility, hospital, or intermediate care facility for the mentally

retarded (ICF/MR), but choose to remain in the home. Eligibility

for all waiver programs requires the following.

o The member must meet IHCP guidelines

o The member would require institutionalization in the

absence of the waiver or other home-based services

o The total IHCP cost of serving the member on the waiver

(waiver cost plus other IHCP services) cannot exceed the

total cost to IHCP for serving the member in an appropriate

institutional setting

o Providers must verify member eligibility and if a member is

enrolled in managed care, the member needs to be

disenrolled from managed care to participate in the HCBS

Waiver Programs

♦ Qualified Medicare Beneficiary (QMB)–Federal law requires that

state Medicaid programs pay Medicare premiums, coinsurance, and

deductibles for certain elderly and disabled people. QMBs must

meet the following eligibility criteria to receive assistance with

Medicare-related costs.

o Entitled to Medicare

o Low income

o Age 65 years or older, or younger than 65 years old and

entitled to Medicare

o Few personal resources

QMB coverage falls into the following three categories.

o QMB-Only coverage: the member’s benefits are limited to

payment of the member’s Medicare premiums as well as

01/31/2007 Narrative 12

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

deductibles and coinsurance for Medicare-covered services

only

o QMB-Also coverage without spenddown: the member’s

benefits include payment of the member’s Medicare

premiums, deductibles, and coinsurance on Medicare-

covered services in addition to Traditional Medicaid

benefits throughout each month of eligibility

o QMB-Also coverage with spenddown: the member’s

benefits include payment of the member’s Medicare

premiums, deductibles, and coinsurance on Medicare-

covered services in addition to Traditional Medicaid

benefits beginning with the date on which the monthly

spenddown is met and continuing through the end of the

month

Claims processing and payment for these three types of QMBs

differ as follows.

o All QMBs–Medicaid pays the Medicare Part B premiums as

well as Medicare deductibles and coinsurance on Medicare-

covered services for which the Medicare payment amount is

less than the Medicaid allowed reimbursement amount. The

member is never responsible for the amount disallowed

(paid at zero) when Medicare paid more than the Medicaid

allowed amount for the service.

o QMB-Only–IHCP pays for only those services covered by

Medicare. For these member’s claims, the IHCP pays the

member’s Medicare deductible and coinsurance on

Medicare-covered services only. Claims for services not

covered by Medicare are denied as Medicaid non-covered

services. The member must make payment in full for

medical supplies, equipment, and other services not offered

by Medicare, such as routine physicals, dental care, hearing

aids, and eyeglasses.

o QMB-Also Without Spenddown–Medicaid claims for

services not covered by Medicare must be submitted as

regular Medicaid claims and not as crossover claims. These

QMB-Also members are enrolled in the Medicaid Select

program and their care is managed by a primary medical

provider (PMP).

o QMB-Also coverage with spenddown-In addition to

coverage for Medicare-related costs, QMBs who are also

eligible for another Medicaid aid category under the

spenddown provision have Traditional Medicaid benefits for

a portion of the months in which they meet their

01/31/2007 Narrative 13

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

spenddown. When spenddown is met for the month, the

member becomes eligible for the full array of services

covered by the Traditional Medicaid program. However, as

with the QMB-Only, the member must pay for services not

covered by Medicare if the Medicare non-covered service is

provided prior to the date when spenddown is met.

IHCP eligibility verification systems are designed to inform a provider of

a member’s Traditional Medicaid/QMB dual eligibility status when

spenddown has not been met for the month. If the QMB member is only

eligible for the coinsurance and deductible for Medicare covered services,

Medicare does not cover the service and Traditional Medicaid does not

cover the service.

Members enrolled in Traditional Medicaid are not assigned to a PMP and

certification codes are not required. However, prior authorization is

required for services as designated by IAC 405-5.

E. Hoosier Healthwise

1. Overview

Hoosier Healthwise is Indiana’s Medicaid Managed Care program

administered by OMPP and the Office of the Children’s Health

Insurance Program (CHIP). The State of Indiana requested approval

of this program through a waiver under the authority of Section

1915(b)(1) of the Social Security Act. The objective of the waiver

program is to reduce costs, prevent unnecessary utilization, reduce

inappropriate utilization, and assure adequate access to primary care

by Medicaid members.

Hoosier Healthwise provides coverage for parents and children who

receive Temporary Assistance for Needy Families (TANF) and for

low-income pregnant women and children. This program

encompasses the following four member eligibility packages.

♦ Package A–Standard Plan

♦ Package B–Pregnancy Coverage Only

♦ Package C–Children’s Health Insurance Plan (CHIP)

♦ Package E–Emergency Services Only (in FFS only)

OMPP began phasing in Hoosier Healthwise for TANF members and

low-income pregnant women and children in selected counties in July

1994. The program became statewide on July 1, 1996.

01/31/2007 Narrative 14

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Narrative 15

Medical Policy Manual

All Hoosier Healthwise participating primary medical providers

(PMP) in Indiana must enroll with an MCO in the RBMC delivery

system.

The goals of Hoosier Healthwise are listed below.

♦ To ensure access to primary and preventive care services

♦ To improve access to all necessary health care

services

♦ To encourage quality, continuity, and appropriateness of medical

care

♦ To provide medical coverage in a cost-effective manner

2. Delivery System

The Office of Medicaid Policy and Planning (OMPP) implemented a

statewide Hoosier Healthwise mandatory risk-based managed care

(RBMC) enrollment for all Indiana counties in 2005. This transitioned

PrimeStep Hoosier Healthwise managed care members from Primary

Care Case Management (PCCM) into local managed care

organizations (MCOs) in the RBMC delivery system. OMPP

submitted a request for federal approval for modification of Indiana's

1915(b) waiver to the Centers for Medicare and Medicaid Services

(CMS). The State anticipated that these counties will be approved for

mandatory MCO enrollment as well. This mandatory transition was

expected to be completed November 2005.

Under RBMC, OMPP contracts with Managed Care Organizations

(MCOs). MCOs are paid a capitated rate per month, per enrolled

Medicaid member by OMPP. Members in RBMC must obtain most

services from the network of the MCO in which they are enrolled.

The RBMC delivery system is a fully capitated prepayment plan in

which the MCOs are at risk to arrange for or administer the provision

of a comprehensive set of covered services to Hoosier Healthwise

members. The MCO accepts a per-member-per-month fee to provide

an agreed upon bundle of services, including high-cost services such

as inpatient hospitalization. Hoosier Healthwise member enrollees

enter the RBMC system by choosing as their PMP a primary care

physician who has contracted with an MCO.

The MCO must purchase reinsurance from a commercial reinsurer and

must establish reinsurance agreements meeting the requirements

stipulated by OMPP. The attachment point must be equal to or less

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

than $125,000. The MCO electing to establish commercial

reinsurance agreements with an attachment point greater than

$125,000 must receive approval from OMPP before changing the

attachment point. The MCO must receive reinsurance coverage of at

least $2,000,000 per member per year.

3. Primary Medical Providers

A basic and pervasive tenet of Hoosier Healthwise is that eligible

members are allowed to select their PMP. Physicians enrolled in

Hoosier Healthwise as PMPs provide preventive and primary care

through an ongoing patient/physician relationship, as well as

authorization and referral for most specialty services. The PMP or a

designee must be available 24 hours a day, seven days a week. The

PMP assists the member in gaining access to the health care system

and monitors, on an ongoing basis, the member's condition, health care

needs, and service delivery. The PMP is responsible for locating,

coordinating, and monitoring all primary care and other medical and

rehabilitation services on behalf of members enrolled in Hoosier

Healthwise.

The Hoosier Healthwise program encourages eligible Medicaid

members to select a PMP. However, if a member in the mandatory

program fails to make a PMP selection within 30 days of being

determined eligible for Medicaid (or re-determined eligible), a PMP is

assigned to the member through an auto-assignment process.

The intent of Hoosier Healthwise is to enhance existing provider-

patient relationships, or to establish a relationship when none exists.

Members enrolled in Hoosier Healthwise are restricted to services

included under Hoosier Healthwise either from the chosen or assigned

PMP or from another qualified provider to whom the member was

referred by the PMP. The member's health care will be managed by the

PMP. However, the member is allowed self-referral for the following

services.

♦ Chiropractic services

♦ Dental services

♦ Diabetes self management services

♦ Emergency services

♦ Family planning services

♦ HIV/AIDS targeted case management

♦ Vision services (except eye care surgical services)

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Podiatry services

A PMP must be a physician qualified in General Practice, Family

Practice, General Pediatrics, General Internal Medicine, or

Obstetrics/Gynecology (OB/GYN). Primary care physicians in any

setting are eligible to be PMPs and may serve as the PMP for any

member within their normal scope of practice. Physicians who enroll

in Hoosier Healthwise agree to be listed as a PMP in the listing of

approved practitioners and agree to accept a panel.

The PMP is responsible for providing or authorizing most primary and

preventive care services. PMP services include, but are not limited to:

physician services; hospital inpatient and outpatient services; and some

ancillary services such as laboratory and radiology;

orthotic/prosthetics; audiology; durable medical equipment and

supplies; home health services; and Early and Periodic Screening,

Diagnosis, and Treatment (EPSDT). PMPs who authorize another

provider to render services must document the referral in the patient's

medical record.

4. Process for Primary Medical Provider Enrollment

A physician interested in becoming a PMP is referred to one of the

participating Hoosier Healthwise MCOs and is required to sign a

contract with one MCO to participate in the RBMC delivery system. A

PMP can only contract with one MCO, however, specialists and other

providers may participate in more than one MCO. This does not

prohibit the PMP from rendering fee-for-service treatment for non-

Hoosier Healthwise members or from serving as a PMP in Medicaid

Select.

5. Process for Member Enrollment

In the DFR county offices, applicants for medical assistance receive a

brief presentation on Medicaid managed care, how to select a PMP,

and a description of the RBMC Hoosier Healthwise program from a

Benefit Advocate (BA). Benefit Advocates are employed by

AmeriChoice through a contract with OMPP. Videotapes and

brochures are available to describe the managed care programs.

Information provided includes a toll-free number to call for further

assistance. The member also is given: (1) a list of qualified PMPs

serving the member's geographic area; (2) a form for choice of a PMP

in RBMC; and (3) brochures for any risk-based managed care MCOs

in their geographic region. Qualified PMPs include only those PMPs

who are currently accepting new enrollees into the RBMC Hoosier

Healthwise program.

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Newly eligible members and members whose eligibility has been re-

determined have up to 30 days to choose a PMP. The member must

indicate a choice of a PMP by either mailing in the form or

telephoning the program. The member is then enrolled with the

selected PMP if he or she is accepting new members.

Qualified PMPs are free to encourage patients to choose them as a care

manager. When a provider is not on the list of qualified PMPs, the

member may encourage the provider to enroll or contact the program

to see if the provider qualifies. OMPP and its contractors market

enrollment to non-participating providers. If the member does not

choose a PMP within thirty (30) days, Hoosier Healthwise assigns the

member to a qualified and suitable PMP via an auto-assignment

process.

The member and the PMP are informed by mail of the member's

enrollment. The PMP may refuse the assignment if he or she does not

feel medically qualified to accept the case or if no further assignments

are being accepted. With the exception of newborns, enrollment in

managed care is not retroactive, so services rendered before the

effective date of Hoosier Healthwise enrollment are not subject to the

waiver's referral requirements.

F. Medicaid Select

1. Overview

Beginning January 1, 2003, IHCP implemented a new aged, blind, and

disabled (ABD) managed care program.

OMPP began phasing in Medicaid Select for ABD members in January

2003. The program became statewide in 2004. The goals of Medicaid

Select are listed below.

♦ To ensure access to primary and preventive care services

♦ To improve access to all necessary health care

services

♦ To encourage quality, continuity, and appropriateness of medical

care

♦ To provide medical coverage in a cost-effective manner

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

2. Delivery System

Medicaid Select operates as a PCCM System The PMP is responsible

for providing or authorizing most primary and preventive care

services. PMP services include, but are not limited to: physician

services; hospital inpatient and outpatient services; and some ancillary

services such as laboratory and radiology; orthotic/prosthetics;

audiology; durable medical equipment and supplies; home health

services; and Early and Periodic Screening, Diagnosis, and Treatment

(EPSDT). PMPs who authorize another provider to render services

must document the referral in the patient's medical record.

Members will continue to have the same ID number and will use the

same Hoosier Health Card. PMPs will be required to provide a

referral by phone or in writing, which will include the Provider ID

number and a special two digit certification code that will allow the

rendering provider to bill and receive reimbursement.

There are no certification code requirements for Medicare crossover

claims in Medicaid Select. However, for services that Medicare does

not cover but Medicaid does, a certification code is required.

Some services are self-referral and will not require PMP authorization.

These services include the following.

♦ Chiropractic services

♦ Dental services

♦ Diabetes self management services

♦ Emergency services

♦ Family planning services

♦ HIV/AIDS targeted case management

♦ Vision services (except eye care surgical services)

♦ Podiatry services

In addition to an administrative fee payment of $4.00 per member/per

month, PMP’s will be reimbursed, as usual, based on the fee-for-

service schedule. Claims will be submitted to the state’s fiscal agent,

EDS, for processing and payment.

3. Primary Medical Providers

Medicaid Select has five standard PMP categories: Family

Practitioner, General Practitioner, Internist, Pediatrician and

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Obstetrician / Gynecologist. In addition, any physician specialist, such

as a Cardiologist, Psychiatrist, or Urologist, may serve as a PMP.

Medicaid Select members are encouraged to select a PMP. Members

will have up to 60 days to select a PMP before they are auto-assigned

to the five traditional PMP types or to a non-traditional PMP type

(specialist), if they have previously been linked to a non-traditional

PMP on a self-selection basis. However, members are able to change

their PMP if they are auto-assigned or choose to see a different doctor

than originally selected.

4. Process for Primary Medical Provider Enrollment

Providers contact a Provider Services Representative at AmeriChoice

to receive information regarding enrollment in Medicaid Select. To

serve as a PMP, providers must be enrolled as an IHCP provider and

are required to sign a Medicaid Provider Agreement Addendum to

provide services to Medicaid Select members.

The five standard PMP categories are allowed member panels of 50 to

1000. All specialist provider types are allowed panels of 1-1000. A

specialist may enroll as a PMP to see only one or two existing patients.

The Medicaid Select panel is maintained separately and cannot be

combined with the Hoosier Healthwise panel.

5. Process for Member Enrollment

Medicaid Select includes all Medicaid recipients in the following aid

categories.

♦ Children receiving adoptive services

♦ Aged recipients

♦ Blind recipients

♦ Physically and mentally disabled recipients

♦ Medicare and Medicaid dual eligible recipients

♦ Individuals receiving room and board assistance

The following individuals are excluded from enrollment in Medicaid

Select.

♦ Breast and cervical cancer group

♦ Wards of the court and foster children

♦ Persons in nursing homes

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Intermediate Care Facilities for the Mentally Retarded and state-

operated facilities

♦ Waiver recipients

♦ Hospice service recipients

♦ Individuals for whom Medicaid pays only the Medicare premiums

♦ Spenddown recipients

6. Managed Care Administrative Contracts

OMPP has contracted many of the administrative activities essential

for managed care, such as development of a management information

system, claims processing, and member and provider enrollment. In

addition to the contracts with risk-based managed care providers, there

are (in 2005) three major administrative contracts: AmeriChoice,

primarily for member education and enrollment; Electronic Data

Systems (EDS) as a part of a larger contract to act as the State's fiscal

agent and pharmacy benefits manager; and HCE, which serves as the

Medical Policy and Review Services contractor.

AmeriChoice has the following specific responsibilities.

♦ Member education and enrollment facilitation

♦ Member hotline development and management

♦ Member outreach and follow-up

♦ Deployment of benefits advocates and related database

development and management

♦ Administrative plan development and execution

♦ Medicaid Select Provider recruitment and orientation

♦ Quality assurance/quality control execution, including member and

provider surveys

♦ Submission of program monitoring reports

EDS responsibilities in relation to managed care are stated below.

♦ Development and administration of an information system for

managed care as a component of IndianaAIM

♦ PMP enrollment

♦ Fee-for-service claims processing

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Monthly administrative payments to PMPs

participating in Medicaid Select

♦ Monthly capitation payments to MCOs participating in the RBMC

program

♦ Processing encounter claims from MCOs (MCOs are paid a

capitated rate but are expected to provide encounter-based data in

the form of shadow claims)

HCE responsibilities in relation to Hoosier Healthwise are listed

below.

♦ Assessing and coordinating existing medical policy

♦ Evaluating input from providers, members, and operational

activities and determining if there are policy implications,

including consideration of who is impacted, what policy needs to

be addressed, why the policy implication is important, when a

policy should be changed or added, where the impact will be felt

the most, and how to best address identified issues

♦ Coordinating the resolution of issues that bridge operations and

policy areas

♦ Recommending new medical policy to address emerging issues

♦ Determining and analyzing indicators to evaluate utilization of

services, access, preventive care, quality of care, and disease

management

♦ Prior authorization

♦ Surveillance and Utilization Review

G. Indiana Health Coverage Programs Provider Participation

Within the restrictions of federal and state law, OMPP (through its

contractors) enrolls various types of medical practitioners, providers of

institutional care, other agencies, and managed care organizations to

provide services to IHCP members.

A provider is said to be participating in the IHCP during a particular time

period if the provider bills for services rendered to IHCP members during

that time. The number and participation rate of enrolled IHCP providers

fluctuates. The number of participating providers can decrease when

some providers cease to treat IHCP members. Increases in the number of

participating providers can be seen when a new service is added or

previous restrictions are lifted. In 2004, there were approximately 46,000

providers approved to participate in the IHCP. The IHCP places a high

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

priority on provider participation so that IHCP members may have

appropriate access to care and choice of providers.

H. Indiana Health Coverage Programs Provider Payment Methodologies

Within the limitations prescribed by federal laws and regulations, the State

has established various methods of determining provider reimbursement

levels for the provision of IHCP covered services. These methods are

described briefly below. It should be noted that, with the exception of

copayment requirements, federal law requires providers to accept IHCP

payment in full, thereby prohibiting providers from billing members for

additional payment. In general, federal regulations require that

reimbursement rates be sufficient to ensure that the availability of health

care services to IHCP members is no less than that for the general

population. The payment methodologies currently utilized by the IHCP

are as follows.

♦ Diagnosis-Related Grouping (DRG) is used for pricing hospital

inpatient claims. If the inpatient claim can be grouped into one of the

established DRG numbers, a DRG number is assigned by IndianaAIM,

the claims processing system used by the IHCP. The principal

diagnosis, surgical procedure code, patient discharge status, and

member's age and sex are used to group the claim into one of the

established DRG numbers. Claims that do not group into an

established DRG number will be paid based on diagnoses, surgical

procedures, and revenue codes reported on the claim. Burn treatment,

rehabilitation, and psychiatric inpatient claims are paid according to

the level-of-care.

♦ Facility-specific per diem rates are used for nursing homes,

Intermediate Care Facilities for Mentally Retarded (ICF/MR),

Community Residential Facilities for the Developmentally Disabled

(CRF/DD), and Psychiatric Residential Treatment Facilities (PRTF).

♦ A case mix reimbursement methodology was implemented, effective

October 1, 1998, for IHCP nursing facilities that provided both skilled

and intermediate care to residents. Under this methodology, payment

is based upon one Medicaid rate, determined each quarter, for all

Medicaid residents in a Medicaid-certified and duly licensed nursing

facility.

♦ The Resource Based Relative Value Scale (RBRVS) system is used to

reimburse most services provided by physicians and other

practitioners.

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ The lowest of the state maximum allowable charge (SMAC), amount

billed, federal upper limit or estimated acquisition cost (EAC) (for

legend drugs), plus a dispensing fee where applicable, is used for

pharmacy claims.

♦ Deductible and coinsurance amounts are paid by Medicaid for

Medicare crossover claims, so long as the Medicaid payment does not

exceed the Medicaid allowable for the service.

♦ Dental, Current Procedural Terminology (CPT), and Health Care

Common Procedure Coding System (HCPCS) codes not subject to

RBRVS are priced based on the lower of a maximum fee or the

submitted charge.

♦ Payment for hospital outpatient services depends on the revenue codes

billed. Surgery revenue codes are priced using Ambulatory Surgical

Center (ASC) rates on file. Treatment room revenue codes are priced

using a flat rate on file. Laboratory revenue codes are priced using the

laboratory pricing methodology described below. Radiology revenue

codes are priced based on the lower of a maximum fee or the

submitted charge. All other revenue codes are priced using a flat rate

on file.

♦ Laboratory fees are calculated at the Medicare-allowed amount based

upon the HCPCS procedure codes with a pricing indicator for

laboratory.

♦ In the RBMC delivery system, capitation fees are paid to contracted

managed care organizations (MCO).

♦ In the PCCM delivery system, an administrative fee of four dollars

($4.00) per member per month is paid to the Primary Medical Provider

(PMP). In addition, the PMP is paid according to the fee-for-service

schedule for services provided.

♦ Home health services are paid according to overhead and wage rates.

♦ Hospice services are reimbursed according to one of four all-inclusive

per diem rates, based on levels of service.

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

III. OTHER STATE PROGRAMS

The State of Indiana also funds various other medical assistance programs for its

population. Other State-funded programs are listed below.

♦ The 590 Program provides coverage for certain health care services

provided off-site to members who are residents of state-owned facilities.

These facilities operate under the direction of the Family FSSA, DMHA,

and the Indiana State Department of Health (ISDH).

♦ Aid to Residents in County Homes (ARCH) provides case review services

to certain residents of county nursing homes.

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

IV. SERVICES, LIMITATIONS, AND EXCLUSIONS

A. Services

Covered services, prior approval requirements, and limitations of coverage

for the Indiana Medicaid program are set out in the Indiana Administrative

Code (IAC) at 405 IAC 5.

B. Limitations

Medicaid limits the provision of certain covered services. 405 IAC 5

specifies the limited services and the conditions of the limitations.

Certain covered services as specified in 405 IAC 5 are available only with

prior authorization. The provider must submit a properly completed

Medicaid prior review and authorization request and receive written notice

indicating the approval for provision of such service prior to providing any

Medicaid service that requires prior authorization except as provided in

405 IAC 5-3-2, which allows for specific providers to request prior

authorization by telephone for specific services.

Any non emergent Medicaid service requiring prior authorization, which

is provided without first receiving prior authorization, shall not be

reimbursed by Medicaid. Services provided out-of-state with exceptions,

require prior authorization. Any authorization of a service by the

contractor is limited to authorization for payment of Medicaid allowable

charges and is not an authorization of the provider’s estimated fees.

Requests for prior authorization are reviewed for appropriate completion

of the request form, the medical and social information provided on the

request form or documentation accompanying the request form, the

criteria set out in 405 IAC 5 for the service requested, and the medical

reasonableness and necessity of the requested service based upon current

professional standards commonly held to be applicable to the case. Refer

to Section V, page 30, for additional information about the prior

authorization function.

Certain Medicaid members have restricted utilization of their Medicaid

cards when it has been determined that services must be controlled. A

provider other than the one to whom the member is restricted may provide

treatment to the member with a referral from the authorized provider, or

without a referral form if the diagnosis is an emergency diagnosis.

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

All Indiana Medicaid providers are subject to ongoing surveillance and

utilization review (SUR) activities. The SUR responsibilities have been

contracted to HCE. Based on paid claim information, statistical profiles

are established on provider peer and class groups to monitor the delivery

and receipt of medical services to identify misutilization and aberrant

practices by analyzing and comparing providers to their peer groups.

Based on the results of the off-site review and/or medical record review

the specific aberrant practice and billing patterns are identified and

prepayment review criteria are developed, unique to each provider. The

established criteria describe specifically what documentation and/or

practice is expected, and what procedure will be followed for each of the

review measures.

The provider will be notified and the prepayment reviewer will initiate the

appropriate system file changes to ensure that the provider’s claims that

meet the prepayment review criteria suspend for manual adjudication. A

minimum of three months of documentation submitted with the dates of

service during the prepayment review period must be reviewed to

determine compliance with the IAC and review criteria before the

prepayment review status can be terminated.

C. Exclusions

The following services are not covered by Medicaid.

1. Services that are not medically reasonable or necessary according to

current professional standards commonly held to be applicable to the

case.

2. Services provided outside the scope of a provider's license,

registration, certification, or other authority to practice under state or

federal law.

3. Experimental drugs, treatments, or procedures, and all related services.

4. Any new product, service, or technology not specifically covered in

IAC. The product, service, or technology will remain a noncovered

product, service, or technology until such time as the OMPP

authorizes the coverage of the product, service, or technology. This

does not apply to legend drugs.

5. Personal comfort or convenience items, including, but not limited to,

television, radio, or telephone rental.

6. Services for the remediation of learning disabilities.

7. Treatments or therapies of an educational nature.

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

8. Experimental radiological or surgical or other modalities and

procedures, including, but not limited to, the following items.

♦ Acupuncture

♦ Biofeedback therapy

♦ Carbon dioxide five percent inhalator therapy for inner ear disease

♦ Hyperthermia

♦ Hypnotherapy

9. Hair transplants

10. Fallopian tuboplasty (reanastomosis of the fallopian tubes) for

infertility or vasovasostomy (reanastomosis of the vas deferens). This

procedure is covered only in conjunction with disease

11. Augmentation mammoplasty for cosmetic purposes

12. Dermabrasion surgery for acne pitting or marsupialization

13. Rhinoplasty or bridge repair of the nose in the absence of a significant

obstructive breathing problem

14. Otoplasty for protruding ears unless one of the following applies to the

case.

♦ Multifaceted craniofacial abnormalities due to congenital

malformation or maldevelopment, for example, Pierre Robin

Syndrome

♦ A member has pending or actual employment where protruding ears

would interfere with the wearing of required protective devices

15. Scar removals or tattoo removals by excision or abrasion

16. Ear lobe reconstruction

17. Removal of keloids complicating pierced ears unless one of the

following is present

♦ Keloids are larger than three centimeters

♦ Obstruction of the ear canal is 50% or more

18. Rhytidectomy

19. Penile implants

20. Perineoplasty for sexual dysfunction

21. Reconstructive or plastic surgery unless deformity is related to disease

or trauma

22. Sliding mandibular osteotomies unless related to prognathism or

micrognathism

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

23. Blepharoplasties when not related to a significant obstructive vision

problem

24. Radial keratotomy

25. Miscellaneous procedures or modalities, including, but not limited to

the following items

♦ Autopsy

♦ Cryosurgery for chloasma

♦ Conray dye injection supervision

♦ Day care or partial day care or partial hospitalization except when

provided pursuant to 405 IAC 5

♦ Formalized and predesigned rehabilitation programs, including, but

not limited to, the following programs

o Pulmonary

o Cardiovascular (Cardiac Rehabilitation Phase 3 is non-covered.)

o Work-hardening or strengthening

♦ Telephone transmitter used for transtelephonic monitor

♦ Telephone, or any other means of communication, consultation from

one doctor to another

♦ Artificial insemination

26. Cognitive rehabilitation, except for treatment of traumatic brain injury

27. Ear piercing

28. Cybex evaluation or testing or treatment

29. High colonic irrigation

30. Services that are not prior authorized under the level-of-care

methodology as required by 405 IAC 5-19

31. Amphetamines when prescribed for weight control or treatment of

obesity

32. Under federal law, drug efficacy study implementation drugs not

covered by Medicaid

33. All anorexics, except amphetamines, both legend and nonaligned

34. Physician samples

01/31/2007 Narrative

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Narrative

Medical Policy Manual

V. PRIOR AUTHORIZATION

The Indiana Medicaid Program allows reimbursement for those services which

are outlined in the Covered Services and Limitation and Medical Policy Rule 405

IAC 5. The IAC contains the rules and regulations that govern IHCP, and serves

as a comprehensive reference to covered services and prior authorization (PA)

procedures and parameters. It is the responsibility of each IHCP provider to read

the portions of the IAC that apply to his/her area of service. Specific prior

authorization criteria should be obtained from 405 IAC 5.

The Health Care Excel Prior Authorization department reviews all requests for

prior authorization for traditional Medicaid, the 590 Program, and the Hoosier

Healthwise and Medicaid Select PCCM programs on an individual case-by-case

basis. The risk-based managed care companies, or their designees, review

requests for prior authorization for members enrolled in the Hoosier Healthwise

Risk-Based Managed Care program. The decision to authorize, modify, or deny a

given request is based upon medical reasonableness and necessity and other

criteria set forth in the IAC. Prior Authorization decisions may also be based on

OMPP approved internal criteria, in addition to the IAC prior authorization

guidelines.

The primary objective of prior authorization review is to allow payment only for

those treatments and/or services that are medically necessary, appropriate, cost-

effective, and to reduce over-utilization and/or abuse of certain services.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: ABORTION

DESCRIPTION:

Surgical abortion is the induced termination of pregnancy before the fetus has developed

to a viable state. This does not include a spontaneous abortion, missed abortion,

incomplete abortion, or medical interventions required in the case of ectopic pregnancy.

MEDICAL TOPICS CROSS-REFERENCES:

Gynecology – Laminaria

Gynecology – Pelvic Exam under Anesthesia

RULES, CITATIONS, AND SOURCES:

42 CFR 50 Subpart C Abortions and Related Medical Services in Federally Assisted

Programs

42 CFR 441.200 Services: Requirements and Limits Applicable to Specific Services

Abortions

405 IAC 5-28-7 Medical and Surgical Services--Abortion

405 IAC 5-27-6 Radiology Services-- Sonography

Indiana State Department of Public Welfare Medical Policy Manual 1991

Indiana Medical Assistance Program Provider Manual 1994

Indiana Health Coverage Programs Provider Manual 1999

01/31/2007 Abortion

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Initial Policy Issue Effective

Date

Implementation

Date

Retroactive

Date

405 IAC 1-7-14

Repealed

8/24/97

Surgical

Services

01/01/1992

405 IAC 1-7-

19(e) Repealed

8/24/97

Sonography 01/01/1992

Revisions:

42 CFR 441.200 Abortions 10/01/1997

405 IAC 5-28-7 Abortion 08/24/1997

405 IAC 5-27-6 Sonography 08/24/1997

APPLICABLE INDIANAAIM EDITS AND AUDITS:

4012-Abortion Diagnosis/Procedure Indicated

4022-Abortion Diagnosis/Procedure Indicated

COVERAGE CRITERIA:

Medicaid reimbursement is available for abortions only if performed to preserve the life of

the pregnant woman or in other circumstances when the abortion is required to be covered

by Medicaid under federal law subject to limitations and restrictions set out in 42 CFR

Subpart C Sec.50.301, 50.302, 50.303, 50.304, 50.306, 42 CFR 441.200 Sec 441.200,

441.201, 441.202, 441.203, 441.206, 441.207, 441.208, 405 IAC 5-28-7 and 405. All

appropriate documentation must be attached to the claim and to claims for directly related

services before reimbursement shall be made.

01/31/2007 Abortion

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Abortion

Medical Policy Manual

ABORTION FACT SHEET

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the Abortion Fact Sheet. The information in this addendum will be

incorporated into the fact sheet at the next review.

Provider Notification: BT200511 Publication Date: 06/01/2005

Subject: Abortion Diagnosis/Procedure Claim Notes

Date Added to Manual: 07/29/2005

Text of Publication

In the claim note, the IHCP accepts indication of medical documentation that supports the

need to save the mother’s life or a police report that indicates rape or incest.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: ANESTHESIA SERVICES

DESCRIPTION

Stedman’s Medical Dictionary defines anesthesia as the loss of sensation resulting from

pharmacologic depression of nerve function or from Neurologic dysfunction.

Additionally, anesthesia is a broad term for anesthesiology as a clinical specialty.

Anesthesia services may include but are not limited to general, regional, supplementation

of local anesthesia, or other supportive services in order to give a patient anesthesia care

deemed optimal by the anesthesiologist to reduce or mitigate pain during any procedure.

The services include the usual preoperative and postoperative visits, anesthesia care

during the procedure, the administration of fluids and/or blood and the usual monitoring

services (for example, ECG, temperature, blood pressure, oximetry, capnography, and

mass spectrometry.) Other monitoring services (for example, intra-arterial, central

venous, and Swan-Ganz) are not included.

SUMMARY OF CURRENT POLICY

Indiana Health Coverage Programs (IHCP) reimbursement is available for covered

anesthesia services subject to the limitations and restrictions set out in the Indiana

Administrative Code (IAC). Providers who are eligible for reimbursement include

licensed anesthesiologists, certified registered nurse anesthetists (CRNA), and licensed

anesthesiologist assistants. Anesthesia services associated with canceled surgeries are

not reimbursed.

The IHCP provides separate reimbursement for the following types of anesthesia, when

provided by a physician other than the operating surgeon.

 Epidural

 Field Block

 Inhalation

 Intravenous

 Nerve Block

 Regional

 Spinal

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Health Insurance Portability and Accountability Act (HIPAA) requirements mandated the

adoption of standards for anesthesia CPT codes. Providers submitting claims for

anesthesia services must use anesthesia CPT codes 00100 through 01999, effective

October 16, 2003. Anesthesia charges must be submitted using the anesthesia CPT code

that corresponds to the surgical procedure performed. General regional or epidural

anesthesia administered by the same provider who performs the surgical or obstetrical

delivery procedure is not reimbursable as it is included in the surgical delivery fee.

COVERAGE CRITERIA (Including Billing Requirements)

Anesthesia services are reimbursed according to a statewide fee schedule calculated on

the total base units, time units, add-on units, and additional units for specific physical

modifiers (as applicable), multiplied by the anesthesia conversion factor established by

the Office of Medicaid Policy and Planning (OMPP). Providers submitting anesthesia

services must use the anesthesia CPT codes 00100 through 01999. Anesthesia charges

must be submitted using the anesthesia CPT code that corresponds to the surgical

procedure performed.

Time

Time starts when the anesthesiologist or CRNA begins preparing the patient for the

procedure in the operating room or other appropriate area. It is not appropriate to start

counting time when the preoperative examination occurs. The preoperative exam is

reimbursed via 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 relative value units (RVU’s) are loaded in IndianaAIM. However, the actual time of

the procedure in minutes, is indicated in Locator 24G of the CMS-1500 claim form or the

837P electronic transaction. IndianaAIM calculates the time units. One unit is allowed

for each 15-minute period or fraction thereof.

Base Units

Base unit values have been assigned to each CPT code that would normally include

anesthesia. Providers should not report the base units on claims. The IndianaAIM claims

processing system automatically determines the base units for the procedure code as

submitted on the CMS-1500 claim form or the 837P electronic transaction. The system

converts each 15 minute block of time to one unit.

For the following procedure codes, IndianaAIM calculates one time unit or each fifteen

minute block of time billed in the first hour of service, and for subsequent hours of

service, calculates one unit of service for every sixty minute block of time or portion

thereof billed.

 01960 – Anesthesia for vaginal delivery only

 01967 – Neuraxial labor analgesia for anesthesia for planned vaginal delivery

(this includes any repeat subarachnoid needle placement and drug

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

injection and/or any necessary replacement of an epidural catheter during

labor)

Additional Units

The IndianaAIM claims processing system recognizes the following circumstances and

calculates any additional units appropriate for reimbursement.

 Patient age – IndianaAIM applies additional units to the base units for

members under one year of age or over seventy years of age

 Procedure code 99140 – Use this code on a separate line item of the claim to

indicate that the anesthesia provided was complicated by emergency

conditions

 Physical status – Providers must use the appropriate modifier to denote any

patient conditions that may warrant payment of additional units these are

listed in Table 1, below

Table 1 – Physical Status Modifiers for Anesthesia

Modifier Description

Additional

Units

Allowed

P1 A normal healthy patient for an elective operation 0 units

P2 A patient with mild systemic disease 0 units

P3 A patient with severe systemic disease that limits activity but is

not incapacitating

1.0 units

P4 A patient with a severe system disease that is a constant threat

to life

2.0 units

P5 A moribund patient who is not expected to survive without the

operation

3.0

P6 A declared brain-dead patient whose organs are being removed

for donor purposes

0 units

Anesthesiologists performing the following procedures must bill with the AA modifier.

These procedures must be billed in units, instead of minutes.

 36555 – Insertion of non-tunneled centrally inserted central venous catheter;

under 5 years of age

 36556 – Insertion of non-tunneled centrally inserted central venous catheter; age 5

years or older

 36568 – Insertion of peripherally inserted central venous catheter (PICC), without

subcutaneous port or pump; under 5 years of age

 36569 – Insertion of peripherally inserted central venous catheter (PICC), without

subcutaneous port or pump; age 5 years or older

 36580 – Replacement, complete, of a non-tunneled centrally inserted central

venous catheter, without subcutaneous port or pump, through same

venous access

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

 36584 – Replacement, complete, of a peripherally inserted central venous catheter

(PICC), without subcutaneous port or pump through same venous access

 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

 99183 – Physician attendance and supervision of hyperbaric oxygen therapy, per

session

 99185 – Hypothermia, regional

Medical Direction and CRNA

The IHCP reimburses 30 percent of an anesthesia CPT procedure code’s allowed amount

when an anesthesiologist submits for medical direction of qualified anesthetists.

Anesthesia details submitted by a CRNA are reimbursed at 60 percent of the procedure

code’s allowed amount.

CRNAs must use anesthesia CPT codes (00100-01999) and bill with the appropriate

medical direction and/or physical status modifiers. CRNA providers use the same

physical status modifiers that apply to anesthesiologists, shown in Table 1 on the

preceding page. Table 2 – Anesthesia Modifiers lists the only modifiers used to identify

services provided by CRNAs.

Table 2 – Anesthesia Modifiers

Modifier Description

QS Monitored anesthesia care service

QX Certified Registered Nursing Anesthetist (CRNA) service, with medical

direction by a physician

QZ CRNA without medical direction by a physician

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. An anesthesiologist billing for medical direction uses modifier QK, Medical

direction of two, three, or four concurrent anesthesia procedures involving qualified

individuals. An anesthesiologist involved in medically directing more than one and up to

four procedures may not be personally performing procedures at the same time. Criteria

for medical direction include the following.

 Ensure that only qualified people administer 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

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

 Perform the postoperative evaluation

 Prescribe anesthesia plan

 Remain immediately available and not perform other services

The IHCP does not allow medical supervision by an anesthesiologist for more than four

concurrent procedures. Therefore, reimbursement is not allowed for services billed with

the AD modifier.

Regional Anesthesia

Regional anesthesia or nerve blocks involve blocking nerve impulses with a local

anesthetic, steroid, narcotic, or other agent. It is administered by a physician and requires

special techniques and attention, especially during the initial phase of instituting the

block. Nerve blocks performed as a surgical procedure for the treatment of a condition

such as chronic pain are billed with the appropriate nerve block code, quantity of one,

with no anesthesia modifier.

When billing regional anesthesia as the anesthesia type for a given surgical procedure

that is performed by a qualified anesthesia professional, regional anesthesia is billed and

paid in the same manner as a general anesthetic, using base units plus time. (See the

section entitled “Coverage Criteria”.) The bilateral procedure code modifier 50 is not

used in conjunction with anesthesia modifiers.

Monitored Anesthesia

Monitored anesthesia care (MAC) involves the intraoperative monitoring of patient vital

signs in anticipation of the need for administration of general anesthesia or the

development of adverse physiological patient reaction to the surgical procedure or

anesthesia. MAC also includes the performance of a preanesthestic examination and

evaluation, prescription of the anesthesia care required, administration of any necessary

oral or parenteral medications (such as Atropine, Demerol, or Valium), and the provision

of indicated postoperative anesthesia care.

The IHCP allows payment for medically reasonable and necessary MAC services on the

same basis as other anesthesia services. The QS modifier must be added to the

appropriate CPT code in addition to other applicable modifiers to identify the services as

monitored anesthesia care.

Postoperative Pain Management Services

The IHCP reimburses for postoperative epidural catheter management services using

CPT procedure code 01996. Procedure code 01996 is not separately paid on the same

day the epidural is placed. Rather, this code is billed on subsequent days when the

epidural is actually being managed. This code is used for daily management of patients

receiving continuous epidural, subdural, or subarachnoid analgesia, and is limited to one

unit of service for each day of management. Procedure code 01996 is only reimbursable

during active administration of the drug. When monitored by an anesthesia provider, no

modifier is appended. Claims submitted with anesthesia procedure codes and the

postoperative pain management codes listed in Table 3 – CPT Codes for Postoperative

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Pain Management, in Table 3, billed on the same day of surgery, must be used in

conjunction with modifier 59, Distinct procedural service, and is subject to post payment

review.

TABLE 3 – CPT Codes for Postoperative Pain Management

CPT

CODE

DESCRIPTION

62310

Injection, single (not via indwelling catheter), not including neurolytic

substances, with or without contrast (for either localization or epidurography),

of diagnostic or therapeutic substances(s) (including anesthetic,

antispasmodic, opiod, steroid, other solution), epidural or subarachnoid;

cervical or thoracic.

62311

Injection, single (not via indwelling catheter), not including neurolytic

substances, with or without contrast (for either localization or epidurography),

of diagnostic or therapeutic substances(s) (including anesthetic,

antispasmodic, opiod, steroid, other solution), epidural or subarachnoid;

lumbar, sacral (caudal)

62318

Injection, including catheter placement, continuous infusion or intermittent

bolus, not including neurolytic substances, with or without contrast (for either

localization or epidurography), of diagnostic or therapeutic substances(s)

(including anesthetic, antispasmodic, opiod, steroid, or solution), epidural or

subarachnoid; cervical or thoracic

62319

Injection, including catheter placement, continuous infusion or intermittent

bolus, not including neurolytic substances, with or without contrast (for either

localization or epidurography), of diagnostic or therapeutic substances(s)

(including anesthetic, antispasmodic, opiod, steroid, or solution), epidural or

subarachnoid; lumbar, sacral (caudal)

64412

Injection, anesthetic agent; spinal accessory nerve

64413

Injection, anesthetic agent; cervical plexus

64415

Injection, anesthetic agent; brachial plexus, single

64416

Injection, anesthetic agent; brachial plexus, continuous infusion by catheter

(including catheter placement) including daily management for anesthetic

agent administration

64417

Injection, anesthetic agent; axillary nerve

64420

Injection, anesthetic agent; intercostal nerve, single

64421

Injection, anesthetic agent; intercostal nerves, multiple, regional block

64445

Injection, anesthetic agent; sciatic nerve, single

64446

njection, anesthetic agent; sciatic nerve, continuous infusion by catheter

(including catheter placement) including daily management for anesthetic

agent administration

64447

Injection, anesthetic agent; femoral nerve, single

64448

Injection, anesthetic agent; femoral nerve, continuous infusion by catheter

(including catheter placement) including daily management for anesthetic

agent administration

64449

Injection, anesthetic agent; lumbar plexus, posterior approach, continuous

infusion by catheter (including catheter placement) including daily

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

TABLE 3 – CPT Codes for Postoperative Pain Management

CPT DESCRIPTION

CODE

management for anesthetic agent administration

64450

Injection, anesthetic agent; other peripheral nerve or branch

ANESTHESIA FOR DENTAL SERVICES

IHCP reimbursement for general anesthesia, billed using code D9220 for the first 30

minutes and D9221 for each additional 15 minutes, is only covered in a dentist’s office

for individuals under the age of 21 years of age. General anesthesia is covered for adults

only if the procedure is performed in a hospital (inpatient or outpatient) or an ambulatory

surgical center. Nitrous oxide analgesia is covered only for members twenty years of age

and younger.

Reimbursement for IV sedation in a dental office for IHCP members of all ages when

provided for oral surgery services only. Documentation in the member’s record must

include specific reasons why such services are needed and is subject to post payment

review.

Documentation for general anesthesia (adults or children) should include why the

individual could not receive necessary dental services unless general anesthesia was

administered. These records must be retained in the member’s file for at least three

years.

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

 Severe physical disorders affecting the tongue or jaw movements

 Seizure disorders

 Significant psychiatric disorders resulting in impairment of the recipient’s

ability to cooperate with procedures

 Previously demonstrated idiosyncratic or severe reactions to IV sedation

medication

A dental cap of $600 applies to ICHP dental services provided in a dental office. Table 4

– CDT Codes Included in the $600 Dental Cap, on the following page, describes

anesthesia codes that are included in the dental cap for IHCP members. Providers can

bill their usual and customary charge to the member for any services provided after the

cap has been exhausted. However, if a service is partially paid by the IHCP because of

the cap limit, the member can only be billed for the difference between what the IHCP

would have reimbursed to the provider and what the IHCP actually paid. The following

guidelines must be met for the IHCP provider to hold a member responsible for payment.

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

 The service rendered by the provider must be an IHCP non-covered service

 The member has exceeded program limitations for a particular service

 The member failed to inform the provider of eligibility. The provider must

maintain documentation to show that the provider billed the IHCP member of

that the provider requested the information within one year of the filing limit

 The member must understand before receiving the service that the service is

not covered by the IHCP, and that the member is responsible for the charges

associated with the service.

 The provider must maintain documentation that the member voluntarily chose

to receive the service knowing that the IHCP would not cover the service.

Table 4 – CDT Codes Included in the $600 Dental Cap

HCPCS Code Description

D9220 Deep sedation/general anesthesia – first 30 minutes

D9221 Deep sedation/general anesthesia – each additional 15 minutes

D9230 Analgesia, anxiolysis, inhalation of nitrous oxide

D9248 Non-intravenous conscious sedation

D9610 Therapeutic drug injection, by report

Monitored sedation for children (Dental procedures)

IHCP reimbursement for monitored sedation, provided in a dentist’s office, is available

for members under the age of 21. Monitored sedation is the administration of

subcutaneous, intramuscular, intravenous or oral sedation, in combination with

monitoring the patient’s vital signs. This service should be billed utilizing procedure

code D9248, Non-intravenous conscious sedation.

ANESTHESIA SERVICES FOR OBSTETRICAL SERVICES

General, regional, or epidural anesthesia administered by the same provider who

performs the surgical or obstetrical delivery procedure is not reimbursable as it is

included in the surgical delivery fee.

Providers billing anesthesia services for vaginal or cesarean deliveries must use the

appropriate anesthesia CPT codes as listed in Table 5 – Anesthesia CPT Procedure

Codes for Vaginal or Cesarean Delivery. This method of billing is the same as for any

other surgery, and should be used for obstetrical anesthesia, regardless of the type of

anesthesia provided, e.g. general or regional, including epidural anesthesia.

Table 5 – Anesthesia CPT Procedure Codes for 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

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 5 – Anesthesia CPT Procedure Codes for Vaginal or Cesarean Delivery

CPT Procedure

Description

Code

01963

Anesthesia for cesarean hysterectomy without any labor

analgesia/anesthesia care

01964 Anesthesia for abortion procedures

01967

Neuraxial labor analgesia/anesthesia for planned vaginal delivery

(this includes any repeat subarachnoid needle placement and drug

injection and/or any necessary replacement of an epidural

catheter during labor)

*10968

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)

* Add-on codes that must be used in conjunction with 01967

When an anesthesiologist starts an epidural anesthesia for labor, and it becomes

necessary to switch to a general anesthetic for a delivery, the total times are combined

and billed for the procedure performed, such as vaginal delivery or cesarean section (C-

section).

When a provider, other than the surgeon or obstetrician, is billing for epidural anesthesia,

that provider is reimbursed in the same manner as is reimbursed for general anesthesia.

MANAGED CARE

The same policies and procedures pertaining to anesthesia services for traditional

Medicaid apply to the PrimeStep program. Anesthesiology services do not require the

PMP certification code for payment. Risk Based Managed Care (RBMC) may have

other, specific standards and practices. For RBMC specific policies, please consult the

appropriate managed care organization.

RELATED MEDICAL TOPICS

Consultations – Second Opinion

Dental Services

Obstetric Care

Surgery – Multiple Procedures/Same Operative Session

Surgery – Removal of Implants

Surgery – Services Requiring Prior Authorization

Surgery – Surgeon and Assistant Surgeon, Same Provider

Surgery – Surgical Services

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Surgery – Suture of Wounds

RULES, CITATIONS, AND SOURCES

405 IAC 5-10 - Anesthesia Services

405 IAC 5-14-11 - Analgesia (Dental)

405 IAC 5-14-15 - General Anesthesia and Intravenous Sedation (Dental)

405 IAC 5-25-1 - Physician Services

405 IAC 5-28-1(h) – Medical and Surgical Services (Reimbursement Limitations)

Hoosier Healthwise Manual for Primary Medical Providers and Office Staff

January 2003

Indiana Health Coverage Programs Provider Manual

1999

July 2004, Version 5.0

Indiana Health Coverage Programs Provider Banner

BR199947 – General Anesthesia – Dental Services

BR200350 – Modifiers for Medical Direction and CRNA Billing Requirements

Indiana Health Coverage Programs Provider Bulletin

BT200324 – Changes to the $600 Dental Cap

BT200353 – HIPAA requirements

BT200401 – 2004 Annual HCPCS Update

Origination Date: 12/31/2000

Revisions and Reviews Reason Date

Indiana State Dept. Of

Public Welfare Medical

Policy Manual 1991

Anesthesia Services Global Fee billing

07/01/1991

470 IAC 5-9-27 Transferred Anesthesia Services 07/01/1991

405 IAC 1-7-26 Repealed

8/24/97

Anesthesia Services

01/01/1992

405 IAC 1-7-26 (1) Anesthesia Reimbursement 12/01/1993

Indiana Medicaid Update

Bulletin 95-21, 05/02/95

Anesthesia Services

02/25/1995

Indiana Medicaid Update

Bulletin 96-26,

Anesthesia Services

07/29/1996

405 IAC 5-25-1 Physician Services 08/24/1997

405 IAC 5-10 Anesthesia Services 08/24/1997

405 IAC 5-14-11 and 405

IAC 5-14-15

Analgesia for Dental Procedures;

General Anesthesia and Intravenous

Sedation for Dental Procedures 08/24/1997

Indiana Medicaid Update

Bulletin 8-03

Anesthesia Services

01/06/1998

405 IAC 5-28-1(h) Medical and Surgical Services,

Reimbursement limitations 07/27/2001

Revision - Updates HIPAA requirements, Dental Services, 04/29/2005

01/31/2007 Anesthesia Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Anesthesia Services

Medical Policy Manual

APPLICABLE INDIANAAIM EDITS AND AUDITS

6002 – Any Two Anesthesiology Provider Same Procedure Requires Review

6096 – The CPT/HCPCS Code Billed Is Not Payable According to the PPS

Reimbursement Methodology

6156 – Procedure 99140 Must Be Billed With Anesthesia Code

6652 – Multiple Surgeries Must Be Billed on Same Claim

6666 – Anesthesia Services Not Allowed by Provider Billing for Surgery

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: BARIATRIC SURGERY AND REVISIONS

DESCRIPTION

Morbid obesity is defined as a body mass index

(BMI) of at least 35 kilograms per meter

squared, with co-morbidity or co-existing medical conditions, such as hypertension,

cardiopulmonary conditions, sleep apnea, or diabetes; or a BMI of at least 40 kilograms

per meter squared without a co-morbidity.

This document is intended to serve as a general summary of the IHCP policies regarding

this service. More specific information may be found in the IHCP provider manual,

program notices, the Indiana Administrative Code (IAC) or other sources as appropriate.

See the “Rules, Citations, and Sources” section of this document for further information.

I. BARIATRIC SURGERY

Bariatric surgery is a procedure of last resort, used to treat morbid obesity, when other

methods of weight management have failed. The term “bariatric surgery” is a collective

term, used to refer to procedures that involve restricting the stomach size with or without

a bypass of the stomach to alter the digestive system. The primary goal of bariatric

surgery is to achieve weight loss through restriction of the ability to eat, restriction of the

body’s ability to absorb nutrients and calories, or a combination of both. These surgeries

are categorized as “restrictive” or “malabsorptive” dependent upon the procedure

utilized.

Restrictive Operations

Restrictive operations limit food intake but do not interfere with the normal digestive

process. This type of surgery restricts the patient’s ability to eat large quantities of food

at one sitting.

♦ Adjustable gastric banding – a hollow band made of special material is placed around

the stomach near its upper end, creating a small pouch and a narrow passage into the

larger remainder of the stomach. The band is then inflated with a saline solution and

can be tightened or loosened over time to change the size of the passage by increasing

or decreasing the amount of saline solution.

♦ Vertical banded gastroplasty (VBG)

– VBG has been the most common restrictive

operation for weight control. Staples are used to create a small stomach pouch. A

Body mass index is equal to weight in kilograms divided by height in meters squared.

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

band of non-absorbable material is placed to limit the emptying of food from that

pouch.

Malabsorptive Operations

Malabsorptive operations are the most common gastrointestinal surgeries for weight

reduction. These operations restrict the amount of food a patient is able to eat, as well as

limit the ability to absorb calories and nutrients.

♦ Roux-en Y gastric bypass (RGB)

– RGB is the most common and successful

malabsorptive surgery. A small stomach pouch is created to restrict food intake. A

Y-shaped section of the small intestine is attached to the pouch to allow food to

bypass the lower stomach. This bypass reduces the amount of calories and nutrients

the body absorbs.

♦ Biliopancreatic diversion (BPD)

– BPD is a more complicated operation that involves

removal of a portion of the stomach. The small pouch that remains is connected

directly to the final segment of the small intestine. This procedure is used less

frequently because of the higher risk for nutritional deficiencies.

COVERAGE CRITERIA – BARIATRIC SURGERY

Bariatric surgery is recognized as medically necessary when used for the treatment of

morbid obesity. All types of bariatric surgery require prior authorization (PA) and are

subject to the following conditions.

1. Scope and duration of failed weight loss therapy must meet the following

criteria.

a. Morbid obesity has persisted for at least five years duration, and

b. Physician-supervised non-surgical medical treatment

has bee

unsuccessful for at least 18 consec

utive months.

Member has successfully achieved weight loss after participating in

physician-supervised non-surgical medical treatment but has been

unsuccessful at maintaining weight loss for two years [ > 3 kg (6.6 lb.)

weight gain].

Successful weight loss therapy is defined as the ability to reduce body weight by

approximately 10% from baseline in a period of eight months. Unsuccessful weight loss

maintenance is defined as a weight regain of > 3 kg (6.6 lb.) in two years and the inability

to maintain a sustained reduction in waist circumference of at least four centimeters.

2. Age and maturity requirements must include both of the following.

a. Member must be between 21 and 65 years of age.

Includes a diet to help create a 500 to 1,000 kcal/day deficit; an increase in physical activity; and

strategies to change eating and physical activity behaviors.

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

b. Member must be physically mature as shown by sexual maturity and the

closure of growth plates.

Documentation in the member’s medical record must be maintained to substantiate the

following.

1. A psychological or psychiatric evaluation by a Health Service Provider in

Psychology (HSPP) or a psychiatrist is required prior to surgery. Members with

the following contraindications will not be candidates for bariatric surgery.

a. Active abuse of alcohol, illicit and/or social drugs and other chemicals,

and/or tobacco use during the six months prior to the request.

b. DSM IV criteria for Bulimia or Binge Eating Disorder (BED).

c. Other eating patterns that are deemed likely to interfere with post-surgical

safety and success.

d. Active psychosis.

e. Uncontrolled depression.

f. Borderline personality disorder.

g. Other complex psychiatric problems that might interfere with a successful

weight-loss outcome.

2. Member is able to understand, tolerate, and comply with all phases of care and is

committed to long-term follow-up requirements.

3. Member is abstinent from alcohol use, illicit drug use, and tobacco use; member

has a negative urine drug screen.

4. Member’s treatment plan includes pre-operative and post-operative dietary

evaluations.

5. Member has received a thorough explanation of the risks, benefits, and complications

of the procedure.

6. Member’s post-operative expectations have been addressed prior to the bariatric

surgery.

7. Member has agreed in writing to participate in all pre-operative and post-

operative evaluations and sessions considered essential to his or her having a

successful outcome to the bariatric surgery.

NONCOVERED SERVICES

The IHCP does not provide reimbursement for the following.

1. Procedures that are considered investigational and/or not meeting safety and/or

efficacy standards will not be covered.

2. Panniculectomy following gastric bypass procedures performed for cosmetic

reasons, even if performed incidentally to a ventral herniorrhaphy, is a non-

covered service.

3. The IHCP will not provide reimbursement for bariatric surgeries reported with

miscellaneous CPT procedure codes. Refer to the billing guidelines in this

document for further information.

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

PRIOR AUTHORIZATION – BARIATRIC SURGERY

All bariatric surgeries, as described in Table 1 in the “Billing Requirements – Bariatric

Surgery” section of this document, require PA. Surgical procedures performed to correct

or revise the initial surgical procedure require PA and are described in the “Surgical

Revisions” section of this document.

HCPCS code S2083, Adjustment of gastric band diameter via subcutaneous port by

injection or aspiration of saline, does not require PA. This procedure is considered a

routine, frequently performed, office procedure that involves accessing a subcutaneous

port, using a needle and syringe, and injecting or aspirating saline and is not a surgical

procedure. Injection or aspiration of saline results in an increase or decrease in the

diameter of the gastric band. The adjustment of the gastric band diameter is based on the

patient’s symptomatology and weight loss, as determined by the surgeon.

Documentation of an attempt to follow a physician-supervised, non-surgical medical

treatment for a minimum of 18 consecutive months must be presented with the request

for PA. Documentation of unsuccessful weight loss or unsuccessful weight maintenance

after successful weight loss must be submitted.

The physician requesting PA is responsible for referral of the member to a psychiatrist or

an HSPP at any time before or during the non-surgical treatment. The consultation would

include an assessment for any psychosocial needs with recommendation for treatment, if

necessary.

Additionally, the request for PA for bariatric surgery must be accompanied by the

following documentation requirements.

1. A signed statement from the member acknowledging an understanding of pre- and

post-operative expectations.

2. Documentation by the primary care physician of the results of the physician-

supervised non-surgical weight loss program for at least 18 consecutive months,

including unsuccessful weight loss or maintenance after successful weight loss.

3. Documentation by a psychiatrist or psychologist licensed as an HSPP that reflects

a psychiatric evaluation for possible behavioral health conditions that are

contraindications to the surgery.

4. Consultation reports from other practitioners who have seen the member for

evaluation (eg. anesthesiologist, pulmonologist, cardiologist, etc).

II. SURGICAL REVISIONS

COVERAGE CRITERIA – REVISIONS

Members may require subsequent surgery due to a complication during the perioperative

period or a revision to correct a technical failure post-operatively. Re-operation to repair

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

a complication or to correct a technical failure requires PA. Examples of perioperative

complications of surgery include, but are not limited to, the following.

1. Gastrointestinal leakage.

2. Stomal stenosis.

3. Anastomatic leakage.

4. Abscess.

Post-operative technical failures of the primary operation include, but are not limited to,

the following.

1. Staple line disruption - documented by x-ray or endoscopy.

2. Gastrogastric fistula with weight gain.

3. Expanded outlet - documented by gastroscopy.

4. Enlarged anastomosis -- documented by gastroscopy.

5. Intolerance to solid food after a band procedure.

6. Intractable reflux after a band procedure.

7. Weight loss as a result of anastomotic stenosis.

8. Stomal ulceration.

PRIOR AUTHORIZATION – REVISIONS

PA is required for re-operation to repair a complication or to correct a technical failure.

PA for revision or conversion to Roux-en-Y shall include a medical review of

documentation. Documentation of medical necessity must include the reason for the

failure and the date of the original surgery. Examples of peri-operative complications

and technical failures are provided in the coverage criteria for surgical revisions.

PA for revision of bariatric surgery due to reasons other than technical failure or due to

noncompliant behavior of the member requires six months of documentation in the

medical record to include the following.

1. Member participation in all pre-operative and post-operative evaluations and

sessions included in the treatment plan.

2. Consultations with the bariatric dietician with documentation in the medical

record of member’s compliance with the post operative dietary treatment plan.

3. When failure is at least in part due to noncompliant behavior of the member,

evaluation by a psychiatrist or psychologist licensed as an HSPP that reflects the

absence of behavioral health contraindications to a successful outcome to revision

of the bariatric surgery.

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

Members enrolled in Primary Care Case Management (PrimeStep) are subject to the

same benefit limits, restrictions, and medical necessity criteria as those individuals

enrolled in traditional Medicaid. Providers should contact the individual managed care

organizations to determine any additional criteria or requirements for bariatric surgery.

Senate Enrolled Act 360 from the 2005 session of the Indiana General Assembly outlines

the following criteria for Risk Based Managed Care (RBMC).

• Morbid obesity is defined as a body mass index* of at least 35 kilograms per

meter squared, with co-morbidity or coexisting medical conditions such as

hypertension, cardiopulmonary conditions, sleep apnea, or diabetes; or a body

mass index of at least 40 kilograms per meter squared without co-morbidity.

*Body mass index is equal to weight in kilograms divided by height in meters

squared.

• Physician-supervised non-surgical medical treatment has to have been

unsuccessful for at least 18 consecutive months.

• Members less than 21 years of age must have documentation in the medical

record by two physicians who have determined that bariatric surgery is

necessary to save the life of the member, or restore the member's ability to

maintain a major life activity defined as self-care, receptive and expressive

language, learning, mobility, self-direction, capacity for independent living or

economic self-sufficiency.

BILLING REQUIREMENTS

The IHCP will provide reimbursement for the bariatric procedures described in Table 1.

Providers must report ICD-9-CM diagnosis code 278.01, Morbid obesity with the most

specific procedure code available that represents the procedure performed.

Table 1 – Bariatric Surgery Codes

Code Description

43644

Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and

Roux-en-Y gastroenterostomy (roux limb 150 cm or less)

43645

Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and

small intestine reconstruction to limit absorption

43842

Gastric restrictive procedure, without gastric bypass, for morbid obesity;

vertical-banded gastroplasty

43843

Gastric restrictive procedure, without gastric bypass, for morbid obesity; other

than vertical-banded gastroplasty

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1 – Bariatric Surgery Codes

Code Description

43845

Gastric restrictive procedure with partial gastrectomy, pylorus preserving

duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit

absorption (biliopancreatic diversion from duodenal switch)

43846

Gastric restrictive procedure, with gastric bypass for morbid obesity; with short

limb (150 cm or less) Roux-en-Y gastroenterostomy

43847

Gastric restrictive procedure, with gastric bypass for morbid obesity; with small

intestine reconstruction to limit absorption

43770

Laparoscopy, surgical; gastric restrictive procedure; placement of adjustable

gastric band (gastric band and subcutaneous port)

43771

Laparoscopy, surgical; gastric restrictive procedure; revision of adjustable gastric

band component only

43772

Laparoscopy, surgical; gastric restrictive procedure; removal of adjustable

gastric band component only

43773

Laparoscopy, surgical; gastric restrictive procedure; removal and replacement of

adjustable gastric band component only

43774

Laparoscopy, surgical; gastric restrictive procedure; removal of adjustable

gastric band and subcutaneous port components

43848

Revision, open, of gastric restrictive procedure for morbid obesity, other than

adjustable gastric band (separate procedure)

43886

Gastric restrictive procedure, open; revision of subcutaneous port component

only

43887

Gastric restrictive procedure, open; removal of subcutaneous port component

only

43888

Gastric restrictive procedure, open; removal and replacement of subcutaneous

port component only

43999 Unlisted procedure, stomach

The IHCP does not provide reimbursement for HCPCS code S2083, Adjustment of

gastric band diameter via subcutaneous port by injection or aspiration of saline, during

the 90-day global period for CPT code 43770, 43773, 43771, 43886, or 43888.

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RELATED MEDICAL TOPICS

Anesthesia Services

Consultations – Second Opinion

Diagnostic Studies

Gastroenterology

Radiology

RULES, CITATIONS, AND SOURCES

Indiana Health Coverage Programs Provider Manual

405 IAC 5-3-13 Services Requiring PA

405 IAC 5-29 Non-Covered Services

Indiana Health Coverage Programs Bulletin BT200410

Indiana Health Coverage Programs Bulletin BT200430

Medical Policy Administrative Report May 2004

Senate Enrollment Act 360

Origination Date 10/01/2000

REVIEW AND REVISIONS REASON DATE

Review Add new codes 02/01/2005

Revision

Senate Enrollment Act 360 and

addition of PA criteria for

bariatric surgery revisions

10/31/2005

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Bariatric Surgery and Revisions

Medical Policy Manual

APPLICABLE INDIANAAIM EDITS AND AUDITS

3000 – Units Exceed PA Master

3001 – Date(s) of Service Not on PA Database

3010 – Out-of-State Provider Requires Prior Authorization

3011 – Out-of-State Provider Requires Prior Authorization-Rendering Provider

6002 – Any Two Anesthesiology Providers Same Procedure Requires Review

6003 – Manual Pricing for Split Care Billing

6022 – Components Not Payable When Global Paid-Digestive Services

6023 – Global Payable at a Reduced Fee When Components Paid-Digestive Services

6034 – Global Surgery Payable at Reduced Amount When Components of Surgical Care

Paid

6035 – Components of Surgical Care Not Payable when Global Surgery Paid

6037 – One Assistant Surgeon Allowed for Select Surgeries

6040 – Co-Surgeon Paid at Reduced Amount when Assistant Surgeon Paid

6096 – CPT/HCPCS Code Billed is Not Payable According to the PPS Reimbursement

Methodology

6652 – Multiple Surgeries Must be Billed On Same Claim

6661 – Duramorph Cannot Be Billed on Same Day as Surgery

6666 – Anesthesia Services Not Allowed by Providers Billing for Surgery

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: CARDIAC REHABILITATION

DESCRIPTION:

Progressive exercise programs have demonstrated benefit in the management and

rehabilitation of individuals with cardiac disease, especially following certain cardiac

events. Cardiac rehabilitation programs are typically divided into three stages. The

initial stage (Phase I) involves the most intensive supervision and occurs in an inpatient

setting. A Phase I program is typically initiated during the acute convalescent period

following a cardiac event. Phase II begins with an overall treatment plan including a

physician’s prescription for progressive exercise based on the individual’s clinical status

and physical capacity. Phase II programs incorporate close monitoring and

individualized progressive increases in the intensity of physical activity, as well as

lifestyle changes such as dietary modifications and smoking cessation. Phase II exercise

programs for cardiac patients may be conducted in specialized, freestanding, cardiac

rehabilitation clinics, as well as in outpatient hospital departments. Phase III is an

ongoing maintenance period, consisting of continued lifestyle changes and aerobic

exercise. All phases of cardiac rehabilitation programs include individualized exercises

and behavior change therapy with the intention of returning the patient to an active life

with minimized symptoms.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding this service. More specific information may be

found in the IHCP Provider Manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

IHCP mirrors Medicare guidelines and regulations for the Cardiac Rehabilitation Phase I

and Phase II services. The cardiac rehabilitation program is to include a medical

evaluation, and a program to modify cardiac risk factors, such as nutritional counseling,

prescribed exercise, education, and behavioral counseling. Phase I is included in the

inpatient DRG; therefore, IHCP does not provide separate reimbursement. IHCP does

not provide reimbursement for Phase III programs.

Reimbursement is available for Phase II cardiac rehabilitation programs when considered

medically reasonable and necessary. Members must be referred by the physician, and

have at least a moderate level of risk stratification.

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

The member must have either of the following criteria.

1. Stable angina pectoris (ICD-9-CM diagnosis codes 413.0 or 413.9) with reduced

activity tolerance substantially altering lifestyle. Stable angina is defined as

exertional chest pains with a constant threshold, predictable symptoms, and the

ability to adjust one’s activity and medications in order to avoid symptoms.

Members who qualify for a Phase II cardiac rehabilitation program are expected

to have a functional classification of Class II or Class III on the Canadian

Cardiovascular Society Functional Classification, as follows.

• Class I

Ordinary physical activity, such as walking and climbing stairs, does not

cause angina. Angina may occur with strenuous, rapid, or prolonged

exertion at work or recreation

• Class II

Slight limitation of ordinary activity including, walking or climbing stairs

rapidly walking uphill, walking or stair climbing after meals, in cold, in

wind, or when under emotional stress, or only during the few hours after

awakening. Walking more than two blocks on a level surface and

climbing more than one flight of ordinary stairs at a normal pace and

under normal conditions

• Class III

Marked limitation of ordinary physical activity. Walking one to two

blocks on a level surface and climbing more than one flight in normal

conditions

• Class IV

Inability to carry on any physical activity without discomfort; anginal

syndrome may be present at rest

2. Have had one of the following preceding the initiation of the Phase II program.

• Coronary artery bypass surgery

• Acute myocardial infarction (within the previous twelve months)

• Old myocardial infarction (that is less than 52 weeks from the date of the

infarction)

• Heart valve repair/replacement

• Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting

• Heart or heart-lung transplant

Cardiac rehabilitation programs may be provided either by the outpatient department of a

hospital or in a freestanding cardiac rehabilitation facility. Cardiac rehabilitation services

must be conducted only when a physician is on the premise and is available to perform

medical duties at all times the facility is open. The IHCP member must be under the care

of a hospital or clinic physician. The facility must have available for immediate use all

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

the necessary cardiopulmonary emergency diagnostic and therapeutic life saving

equipment accepted by the medical community as medically necessary, such as oxygen,

cardiopulmonary resuscitation equipment, and defibrillator.

Services provided in connection with a cardiac rehabilitation exercise program may be

considered reasonable and necessary for up to 36 sessions, usually a maximum of three

sessions a week, in a single 12- week period. Coverage for continued participation in

cardiac exercise programs beyond 12 weeks are approved on a case-by-case basis with

exit criteria taken into consideration.

Documentation in the medical record must show the medical necessity for unusual

frequency or duration of Phase II. Documentation must be specific in terms of exit

criteria and/or setbacks that changes the exercise prescription. Claims for Phase II

accompanied documentation indicating the member has not reached an exit level within

12 weeks are considered on a case-by-case basis. Reimbursement is not available for

Phase II exceeding a maximum of 24 weeks.

A member may be progressed to the maintenance (Phase III) program when the following

criteria are met.

1. The member has achieved a stable level of exercise tolerance without ischemia or

dysrhythmia as evidenced by electrocardiogram (ECG)

2. Symptoms of angina or dyspnea are stable at the member’s maximum exercise

level

3. The member’s resting blood pressure and heart rate are within normal limits, or

are stable on optimal medical therapy

4. The stress test is not positive during exercise. (A positive test in this context

means an ECG with a junctional depression of greater than or equal to 2 mm

associated with slowly rising, horizontal, or down-sloping ST segment)

A routine cardiac rehabilitation visit must include at least one of the following services.

1. Continuous ECG telemetric monitoring during exercise

2. ECG rhythm strip with interpretation and physician’s revision of exercise

prescription

3. Physician evaluation to assess the member’s performance, adjust medication, or

other treatment changes. This physician evaluation is considered an element of

the cardiac rehabilitation visit, and is not a separate reimbursement. Additional

physician reimbursement requires documentation of a separately identifiable

evaluation and management (E/M) service

Other cardiac rehabilitation services may include, but are not limited to, the following.

1. New patient comprehensive evaluation, including history, physical, and

preparation of initial exercise prescription. One comprehensive evaluation is

allowed and separately payable at the beginning of the program, if not

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

already performed by the member’s attending physician, or if the evaluation

performed by the member’s attending physician is not acceptable to the

program’s director. An assessment performed by a nurse or other personnel

does not meet this requirement.

2. ECG stress test (treadmill or bicycle ergometer) with physician monitoring

and report. One is allowed at the beginning of the program and one after 3

months (usually at the completion of the program). Pharmacologic stress

testing may be indicated in certain circumstances and would be allowed only

on a case-by-case basis with appropriate documentation of medical necessity.

PRIOR AUTHORIZATION

Prior authorization is not required for Cardiac Rehabilitation services.

BILLING GUIDELINES

Phase II Cardiac Rehabilitation services are to be reported with the appropriate CPT

procedure code as noted in Table 1 and an appropriate ICD-9-CM Diagnosis code as

described in Table 2. According to the ICD-9-CM coding narratives, cardiac

rehabilitation that begins within eight weeks of the date of the infarction should be coded

as 410.00 - 410.92. Cardiac rehabilitation beginning eight weeks or greater from the date

of the infarction (but less than 52 weeks) should be coded as 412 or 414.8.

Table 1–CPT Procedure Codes for Phase II Cardiac Rehabilitation

Code Description

93797 Physician services for outpatient cardiac rehabilitation; without continuous

ECG monitoring (per session)

93798 Physician services for outpatient cardiac rehabilitation; with continuous ECG

monitoring (per session)

Table 2–ICD-9-CM Diagnosis Codes for Phase II Cardiac Rehabilitation

Code Description

410.00 Acute myocardial infarction of anterolateral wall; episode of care unspecified

410.01 Acute myocardial infarction of anterolateral wall; initial episode of care

410.02 Acute myocardial infarction of anterolateral wall; subsequent episode of care

410.10 Acute myocardial infarction of other anterior wall; episode of care unspecified

410.11 Acute myocardial infarction of other anterior wall; initial episode of care

410.12 Acute myocardial infarction of other anterior wall; subsequent episode of care

410.20 Acute myocardial infarction of inferolateral wall; episode of care unspecified

410.21 Acute myocardial infarction of inferolateral wall; initial episode of care

410.22 Acute myocardial infarction of inferolateral wall; subsequent episode of care

410.30 Acute myocardial infarction of inferoposterior wall; episode of care

unspecified

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 2–ICD-9-CM Diagnosis Codes for Phase II Cardiac Rehabilitation

Code Description

410.31 Acute myocardial infarction of inferoposterior wall initial episode of care

410.32 Acute myocardial infarction of inferoposterior wall subsequent episode of care

410.40 Acute myocardial infarction of other inferior wall; episode of care unspecified

410.41 Acute myocardial infarction of other inferior wall; initial episode of care

410.42 Acute myocardial infarction of other inferior wall; subsequent episode of care

410.50 Acute myocardial infarction of other lateral wall; episode of care unspecified

410.51 Acute myocardial infarction of other lateral wall; initial episode of care

410.52 Acute myocardial infarction of other lateral wall; subsequent episode of care

410.60 Acute myocardial infarction true posterior wall infarction; episode of care

unspecified

410.61 Acute myocardial infarction true posterior wall infarction; initial episode of

care

410.62 Acute myocardial infarction true posterior wall infarction; subsequent episode

of care

410.70 Acute myocardial infarction subendocardial infarction; episode of care

unspecified

410.71 Acute myocardial infarction subendocardial infarction; initial episode of care

410.72 Acute myocardial infarction subendocardial infarction; subsequent episode of

care

410.80 Acute myocardial infarction of other specified sites; episode of care

unspecified

410.81 Acute myocardial infarction of other specified sites; initial episode of care

410.82 Acute myocardial infarction of other specified sites; subsequent episode of care

410.90 Acute myocardial infarction unspecified site; episode of care unspecified

410.91 Acute myocardial infarction unspecified site; initial episode of care

410.92 Acute myocardial infarction unspecified site; subsequent episode of care

412 Old myocardial infarction

413.0 Angina decubitus*

413.9 Other and unspecified angina pectoris

414.8 Other specified forms of chronic ishemic heart disease

V15.1 Surgery to heart and great vessels

V42.1 Organ or tissue replaced by transplant; heart

V42.2 Organ or tissue replaced by transplant; heart valve

V43.3 Organ or tissue replaced by other means; heart valve

V45.09 Cardiac device in situ; other specified cardiac device

V45.81 Postsurgical status, aortocoronary bypass

V45.82 Percutaneous transluminal coronary angioplasty status

*Includes nocturnal angina

It is the responsibility of the provider to code to the highest level specified in the ICD-9-

CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code listed above

does not assure coverage of a service. The service must be reasonable and necessary in

the specific case and must meet the criteria specified in this policy.

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

The appropriate revenue code for cardiac rehabilitation services is 943. All charges

associated with the elements of a cardiac rehabilitation service as noted previously in this

document, including telemetry and supplies for telemetry, are to be included in this

charge. Separate reimbursement for charges for telemetry, electrodes, etc. are not

provided. One unit equals one cardiac rehabilitation visit. The number of units must be

shown on the UB-92 in field 46. A stress test may be billed using revenue code 482. The

date of onset or surgery must be indicated on the UB-92 in fields 32-35 with occurrence

code 11. The date of the first cardiac rehabilitation session must be indicated in fields

32-35 with occurrence code 46. The total number of cardiac rehabilitation visits from the

start of care, including the current claim, must be entered on the UB-92 in fields 39-41

with value code 53.

Reasons for Denial

The IHCP will deny reimbursement for, but not limited to, the following reasons.

Although members may meet a provider’s protocol for cardiac rehabilitation services,

they must also meet the IHCP coverage criteria for medical necessity.

1. Lack of documentation of a covered diagnosis

2. Lack of documentation of the elements of a cardiac rehabilitation visit

3. Duration beyond 12 weeks without documentation showing medical

necessity as indicated above

4. Services determined to be not reasonable and necessary as stated previously

in this document

Documentation Requirements

The diagnosis of stable angina should be substantiated with a physician history and

physical, a hospital discharge summary, or a physician statement to confirm the

diagnosis. The member’s medical record must contain documentation that fully supports

the medical necessity for cardiac rehabilitation, as it is covered by IHCP. This

documentation includes, but is not limited to, medical records confirming the diagnosis,

evidence of the elements of a cardiac rehabilitation session (e.g., telemetry monitoring

strips), and medical reason for extension of the 12-week limit.

MANAGED CARE

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for more specific guidelines. Refer to the

Provider Manual, Chapter 1, for detailed information about the fee-for-service (FFS),

Primary Care Case Management (PCCM), and Risk Based Managed Care (RBMC)

delivery systems.

IHCP members enrolled in Medicaid Select PCCM receive the same benefit coverage,

and are subject to the same limitations as traditional Medicaid FFS. Refer to the

Medicaid Select Manual for Primary Care Providers and Office Staff for further

information.

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Cardiac Rehabilitation

Medical Policy Manual

RELATED MEDICAL TOPICS

Medical/Surgical

Hospital Inpatient

Hospital Outpatient

RULES, CITATIONS, AND SOURCES:

405 IAC 5-2-17 – Medically reasonable and necessary service

Indiana Health Coverage Program Provider Manual, Version 5.1

Origination Date: 12/31/2002

Review and

Revision

Reason Date

405-IAC-5-2-17 Medically reasonable and necessary service 07/25/1997

Review Scheduled 01/31/2007

APPLICABLE INDIANAAIM EDITS AND AUDITS:

6096 – The CPT/HCPCS Code Billed is Not Payable According to the PPS

Reimbursement Methodology

6652 – Multiple Surgeries Must be Billed On the Same Claim

6768 – Services Not Covered for Telemedicine

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: CASE MANAGEMENT—PREGNANT WOMEN

DESCRIPTION

Case management (care coordination) for pregnant women is an active, ongoing process

of assisting a member to identify, access, and utilize community resources. Care

coordinators perform prenatal risk assessments to identify Indiana Health Coverage

Programs (IHCP) benefit eligible women whose pregnancies are at risk of preterm birth,

low birth weight, or poor pregnancy outcomes. Case managers coordinate the services to

meet member needs by locating community resources, making appointments for services,

and following up to verify or reschedule appointments. Pregnant women, identified by

the Prenatal Risk Assessment Form as high-risk members due to medical or psychosocial

conditions, may also receive pregnancy care coordination services through the IHCP.

The Prenatal Risk Assessment Form can be located on the IHCP website at

www.indianamedicaid.com, under forms.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding this service. More specific information may be

found in the IHCP Provider Manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations and Sources” section of

this document for further information.

COVERAGE CRITERIA

IHCP reimbursement is available for care coordination services provided to eligible

pregnant women by any of the following providers.

• A physician licensed by the state

• A registered nurse licensed by the state

• A social worker with a baccalaureate or master’s degree from a school accredited

by the Council on Social Work Education

• A social worker certified by the state

• A dietician registered with the Commission on Dietetic Registration of the

American Dietetic Association and with certified training in pregnancy case

management to combat poor pregnancy outcomes

• A community health worker may perform all care coordination services except

the home encounter portion of the initial assessment and the postpartum or

newborn assessment

01/31/2007 Case Management – Pregnant Women

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

A care coordinator must be certified by and have successfully completed perinatal care

coordination training from a program approved by the Office of Medicaid Policy and

Planning (OMPP). Care coordination includes the following services.

• Case finding

• Risk assessment

• Plan-of-care development

• Coordination

• Referral

• Linkage

• Follow-up monitoring

All eligible pregnant women may receive initial assessment services; however, only those

deemed at risk, according to a prenatal risk assessment form approved by OMPP, are

eligible for additional services. Reassessment and postpartum assessment are not covered

services, when an initial assessment determines a pregnancy is not at risk. However,

services may be covered later in the pregnancy if risk factors from the prenatal risk

assessment form, which were not evident or present during the initial assessment, are

discovered.

Care coordination services are exempt from prior authorization (PA) requirements,

except for members with Primary Care Case Management (PCCM). PCCM pregnancy

care coordination services require authorization by the member’s Primary Medical

Provider (PMP).

Pregnancy care coordination services are designed to prevent preterm births or poor

pregnancy outcomes by facilitating the linking of the pregnant women to all necessary

services, including medical, health promotion, and social services. The following

services, available on a trimester basis, may be provided by physicians, registered nurses,

social workers, and registered dieticians with certified training in pregnancy case

management to combat poor pregnancy outcomes.

• Home visits, including the initial and postpartum home visit

• Referral to social service agencies

• Follow-up activities to ensure services were received

Intensive intervention by the pregnancy care coordinators must occur if the initial

prenatal risk assessment indicates a high-risk condition that could potentially result in a

poor pregnancy outcome. The pregnancy care coordinator should conduct up to two

additional prenatal reassessments and a postpartum assessment, as well as the required

home visit following the delivery to gather vital information about the pregnancy

outcome and assessment of the newborn care needs. The postpartum visit is the only

service that requires a completed copy of the Care Coordination Outcome Report to be

attached to the claim.

01/31/2007 Case Management – Pregnant Women

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Effective for claims with dates of service of November 20, 2001 and later; the IHCP

requires the use of the new Prenatal Care Coordination Outcome Report Form. The new

form permits accumulation of statistical data regarding 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 sent to EDS. Prenatal

care coordinators no longer send claims or outcome reports to EDS unless a client is in

Medicaid Select or not enrolled in a Managed Care Organization (MCO). In addition,

Risk-Based Managed Care (RBMC) is mandatory in all counties. The assessment forms

for RBMC members are sent to the MCO in which the member is enrolled. To reduce

reports received by the MCOs the data found on the Care Coordination Outcome Report

has been incorporated into the Combined Initial and Reassessment Prenatal Care

Coordination Assessment Form (CIRPNCCAF) and the Postpartum Assessment Form

(PPAF). All providers are required to complete the CIRPNCCAF and the PPAF. These

forms can be located on the IHCP website at www.indianamedicaid.com

, under forms.

A member may not appear to be high-risk by traditional assessment methods.

Physicians/practitioners may acquire additional information regarding the risk of preterm

delivery by performing the salivary estriol test, which would allow them to take steps to

treat the member. Please refer to the Medical Policy (MP) Fact Sheet regarding

Laboratory Services-Salivary Estriol Test for Preterm Labor Risk Assessment for

additional information.

PRIOR AUTHORIZATION

PA is not required for care coordination services. However, PCCM members require

authorization from the member’s PMP.

MANAGED CARE

For members enrolled in RBMC, providers must contact the member’s MCO for more

specific guidelines. Refer to the Provider Manual, Chapter 1, for detailed information

about the fee-for-service (FFS), PCCM, and RBMC delivery systems.

IHCP members enrolled in Medicaid Select PCCM receive the same benefit coverage,

and are subject to the same limitations as traditional Medicaid FFS. Refer to the

Medicaid Select Manual for Primary Medical Providers and Office Staff for further

information.

BILLING REQUIREMENTS

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

01/31/2007 Case Management – Pregnant Women

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

after the initial assessment), and one home visit postpartum assessment. The following

codes are used to report these services.

• Healthcare Common Procedure Coding System (HCPCS) codes that are used to

report prenatal care coordination for the initial assessment and re-assessments are

as follows.

• H1000, Prenatal care, at-risk assessment-initial

• H1004, Prenatal care, at-risk enhanced service; antepartum management-

reassessment

• Current Procedural Terminology (CPT) code 99501, Home visit for postnatal

assessment and follow-up care, is used to report the postpartum visit and is the

only service that requires a copy of the Care Coordination Outcome Report form

be completed by the care coordinator and submitted with the claim when billing

for the visit.

RELATED MEDICAL TOPICS

Family Planning

Gynecology−Pelvic Exam under Anesthesia

Laboratory Services-Salivary Estriol Test for Preterm Labor Risk Assessment

Obstetric Care

Surgery−Surgical Services

Transportation Services

RULES, CITATIONS, AND SOURCES

405 IAC 5-11, Case Management Services for Pregnant Women

Indiana Health Coverage Programs Provider Manual 2006

Indiana Health Coverage Programs Provider Bulletin

BT200014-Salivary Estriol Test For Preterm Labor Risk Assessment

Indiana Health Coverage Programs Provider Bulletin

BT200353-HIPAA-Mandated Elimination of Local Codes and Local Code

Modifiers

Indiana Health Coverage Programs Provider Bulletin

BT200604-Assessment Forms and Outcome Report as a Result of State-Wide

Hoosier Healthwise Mandatory MCO Transition

Indiana Health Coverage Programs Provider Banner

BR200207

Indiana Health Coverage Programs Provider Banner

BR200214

Indiana Health Coverage Programs Provider Banner

BR200316

01/31/2007 Case Management – Pregnant Women

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Case Management – Pregnant Women

Medical Policy Manual

Indiana Health Coverage Programs Provider Banner

BR200317

Indiana Health Coverage Programs Provider Newsletter

NL200508

Origination Date: 07/01/1991

Revisions and

Review

Reason Date

470 IAC 5-9-25.1

Transferred

Case Management Services For Pregnant

Women

07/01/1991

405 IAC 1-7-24

Repealed 08/24/1997

Care Coordination Services For Pregnant

Women

01/01/1992

405 IAC 5-11 Case Management-Pregnant Women 08/24/1997

405 IAC 5-11-1

Amended

Case Management-Pregnant Women 10/27/1999

405 IAC 5-11-7

Amended

Case Management-Pregnant Women 10/27/1999

Review Scheduled 10/31/2006

APPLICABLE INDIANAAIM EDITS AND AUDITS

6050-Care Coordinator-Reassessment

6051-Care Coordinator-Initial Assessment

6052-Care Coordination Post-Partum Assessment/Outcome

6096-The CPT/HCPCS Code Billed Is Not Payable

6652-Multiple Surgeries Must Be Billed On Same Claim

6768-Services Not Covered For Telemedicine

6800-Care Coordination-Transportation For Home Visits

6801-Care Coordination-Transportation For Home Visits

6802-Care Coordination-Transportation (Postpartum)

6916-Global-Home Uterine Monitoring

6917-Components-Home Uterine Monitoring

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: CHIROPRACTIC SERVICES

DESCRIPTION

Chiropractic services are defined in Indiana Code (IC) 25-10 as the diagnosis and

analysis of any interference with normal nerve transmission and expression, the

procedure preparatory to and complementary to the correction thereof by an adjustment

of the articulations of the vertebral column, its immediate articulation, and includes other

incidental means of adjustments of the spinal column and the practice of drugless

therapeutics.

COVERAGE CRITERIA

Indiana Health Coverage Programs (IHCP) reimbursement is available for covered

services provided by a licensed chiropractor subject to restrictions and limitations set out

in the Indiana Code (IC) 25-10-1-1, 5.5, 13, 14, and the Indiana Administrative Code

(IAC) 405 IAC 5-12 and 407 IAC 3-12. Reimbursement is not available for any

chiropractic services provided outside the scope of IC 25-10-1 and 846 IAC 1-1, or for

any chiropractic service for which federal financial participation is not available.

Effective July 1, 2003, reimbursement is limited to a total of fifty visits and spinal

manipulations or physical medicine treatments per member per rolling twelve month

period. As part of this limitation, reimbursement will be made for no more than five

office visits out of the total fifty visits allowed per member per rolling twelve month

period. New patient office visits are reimbursed once per lifetime, per recipient, per

provider, or provider of the same specialty and in the same practice within a three year

time period. 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

Reimbursement is not available for durable medical equipment (DME) provided by

chiropractors. Additionally, electromyogram (EMG) testing is no longer a covered IHCP

service for chiropractors.

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Reimbursement is limited to one set of full spinal x-rays per year. Chiropractors must

provide the actual x-ray films previously taken at no cost to IHCP members when

requested. The IHCP will not reimburse for additional x-rays 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.

Claim payment is limited for chiropractic practitioners (specialty 150) to the Current

Procedural Terminology (CPT) procedure codes listed in tables one through four and the

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-

CM) diagnosis codes listed in the tables five and six included in this document.

Prior Authorization

Manual muscle testing services require prior authorization according to 405 IAC 5-12-5.

Package C chiropractic services are restricted to five visits and fourteen procedures per

rolling 12 month period. Additional procedures that are medically necessary may be

reimbursed subject to prior authorization according to 407 IAC 3-12-2. There is a 50

treatment limit per rolling 12 month period, which includes no more than five office

visits.

Managed Care

Chiropractic services are self-referral for Risk Based Managed Care (RBMC). Self-

referral services do not require Primary Medical Provider (PMP) authorization.

Benefits under Hoosier Healthwise Package A - Standard Plan - have not been modified.

Reimbursement is limited to a total of 50 visits, which includes no more than five office

visits per recipient per rolling 12 month period.

Benefits under the Hoosier Healthwise Package B - Pregnancy Coverage Only - have not

been modified. Coverage is limited to services related to pregnancy, conditions that may

complicate the pregnancy, or urgent care services. Three principal diagnosis codes were

covered specifically for Package B members effective July 1, 2003 and are listed in table

five in this document. Refer to the Obstetric Care Fact Sheet for more information

regarding billing chiropractic services for Package B members.

Benefits under the Hoosier Healthwise Package C - Children’s Health Insurance

Program - have not been modified. Package C chiropractic services are restricted to five

visits and fourteen procedures per rolling 12 month period. Additional procedures that

are medically necessary may be reimbursed subject to prior authorization. There is a 50

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

rreatment limit per rolling 12 month period, which includes no more than five office

visits.

Tables one through four identify the procedure codes that can be billed to the IHCP by

chiropractors.

Table 1–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 to 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 2–Covered IHCP Chiropractic Codes for Manipulative Treatment

CPT

Code

Description

98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions

98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions

98942 Chiropractic manipulative treatment (CMT); spinal, five regions

98943

Chiropractic manipulative treatment (CMT); extraspinal, one or more regions

Chiropractors may perform laboratory tests, which fall within their scope of

practice for the State of Indiana (IC 25-10-1 and Title 846, which include blood

analysis and urinalysis).

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 3–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 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

views

72120

Radiologic examination, spine, lumbosacral, bending views 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; two 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

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 3–Covered IHCP Chiropractic Codes for Radiology

CPT

Code

Description

73140

Radiologic examination, finger (s), minimum of two views

73500

Radiologic examination, hip, unilateral; one view

73510

Radiologic examination, hip, unilateral; 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 4–Covered IHCP Chiropractic Codes for Medicine Services

CPT

Code

Description

95831

Muscle testing, manual (separate procedure) with report; extremity (excluding

hand) or trunk

95832

Muscle testing, manual (separate procedure) with report; hand, with or without

comparison with normal side

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

97020

Application of a modality to one or more areas; microwave

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

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 4–Covered IHCP Chiropractic Codes for Medicine Services

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

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; 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 exercises

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)

97139

Therapeutic procedure, one or more areas, each 15 minutes; unlisted therapeutic

procedure (specify)

97140

Manual therapy techniques (e.g. mobilization/manipulation, manual

lymphatic drainage, manual traction), one or more regions, each 15

minutes

Tables five and six identify diagnosis codes appropriate for chiropractic services billed to

the IHCP. Table five lists principal diagnosis codes and table six lists secondary

diagnosis codes.

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

739.3

Nonallopathic lesions, not elsewhere classified – Lumbar region

739.4 Nonallopathic lesions, not elsewhere classified – Sacral region

739.5 Nonallopathic lesions, not elsewhere classified – Pelvic region

739.6 Nonallopathic lesions, not elsewhere classified – Lower extremities

739.7 Nonallopathic lesions, not elsewhere classified – Upper extremities

739.8 Nonallopathic lesions, not elsewhere classified – Rib cage

Table 5– Diagnosis Codes for Chiropractic Services, Principal ICD-9-CM Codes

Principal ICD-9-CM Codes

Dia

nosis

Codes

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 classifiable elsewhere, antepartum condition or

complication

739.0 Nonallopathic lesions, not elsewhere classified – Head region

739.1 Nonallopathic lesions, not elsewhere classified – Cervical region

739.2 Nonallopathic lesions, not elsewhere classified – Thoracic region

*Limited to medically necessary services rendered to Package B members

effective July 1, 2003.

Table 6–Diagnosis Codes for Chiropractic Services, Secondary ICD-9-CM Codes

Secondary ICD-9-CM Codes

Dia

nosis

Codes

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

346.10 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

346.80 Other forms of migraine without mention of intractable migraine

346.81 Other forms of migraine with intractable migraine, so stated

346.90 Migraine, unspecified, without mention of intractable migraine

346.91 Migraine, unspecified, with intractable migraine, so stated

353.0 Brachial plexus lesions

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 6–Diagnosis Codes for Chiropractic Services, Secondary ICD-9-CM Codes

Secondary ICD-9-CM Codes

Dia

nosis

Codes

Description

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

719.40 Pain in joint, site unspecified

719.48 Pain in joint, other specified sites

719.49 Pain in joint, multiple sites

720.0 Ankylosing spondylitis

720.1 Spinal enthesopathy

721.0 Cervical spondylosis without myelopathy

721.2 Thoracic spondylosis without myelopathy

721.3 Lumbosacral spondylosis without myelopathy

721.6 Anklyosing vertebral hyperostosis

721.7 Traumatic spondylopathy

721.90 Spondylosis of unspecified site without mention of myelopathy

722.0 Displacement of cervical intervertebral disc without myelopathy

722.10 Lumbar intervertebral disc without myelopathy

722.11 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 of 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

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 6–Diagnosis Codes for Chiropractic Services, Secondary ICD-9-CM Codes

Secondary ICD-9-CM Codes

Dia

nosis

Codes

Description

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

Brachial 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, other

724.1 Pain in thoracic spine

724.2 Lumbago

724.3 Sciatica

724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified

724.5 Backache, unspecified

724.6 Disorders of sacrum

724.70 Unspecified disorder of coccyx

724.79 Disorders of coccyx, other

724.8 Other symptoms referable to back

724.9 Other unspecified back disorders

728.71 Plantar fascial fibromatosis

728.85 Spasm of muscle

729.1 Myalgia and myositis, unspecified

729.4 Fasciitis, unspecified

732.0 Juvenile osteochondrosis of spine

737.0

Adolescent postural kyphosis

737.10

Kyphosis (acquired) (postural)

737.12

Kyphosis, postlaminectomy

737.19

Kyphosis, other

737.20

Lordosis (acquired) (postural)

737.21

Lordosis postlaminectomy

737.22

RELATED MEDICAL TOPICS

Consultation – Second Opinions

Diagnostic Studies

Physical Rehabilitation Services

Medical Supplies and Equipment

Out-of-State Services

Package B

Obstetric Care

RULES, CITATIONS, AND SOURCES

IC 25-10-Chiropractors

405 IAC 5-12-Chiropractic Services

407 IAC 3-12-Chiropractic Services

846 IAC-Chiropractic Examiners

Indiana Health Coverage Programs Provider Bulletins

BT200323

BT200329

Indiana Health Coverage Programs Provider Newsletter

NL2004099

State Medicaid Plan - Chiropractors’ Services

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Origination Date: 12/31/2000

Revisions and

Reviews

Reasons Date

405 IAC 5-12-1 Chiropractic Services 08/24/1997

405 IAC 5-5 Out-of-State services 08/24/1997

405 IAC 5-12-2 Office Visits

08/24/1997

modified

05/01/2003

405 IAC 5-12-3 Chiropractic X-ray Services

08/24/1997

modified

05/01/2003

405 IAC 5-12- 4 Laboratory Services

08/24/1997

modified

05/01/2003

405 IAC 5-12-6

Repealed 5/1/2003

Electromyography Services 08/24/1997

405 IAC 5-12-7 Durable Medical Equipment

08/24/1997

modified

05/01/2003

Indiana Health

Coverage

Provider Bulletins

BT200323 and

BT200329

Changes in Chiropractic Services

Chiropractic Service Limitations

07/01/2003

Indiana Health

Coverage Provider

Newsletter

NL2004099

Addition of Pregnancy Diagnosis

Codes for Package B Members

04/30/2005

01/31/2007 Chiropractic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Chiropractic Services

Medical Policy Manual

APPLICABLE INDIANAAIM EDITS AND AUDITS

4070 - Select Radiological Procedures Billed by a Chiropractor (inactive)

4071 - Lab Services Billed by Chiropractor Require Review (inactive)

6098 - Chiropractic Services Limited to Procedure and Diagnosis Codes Identified

6100 - Max of 50 Chiropractic Therapeutic Physical Medicine Treatments

6101 - Chiropractic Restrictive Office Visits Codes (NP)

6102 - Chiropractic Office Visits Limited to 5 Per Year

6103 - Component Spinal X-Rays vs Full Spine X-ray

6104 - DME Rental from Chiropractor of More Than 1 Month

6105 - One Full Spine X-Ray Per Year for Chiropractor

6106 - Component Spinal X-Rays Greater Than $95.00/Year

6107 - Full Spinal X-Ray Payable at Reduced Amount When Component Previously

Paid

6108 - Global Payable at a Reduced Fee When Components Paid

6111 - Chiropractic Office Visits Limited to Five per Year

6112 - Maximum of 14 Chiropractic Therapeutic Physical Medicine Treatments Per

Calendar Year

6122 - Chiropractic Therapeutic Physical Medicine Treatments 15 Through 50 Require

Prior Authorization

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: CLINIC SERVICES—FQHC AND RURAL HEALTH

CLINIC SERVICES

DESCRIPTION

Federally Qualified Health Clinics (FQHC) and Rural Health Centers (RHC) are facilities

for physical examination and treatment of ambulatory patients who are not hospitalized

where preliminary diagnosis is made and treatment is provided. Often, a RHC may

provide services to a medically underserved area.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding this service. More specific information may be

found in the IHCP Provider Manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

Reimbursement is available for IHCP members seeking medical care in rural health

clinics and other qualified health clinics. The provider may be a physician, nurse

practitioner, physician assistant, clinical psychologist, or clinical social worker. A valid

encounter visit is described as a face-to-face encounter between a clinic patient and a

provider, as noted above.

IHCP reimbursement is available for services and supplies incidental to such services,

which would otherwise be covered if furnished by a physician or an incident to a

physician’s services. Services to a home bound individual are only available in the case

of those FQHCs located in an area with a shortage of home health agencies as determined

by Medicaid. Any other ambulatory service included in the IHCP state plan is considered

a covered FQHC service if the FQHC offers such a service. FQHC services are defined

the same as services provided by RHCs.

FQHCs receive funds through the Public Health Services and receive FQHC status from

the Centers for Medicare and Medicaid Services (CMS). To enroll as an FQHC with the

IHCP, the CMS letter granting the FQHC status must be forwarded to EDS Provider

Enrollment with a completed application. RHCs receive their Medicare designation

01/31/2007 Clinic Services – FQHC and Rural Health Clinic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

through the CMS and must contact the Indiana State Department of Health (ISDH) to

receive RHC status as an IHCP provider.

IHCP reimbursement is limited to one encounter per IHCP member, per provider, per day

unless the diagnosis differs. Should a member visit an office twice on the same day with

a different diagnosis, the second claim can be submitted. This policy does not allow a

provider to bill multiple claims for one visit with multiple diagnoses by separating the

diagnoses on different claims. Documentation includes, but is not limited to, the

following.

• Visits performed at separate times of the day that indicate the times and

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 the medical record supports the medical reason for an

additional visit and includes presenting symptoms or reason for the visit, onset

of symptoms and treatment rendered

• Documentation that the diagnosis for each encounter is different

IHCP reimbursement is also available 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. These services can be included

in the encounter reimbursement when performed in conjunction with the office visit to a

valid provider. These services are not reimbursable through claim submission if

performed without a face-to-face visit to a valid provider.

FQHCs and RHCs can provide preventive services and encounters, care coordination,

and Health Watch services. Refer to the IHCP Provider Manual or the Health Watch

Early and Periodic Screening, Diagnostic & Treatment Program supplemental provider

manual for further information about those services.

The valid FQHC/RHC encounter code list is reviewed annually and is published on the

Myers and Stauffer [the rate setting contractor for the Office of Medicaid Policy and

Planning (OMPP)] Website at http://www.mslcindy.com

PRIOR AUTHORIZATION

FQHCs and RHCs are subject to the same prior authorization (PA) requirements for

IHCP services as Traditional Medicaid. The provider may contact the PA department for

specific information regarding requirements and guidelines. Additionally, further

information can be located in the IHCP Provider Manual, Chapter 6, Prior Authorization.

01/31/2007 Clinic Services – FQHC and Rural Health Clinic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

An FQHC/RHC can participate with a managed care organization (MCO). The MCO

provider contract must specify the contractual arrangements to ensure that the FQHC or

RHC is reimbursed for services.

Claims for members in a Risk-Based Managed Care (RBMC) plan should continue to be

billed in the manner applicable to the specific MCO. The T1015 encounter code should

not be included on these claims. All MCO claims will be reconciled to the provider

specific Prospective Payment System (PPS) rate on a quarterly basis by the rate setting

contractor and settlements will be made at that time. These reconciliations will continue

until such time that the MCOs adapt the systems to the PPS methodology.

Claims submitted for members currently in the Medicaid Select Managed Care will

continue to include all Primary Medical Provider (PMP) information on the CMS-1500

claim form and the 837P electronic transaction. PMP information is required on the

claim in the following fields: 17, PMP name; 17a, PMP’s nine-digit IHCP provider

number; and 19, the PMP’s two-digit certification code.

BILLING REQUIREMENTS

All FQHC and RHC facilities are required to submit claims using the appropriate HCPCS

code and HCPCS code T1015, Clinic visit/encounter, all inclusive. HCPCS code T1015

is reimbursed at a facility-specific PPS rate determined by the rate-setting contractor for

the specific FQHC/RHC provider enrollment file.

For claims submitted with a Place of Service 50, Federally Qualified Health Center, 72,

Rural Health Clinic; 11, Office; 12, Home; 31, Skilled Nursing Facility; or 32, Nursing

Facility, providers must use both the T1015 encounter code and the appropriate CPT or

HCPCS procedure code. If the claim contains both T1015 and one of the allowable

procedure codes from a list of valid CPT/HCPCS codes approved by OMPP, the CPT or

HCPCS code will correctly deny. The T1015 encounter code will be reimbursed

according to the usual and customary charge as established in the provider’s file.

If the CPT or HCPCS code billed is not on the list of allowable procedure codes from the

encounter criteria for place of service 50, 72, 11, 12, 31, or 32 the claim will deny.

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, should instead be reflected in the facility’s

end of year cost report.

Claims submitted with a Place of Service 20-26, described in Table 1 on the next page,

will reimburse each line item detail at the current rate for that CPT/HCPCS code. It is

not necessary to include the T1015 encounter code on claims with Place of Service 20-

26. These services are not considered FQHC/RHC services by a valid provider.

01/31/2007 Clinic Services – FQHC and Rural Health Clinic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1 – Place of Service Codes for Other Than

RHC/FQHC Setting

Code Description

20 Urgent Care Center

21 Inpatient Hospital

22 Outpatient Hospital

23 Emergency Room – Hospital

24 Ambulatory Surgical Center

25 Birthing Center

26 Military Treatment Facility

Only one valid encounter per IHCP member, per provider, per day is allowed unless the

diagnosis code differs. Valid encounters with differing diagnosis codes for a member

that exceeds the allowed one encounter per day can be submitted to the IHCP for manual

processing.

All Third Party (TPL), patient liability, and co-payments will continue to apply as

appropriate. Previous TPL payments and spenddown will be applied to the total amount

due. All Medicare crossover claims are excluded from the PPS logic as well as the

crossover reimbursement methodology, and will continue to pay co-insurance and

deductible amounts.

DENTAL CLAIMS

Dental claims for FQHC/RHC are to be billed on a dental claim form using Current

Dental Terminology (CDT) codes. The T1015 encounter code should not be included on

the dental claim form. Dental claims will be reconciled to the provider-specific PPS rate.

Reconciliation of claims will occur until a national dental code is established to act as an

all inclusive code on the dental claim form.

RELATED MEDICAL TOPICS

Evaluation and Management Services

Family Planning

Nursing Services

RULES, CITATIONS, AND SOURCES

405 IAC 5-16-5 Rural health clinics and federally qualified health clinics; reimbursement

405 IAC 5-16-6 Free-standing clinics and surgical centers; limitations

Indiana State Department of Public Welfare Medical Policy Manual 1991

Indiana Health Coverage Programs Provider Bulletins

BT200318, Change in Method of Filing Claims

01/31/2007 Clinic Services – FQHC and Rural Health Clinic Services

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Clinic Services – FQHC and Rural Health Clinic Services

Medical Policy Manual

BT200357, Update of FQHC/RCH Valid Encounters

BT200340, Hoosier Healthwise Mandatory MCO Transition

Indiana Health Coverage Programs Provider Manual

Version 5.1, March, 2005

Origination date: 12/31/2000

Revisions and Reviews Reason Date

Indiana State Department of

Public Welfare Medical Policy

Manual 1991

Rural Health Clinics 07/1/1991

470 IAC 5-8-11

Transferred

Rural Clinics, FQHC 07/1/1991

405 IAC 1-6-11

Repealed 8/24/97

Home Health Agency, Clinic, FQHC,

and Laboratory Services

01/1/1992

405 IAC 5-16-5 RHC and FQHC; reimbursement 08/24/1997

405 IAC 5-16-6

Free-standing clinics and surgical

centers; limitations

08/24/1997

Review Scheduled 10/31/2006

APPLICABLE INDIANAAIM EDITS AND AUDITS:

4124 – FQHC and RHC Services Must be Billed According to the PPS reimbursement

methodology

6096 – The CPT/HCPCS code billed is not a valid encounter

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: CLINICAL TRIALS

DESCRIPTION

On September 19, 2000, Medicare established guidelines to cover the routine costs of

approved clinical trials, as well as reasonable and necessary items and services used to

diagnose and treat complications arising from beneficiaries’ participation in clinical

trials. In 2000, the Office of Medicaid Policy and Planning (OMPP) began following

Medicare’s guidelines to reimburse for routine costs and complications of clinical trials.

In 2003 the IHCP 1) developed a definition of experimental and investigational services;

2) defined investigational and experimental procedures, and routine costs in the context

of clinical trials; and 3) adopted IHCP policy for coverage of clinical trials based on

Medicare policy.

SUMMARY OF CURRENT POLICY

The IHCP covers the routine costs of approved clinical trials as well as reasonable and

necessary items and services used to prevent complications and to diagnose and treat

complications arising from participation in all clinical trials. Routine costs include items

and services that would otherwise be covered by the IHCP if they were not provided in a

clinical trial. The investigational item(s) or service(s) of the clinical trial are experimental

or investigational, are not considered routine costs involved in the trial and are not

covered by the IHCP.

RELATED MEDICAL TOPICS

Experimental services

Investigational services

Investigational new drug

Investigational device exemption

Wegener’s Granulomatosis

Crohn’s Disease

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RULES, CITATIONS, SOURCES

§1862 (a)(1)(E) of the Social Security Act

Coverage Issues Manual 30-1, Clinical Trials

IC 25-22.5-1-2.1

Anthem Blue Cross Blue Shield of Kentucky – Definition of

Experimental/Investigational Services

Washington State Administrative Code WAC 284-44-043 (2) – Disclosure Requirements

for Experimental or Investigational Services

Blue Cross of Oregon – Definition of Experimental or Investigational Services

21 CFR312 – Investigational New Drug Application

21 CFR812 – Investigational Device Exemption,

21 CFR 405.201 and 405.203 - Class I-III devices

HCFA Fact Sheet – Medicare Coverage Routine Costs of Beneficiaries in Clinical Trials

ORIGINATION, REVISION, AND REVIEWS

Origination Date: 10/31/04

Revisions and Reviews

Reason Date

Medical Policy Administrative

Report – Clinical Trials

Clinical Trials Policy – Approved by OMPP 10/29/04

APPLICABLE AIM EDITS AND AUDITS

None

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

EXPERIMENTAL AND INVESTIGATIONAL SERVICES

The terms “experimental” and “investigational” are used interchangeably, are described

under the same definition, and have the same coverage guidelines. Medicare defines an

experimental item or service as for “research use only” or for “investigational use only.”

Section 1862(a)(1) of the Social Security Act states experimental services are denied for

coverage as not reasonable and necessary because they are not proven safe and effective.

DEFINITION OF EXPERIMENTAL AND/ OR INVESTIGATIONAL SERVICES

Experimental or Investigational Services: Procedures, treatments, supplies, devices,

equipment, drugs, biologicals, hospitalizations, or medical services (hereinafter called

services) which are:

1. Not of proven benefit for the particular diagnosis or treatment of the member’s

particular condition. (This would include services currently covered by the IHCP for

specific diagnoses, but that are being tested for use outside the scope of coverage);

2. Not yet approved by the U.S. Food and Drug Administration for other than

experimental, investigational, or clinical trials testing;

3. Provided or performed in special settings for research purposes or under a controlled

environment or clinical protocol or subject of a Phase I, II, or III clinical trial;

4. Not generally recognized in peer-reviewed medical literature as having a definitive

positive effect on health outcomes (i.e., the service’s medical benefits do not

outweigh any harmful effects); or

5. Not recognized by a federal government agency or a national professional medical

society as effective or appropriate for the particular diagnosis or treatment of the

member’s particular condition.

CLINICAL TRIALS - DEFINED

A clinical trial is a research study in human volunteers to answer specific health

questions. Clinical trials are performed to find new ways of using known treatments and

to determine whether new drugs, devices, and procedures are both safe and effective for

general use. Carefully conducted clinical trials are the fastest and safest way to

determine what new treatments will be effective in improving the health of the public.

Clinical trials are conducted in four phases.

• Phase I – Researchers test a new drug, treatment, or device in a small group for the

first time to evaluate safety, determine dosage range, and identify side effects.

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Phase II – Expands the study to a larger group of people to further evaluate safety

and effectiveness.

• Phase III – A still larger group is studied to confirm effectiveness, monitor side

effects, and compare to commonly used treatments.

• Phase IV – Studies performed after drug, treatment, or device is marketed. Study is

continued to collect information about the effect of the drug, treatment, or device in

various populations and to identify any side effects associated with long-term use.

All clinical trials must have peer-reviewed, written protocol with clear definitions and

statements that describe the study objectives and trial criteria. The trial criteria should

include specifications of study size, study duration, statistical requirements and

endpoints, patient eligibility criteria, diagnostic protocol, and treatment protocol. Every

clinical trial in the U.S. must be approved and monitored by a federally registered

Institutional Review Board (IRB). The IRB is an independent committee of physicians,

statisticians, community advocates, and others that ensures a clinical trial is ethical and

that the rights of study participants are protected.

A clinical trial is sponsored or funded by an organization or individual that initiates, but

does not actually conduct, the investigation. Sponsors can include physicians, medical

institutions, foundations, pharmaceutical companies, and federal agencies. Some of the

foremost federal agencies that sponsor clinical trials are the National Institute of Health

(NIH), the Department of Defense (DOD), the Department of Veteran Affairs (VA), the

U.S. Food and Drug Administration (FDA), and the Centers for Disease Control (CDC).

EXPERIMENTAL AND INVESTIGATIONAL PRODUCTS AND PROCEDURES

RELATED TO CLINICAL TRIALS

Drugs and Devices

In order for a drug or device to be tested in a clinical trial, it must be approved by the

FDA and/or an IRB. Most drugs must have an approved Investigational New Drug

(IND) Application to qualify for clinical trials (see 21 CFR 312.2 for exemptions).

Medical devices must have an approved Investigational Device Exemption (IDE) to

qualify for clinical trials. If the device poses a significant risk, meaning that it presents a

potential for serious risk to the health, safety, or welfare of a clinical trial subject, it must

be approved by the FDA before studies can begin. If the device does not pose a

significant risk, the study can be approved by an IRB. Table 1 defines IND, IDE, and

related terms.

Procedures

Procedures are not regulated by the FDA or other guiding entities. In order for a

procedure to be tested in a clinical trial, an organization must conclude that the procedure

is appropriate for further evaluation in a clinical trial and agree to sponsor the research.

The principal investigator must write protocol for the trial and submit it to an IRB for

approval and monitoring during the trial.

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1 – Clinical Trial Terms

TERM SOURCE DEFINITION

Experimental

drug

Clinicaltrials.go

A drug that is not FDA licensed for use in humans, or as a

treatment for a particular condition.

Investigation

al New Drug

(IND)

21 CFR 312.3 IND means a new drug or biological drug that is used in a

clinical investigation. The term also includes a biological

product that is used in vitro for diagnostic purposes.

IND

application

21 CFR 312.1 An investigational new drug for which an IND application is in

effect in accordance with this part is exempt from the

premarketing approval requirements that are otherwise

applicable and may be shipped lawfully for the purpose of

conducting clinical investigations of that drug.

IND

exemption

21 CFR 312.2 Certain drugs can be lawfully marketed or studied in the U.S.

without having to be approved by the FDA through an IND

application. Some examples include drugs that are not

intended to be reported to the FDA with a new indication for

use, the drug is already marketed in the US and the

investigation is not going to significantly change the

advertising of the drug, etc. Refer to the CFR for further

details.

Investigation

al Device

21 CFR 812.3

(g)

Investigational device means a device, including a transitional

device, which is the object of an investigation.

Investigation

al Device

Exemption

21 CFR 812.1 An approved investigational device exemption permits a

device that otherwise would be required to comply with a

performance standard or have premarket approval to be

shipped lawfully for the purpose of conducting investigations

of that device.

Experimental

Investigation

al (Category

A) Devices

42 CFR

405.201

The FDA assigns devices with an FDA-approved IDE to one

of two categories: A&B.

Category A includes innovative devices believed to be in Class

III for which “absolute risk” of the device type has not been

established (that is initial questions of safety and effectiveness

have not been resolved and the FDA is unsure whether the device

type can be safe and effective)

Non-

experimental

Investigation

al (Category

B) Devices

42 CFR

405.201

The FDA assigns devices with an FDA-approved IDE to one

of two categories: A&B.

Category B includes devices believed to be in Class I or Class

II, or a device believed to be in Class III for which the

incremental risk is the primary risk in question (that is,

underlying questions of safety and effectiveness of the device

type have been resolved), or it is known that the device type

can be safe and effective because, for example, other

manufacturers have obtained FDA approval for that device

type.

Class I 42 CFR Devices for which general controls of the Food, Drug, and

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Clinical Trials

Table 1 – Clinical Trial Terms

TERM SOURCE DEFINITION

405.201 Cosmetics Act, such as adherence to good manufacturing

practice regulations, are sufficient to provide a reasonable

assurance to safety and effectiveness.

Class II 42 CFR

405.201

Devices that, in addition to general controls, require special

controls, such as performance standards or postmarket

surveillance, to provide a reasonable assurance of safety and

effectiveness.

Class III 42 CFR

405.201

Devices that cannot be classified into Class I or Class II

because insufficient information exists to determine that either

special or general controls would provide reasonable assurance

of safety and effectiveness. Class III devices require

premarket approval.

(NOTE: Categories assigned to devices by the FDA prior to clinical trials are subject to

change during and after clinical trials. The Centers for Medicare and Medicaid Services

(CMS) uses the categorization of the device as a factor in making Medicare coverage

decisions.)

CLINICAL TRIAL COVERAGE

Routine Costs - Defined

This section provides definitions and examples of routine costs and investigational costs.

General case examples of routine costs in national clinical trials are presented. Two

specific case examples of clinical trials in which IHCP participation was requested are

also outlined to illustrate proposed IHCP coverage of routine costs.

The IHCP will pay most of a member’s costs in a clinical trial once the clinical trial is

considered an approved clinical trial. Specifically, the IHCP will cover the routine costs

involved in the clinical trial that are provided in either the experimental or the control

arms of a clinical trial. The routine items must not be items that are otherwise excluded

from coverage by the program. There are five types of covered routine costs associated

with a clinical trial.

1. Items and services that would otherwise be covered by the program if they were not

provided in the context of a clinical trial. For example:

• Nursing/staffing fees

• Patient monitoring and evaluation

• DME equipment

• IVs/catheters/line placement

2. Items or services required for the administration and provision of the investigational

item or service, up to but not including the actual cost of the investigational item or

service. For example:

• Administration fee for investigational chemotherapeutic agent

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Equipment and ancillary staffing for the implantation of investigational device

• Provision of a nebulizer to administer an investigational drug

• Room and board as part of a hospital stay required as part of the clinical trial

3. Items or services required for the clinically appropriate monitoring of the effects of

the investigational item or service. For example:

• ECGs, EEGs,

• Monitoring blood pressures

4. Items and services required for the prevention of complications. For example:

• Costs of anti-nausea drug for investigational chemotherapeutic agent

5. Items or services needed for reasonable and necessary care arising from the provision

of an investigational item or service – in particular, for the diagnosis or treatment of

complications. For example:

• Treatment of pneumonia caused by an investigational lung procedure

The IHCP also adopted a Medicare policy on coverage of routine costs for items and

services that are the subject of a clinical trial, but are already covered items or services

under policy. The IHCP will extend coverage to routine care provided in clinical trials,

but not withdraw IHCP coverage for items and services that are currently covered outside

the context of a clinical trial as a result of, national coverage policies, statutes, rules, etc.

The policy also does not expand coverage beyond what would ordinarily be covered

outside a clinical trial. Therefore, if a clinical trial is investigating an item or service that

is covered outside the context of a clinical trial, the IHCP would continue to cover the

investigational item or service in accordance with existing coverage rules and regulations.

The IHCP policy on clinical trials will not render these investigational items or services

noncovered.

Investigational Costs

Items that are not considered routine costs and are not covered by the IHCP include the

following.

1. The investigational item(s) or service(s).

2. Items and services provided solely to satisfy data collection and analysis needs that

are not used in the direct clinical management of the patient. For example:

• Monthly CT scans for a condition usually requiring only a single scan.

• Weekly blood draws not needed to monitor side effects.

• Quarterly PAP smears for a condition requiring yearly PAP smears.

3. Items and services customarily provided by the research sponsors free of charge for

any enrollee in the trial. For example:

• Peak flow meters will not be reimbursed in a respiratory trial if the sponsor

provides them free of charge to the enrollees.

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Clinical Trials Case Examples

On the following pages are several case examples of clinical trials. Cases 1 and 2

illustrate clinical trial policy applied to current national clinical trials. Case 3 applies the

policy to an actual clinical trial that the IHCP reimbursed in 2003 for a member with

Crohn’s disease. Case 4 illustrates application of the policy to a request for clinical trial

coverage received from Northwestern Hospital on behalf of a member with Wegener’s

Granulomatosis. This trial has not been reimbursed by the IHCP because the trial is not

funded and the member has not been able to raise the funds necessary to cover the

investigational costs.

Case 1

Title Diagnostic Study of CT Scans in Women at High Risk for Lung Cancer

Description

To determine the ability of CT to detect early lung abnormalities in women at

high risk for lung cancer, and determine the number of abnormal findings

detected by CT that develop into lung cancer in these patients.

Outline of the

Clinical Trial

1. Questionnaire including medical history and demographics.

2. CT scans without contrast for all patients.

a. Patients with normal results receive additional CT every 12 months.

b. Patients with abnormal results receive diagnostic CT scan with contrast.

3. Patients with indeterminate nodules have repeat scans at 6 months and 1

year.

4. Patients with abnormalities suspicious for malignancy undergo

bronchoscopy with biopsy and bronchoaveolar lavage (BAL).

a. If no confirmed malignancy, repeat CT scans at 6 months and 1 year.

b. If confirmed malignancy, refer for definitive treatment.

Coverage

1. Non-routine, non-covered items include the questionnaire, the initial CT

scans, and any additional CT scans not necessary for the direct clinical

management of the patient. These are noncovered costs because they are

items and services provided to satisfy data collection and analysis.

2. If policy allows for a repeat CT scan of an indeterminate finding at 6

months, or a bronchoscopy with biopsy for a suspicious abnormality, these

procedures would be considered routine costs and would be reimbursable.

3. Complications such as reactions to anesthesia during bronchoscopy,

reactions to contrast dye, or development of infection after bronchoscopy

would be considered routine reimbursable costs.

Case 2

Title Combination Chemotherapy in Treating Patients With Advanced Cancer

Description

To determine the effects of the combination of Flavopiridol, Fluorouracil, and

Leucovorin Calcium with and without Irinotecan on the destruction of tumor

cells in patients who have advanced cancer with no known therapies.

Outline of the

Clinical Trial

1. Two patient groups reside in the hospital for 5 days every 3 weeks while

receiving chemotherapy.

2. One group receives the combination chemotherapy only.

3. The second group of patients receives the combination chemotherapy plus

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Irinotecan.

4. Tumors will be monitored by CT, MRI, or other appropriate clinical

determinants.

Coverage

1. Noncovered services would include the actual chemotherapeutic drugs

being administered because the trial protocol indicated there are no known

standard therapies for these tumors. The CTs, MRIs, etc. would also be

noncovered for the same reasons.

2. Routine care services that would otherwise be reimbursed by the IHCP if

not included in the context of a clinical trial encompasses nursing services,

room and board, and supplies that would be used to administer the

chemotherapy, (e.g., intravenous pumps and tubing).

3. Services required for the administration of investigational items or services

would also be covered such as administration of the chemotherapeutic

agents.

4. Other routine costs include prevention of complications such as treatment

of nausea and treatment of complications such as an electrolyte imbalance,

or an acute toxicity reaction.

Case 3

Title

Immune Ablation with Chemotherapy followed by Stem Cell Transplant for

Patients with Severe Crohn’s Disease

Description

To determine the safety and efficacy of immune ablation with high-dose

cyclophosphamide and anti-thymocyte globulin followed by autologous

peripheral blood stem cell rescue in patients with severe Crohn’s disease.

Outline of the

Clinical Trial

1. Mobilization of peripheral stem cells with cyclophosphamide IV on the first

day and filgrastim beginning on the third day until adequate blood counts

are reached.

2. Undergo leukapheresis for approximately 10 days until target number of

cells are reached.

3. A central line is placed, and an immune-ablation conditioning period is

initiated on a 5 day countdown with cyclophosphamide IV days 5-2 and

anti-thymocyte globulin IV on days 4-2.

4. Undergo autologous T lymphocyte-depleted peripheral stem cell transplant

after completing routine labs and tests on day 1.

5. Receive filgrastim on day 0.

6. Follow-up visits with serial small intestine absorption assessments at 3, 6,

and 12 months, then annually thereafter.

Coverage

1. Noncovered services include all chemotherapeutic agents because

chemotherapeutic agents are not peer-approved, nationally approved, or

FDA approved drugs for the treatment of Crohn’s disease. The

chemotherapeutic agents include cyclophosphamide, anti-thymocyte, and

filgrastim. The leukapheresis would be noncovered even though it is a

covered code by the IHCP because leukapheresis is not a procedure

normally performed on patients with Crohn’s disease, but it is a procedure

that is part of the investigational component of this trial. The stem cell

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Clinical Trials

Case 3

Immune Ablation with Chemotherapy followed by Stem Cell Transplant for

Title

Patients with Severe Crohn’s Disease

transplant is also noncovered as an investigational procedure because a

peripheral stem cell transplant for Crohn’s disease is outside the scope of

coverage for stem cell transplant. Serial small intestine absorption

assessments would not be covered because these are services to satisfy data

collection.

2. Routine costs include placement of the central line, administration fees for

all drugs, including the investigational chemotherapeutic agents, and

Methylprednisone, room and board for any necessary hospital stay during

the conditioning phase and the transplant, and the costs of the labs and tests

(that have not been performed in the last 90 days) that are required for the

transplant.

3. Methylprednisone is covered because this is an approved treatment for

Crohn’s disease. The costs of services to prevent side effects, such as the

cost of the MESNA would be covered because MESNA is a drug used to

prevent side effects of Cytoxan.

4. The costs of the labs and tests prior to the transplant are covered if they

have not already been performed within the last 90 days because IHCP

policy states that the policy is to extend coverage to routine care provided in

clinical trials, but not to withdraw coverage for items and services that are

currently covered outside the context of a clinical trial. The IHCP current

policy for stem cell transplant requires that these tests must have been done

within the last 90 days.

5. Routine costs will also include any physician or nursing fees, monitoring

fees, or equipment fees that may arise during the clinical trial that would

normally be considered a covered service if not performed in the context of

a clinical trial. If any additional medications are needed to prevent side

effects or if complications occurred, these would also be covered services.

Case 4

Title

Hematopoietic Stem Cell Therapy for Patients with Systemic Necrotizing

Vasculitis (Wegener’s Granulomatosis)

Description

To determine the safety and efficacy of immune ablation with high-dose

cyclophosophamide and anti-thymocyte globulin followed by autologous

peripheral blood stem cell rescue in patients with Wegener’s Granulomatosis.

Outline of

the Clinical

Trial

1. Mobilization of peripheral stem cells with Cytoxan 2gm/m

(cyclophosphamide) and filgrastim 10 mcg/kg until adequate blood counts

are reached.

2. Undergo leukapheresis for approximately 4 days until target number of cells

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Clinical Trials

Case 4

Hematopoietic Stem Cell Therapy for Patients with Systemic Necrotizing

Title

Vasculitis (Wegener’s Granulomatosis)

are reached.

3. Rest for approximately 3-4 weeks.

4. A central line is placed, and an ablation conditioning period is completed

with combinations of high-dose Cytoxan 50mg/kg, Rabbit ATG 0.5mg/kg,

Methylprednisone 1gm, and MESNA 50mg/kg per day for 6 days.

5. Undergo stem cell transplant after checking routine labs and tests.

6. Receive filgrastim 5mcg/kg the day after transplant.

7. Inpatient transplant recovery as needed.

Coverage

1. The trial is sponsored by Northwestern Hospital which would not make it an

automatically qualified clinical trial; however, the trial has an approved

investigational new drug application by the FDA which does qualify it as an

approved clinical trial. Therefore, routine costs would be covered.

2. Noncovered services include all chemotherapeutic agents except the Cytoxan

used in the mobilization phase of therapy. The Cytoxan used in the

mobilization phase of therapy is dosed at 2gm/m

. Cytoxan is a prescribed

treatment for Wegener’s Granulomatosis at this dose. The remainder of the

chemotherapeutic agents are not peer-approved, nationally approved, or

FDA approved drugs for the treatment of Wegener’s. The chemotherapeutic

agents include Cytoxan 50mg/kg, filgrastim, and Rabbit ATG. The

leukapheresis would be noncovered even though it is a covered code by the

IHCP because leukapheresis is not a procedure normally performed on

patients with Wegener’s Granulomatosis, but it is a procedure that is part of

the investigational component of this trial. The stem cell transplant is also

noncovered as an investigational procedure because a transplant for

Wegener’s is outside the scope of coverage for stem cell transplant.

3. Routine costs include placement of the central line, administration fees for

all drugs, including the investigational chemotherapeutic agents, coverage of

the MESNA and Methylprednisone, room and board for any necessary

hospital stay during the conditioning phase and the transplant, and the costs

of the labs and tests (that have not been performed in the last 90 days) that are

required for the transplant.

4. The cost of the MESNA is covered because MESNA is a drug used to

prevent side effects of Cytoxan. Methylprednisone is covered because this is

an approved treatment for Wegener’s.

5. The costs of the labs and tests prior to the transplant are covered if they have

not already been performed within the last 90 days because IHCP policy

states that the policy is to extend coverage to routine care provided in clinical

trials, but not to withdraw coverage for items and services that are currently

covered outside the context of a clinical trial. The IHCP current policy for

stem cell transplant requires that these tests must have been done within the

last 90 days.

6. Routine costs will also include any physician or nursing fees, monitoring

fees, or equipment fees that may arise during the clinical trial that would

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Clinical Trials

Case 4

Hematopoietic Stem Cell Therapy for Patients with Systemic Necrotizing

Title

Vasculitis (Wegener’s Granulomatosis)

normally be considered a covered service if not performed in the context of a

clinical trial. If any additional medications are needed to prevent side effects

or if complications occurred, these would also be covered services.

IHCP CLINICAL TRIALS POLICY

The IHCP covers the routine costs of approved clinical trials as well as reasonable and

necessary items and services used to prevent complications and to diagnose and treat

complications arising from participation in all clinical trials.

Routine costs of a clinical trial include all items and services that are available to IHCP

members (i.e., there exists a benefit category and the item or service is not listed as a

noncovered service in the Indiana Administrative Code) that are provided in either the

experimental or the control arms of the trial.

Routine costs in clinical trials include the following.

• Items and services that would otherwise be covered by the program if they were

not provided in the context of a clinical trial.

• Items or services required for the administration and provision of the

investigational item or service, up to but not including the actual cost of the

investigational item or service (e.g., administration for a noncovered

chemotherapeutic agent).

• Items required for the clinically appropriate monitoring of the effects of the

investigational item or service.

• Items and services required for the prevention of complications.

• Items or services needed for reasonable and necessary care arising from the

provision of an investigational item or service; in particular, for the diagnosis or

treatment of complications.

• Items or services already covered by the IHCP will be considered a routine cost in

accordance with existing coverage rules and regulations even if the item or

service is the investigational item or service. The IHCP policy on clinical trials

will not render these investigational items or services noncovered. However, if

the investigational item or service is currently covered only for certain medical

conditions and is being tested for use outside the scope of coverage, the item or

service will still be considered investigational.

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Items that are not considered routine costs in a clinical trial and are not covered by the

IHCP include the following.

• The investigational item(s) or service(s).

• Items and services provided solely to satisfy data collection and analysis needs

that are not used in the direct clinical management of the patient (e.g., monthly

CT scans for a condition usually requiring only a single CT scan).

• Items and services customarily provided by the research sponsors free of charge

for any enrollee in the trial.

All investigators requesting IHCP coverage of routine costs for a clinical trial must first

meet the following three requirements.

1. The subject or purpose of the trial must be the evaluation of an item or service that

would be covered under Indiana Administrative Code (IAC) guidelines. The items or

service being investigated must not be a non-covered item or service as listed under

405 IAC 5-10-5, 5-19-18, 5-24-3, 5-29-1, or 5-30-3.

2. If a clinical trial has one objective, it must have a therapeutic intent. If a clinical trial

has multiple objectives, it must have a therapeutic intent as a primary objective. It

must have some ability to improve a subject’s condition such as prolongation of life,

shrinkage of a tumor, or improved quality of life even though cure or dramatic

improvement may not necessarily be affected. The trial cannot be designed

exclusively to test toxicity or disease pathology.

3. Trials of therapeutic intervention only must enroll members with diagnosed disease

rather than healthy members. Trials including diagnostic interventions may enroll

healthy members in order to have a proper control group.

The three requirements above are insufficient by themselves to qualify a clinical trial for

IHCP coverage of routine costs. In order for the IHCP to cover the routine costs involved

in clinical trials, the clinical trial must be deemed “automatically qualified” under

Medicare guidelines. The following clinical trials are deemed to be automatically

qualified as approved clinical trials.

• Trials funded by the NIH, CDC, AHRQ, CMS, DOD, or VA.

• Trials supported by centers or cooperative groups that are funded by the NIH,

CDC, AHRQ, CMS, DOD, or VA including but not limited to the FDA, NHLBI,

National Human Genome Research Institute, NCI, NIDDK, NIMH, and others.

01/31/2007 Clinical Trials

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Clinical Trials

Medical Policy Manual

• Trials conducted under an Investigational New Drug (IND) application reviewed

by the FDA.

• Drug trials that are exempt from having an IND under 21 CFR 312.2 (b)(1) will

be deemed automatically qualified.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: COLLAGEN IMPLANTS FOR STRESS URINARY

INCONTINENCE

DESCRIPTION

Stress urinary incontinence (SUI) can be caused by incompetence of the urethral

sphincter mechanism at the bladder neck. This type of SUI may be caused by scarring

from previous surgery (e.g. prostatectomy), urethral hypermobility, myelomeningocele,

epispadias, trauma, radiation, or sacral cord lesions or by any process that limits the

ability of the proximal sphincter to form an effective watertight seal.

Collagen implants, such as Contigen are used to control urinary incontinence due to SUI

caused by intrinsic sphincter deficiency. The collagen implant is injected endoscopically

into the submucosal tissue of the urethra and/or bladder neck, increasing tissue and

urethral resistance. Collagen injections thicken the urethra sphincter mechanism at the bladder

neck, allowing the proximal urethra to form a watertight seal during bladder filling and to

maintain this seal during physical stress.

Collagen is a natural fibrous protein found in human bone, cartilage, and connective

tissue. The collagen used for treatment of SUI is sterile, biocompatible, biodegradable,

purified bovine dermal collagen. Allergic reactions to collagen are infrequent but can

occur, so patients must be evaluated preoperatively to limit the possibility of adverse

reactions to collagen. Urologists who perform this treatment must complete training

programs specifically related to this treatment.

RELATED MEDICAL TOPICS

Anesthesia Services

Consultations – Second Opinion

Diagnostic Studies

Surgery – Global Billing/Payment Guidelines

Surgery – Services Requiring Prior Authorization

Surgery – Surgical Services

01/31/2007 Collagen Implants for Stress Urinary Incontinence

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RULES, CITATIONS, AND SOURCES

Indiana Medicaid Update Bulletin 95-21

Indiana Health Coverage Programs Provider Manual

ORIGINATION, REVIEWS, AND REVISIONS

Origination date: 7/11/94

Review and Revisions Reason Date

Review and Revision Routine 10/29/04

APPLICABLE INDIANAAIM EDITS AND AUDITS

6061

6706

COVERAGE CRITERIA

Indications for the implants are as follows.

♦ Indicated for the treatment of urinary incontinence due to Intrinsic Sphincter

Deficiency (ISD) – Diagnosis: Code 599.82

♦ Should be considered after a patient with ISD has demonstrated consistent symptoms

and signs of urinary incontinence for at least twelve months.

♦ Since the collagen is potentially immunogenic, the patient must be evaluated by a

skin test prior to treatment.

♦ Providers should be skilled in the endoscopic procedures necessary to carry out the

injection and have credentials to perform these procedures in the respective

institution. Additionally, FDA requirements mandate that the performing physician

must have completed a Contigen Implant Training Program.

♦ Repeat injections of the collagen should be performed no less than seven days after

the initial treatment. Patients who have failed to demonstrate improvement after five

injection sessions are considered treatment failures; further attempts to use collagen

should not be undertaken.

Restrictions and limitations to the use of collagen implants are as follows.

♦ Limit 12 injections per member for same date of service

01/31/2007 Collagen Implants for Stress Urinary Incontinence

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Collagen Implants for Stress Urinary Incontinence

Medical Policy Manual

100

♦ Five units (sessions) per member per lifetime

♦ Diagnosis code 599.82 Intrinsic Sphincter Deficiency (ISD) must be included on the

claim

♦ Prior authorization is not required

♦ Contraindications for collagen therapy include:

a. Untreated urinary tract infections

b. Unmanaged detrusor muscle instability

c. Known hypersensitivity to bovine collagen

♦ Place of service: Inpatient/Outpatient/Physician Office

BILLING INFORMATION

Medicaid reimbursement is available for collagen implants used to control urinary

incontinence due to intrinsic sphincter deficiency, demonstrated by consistent symptoms

and signs of urinary incontinence for at least twelve months. Appropriate HCPCS codes

for billing are listed in Table 1 – HCPCS CODES. Prior authorization is not required.

Diagnosis code 599.82, Intrinsic Sphincter Deficiency, must be included with the HCPCS

code in the request for reimbursement.

Table 1 – HCPCS CODES

HCPCS CODE DEFINITION

LIMITATIONS/

RESTRICTIONS

L8603

Collagen implant, urinary tract, per

2.5cc syringe, includes shipping and

necessary supplies

Limit 12 injections per

recipient for each date of

service

51715

Endoscopic injection of implant

material into the submucosal tissues of

the urethra and/or bladder neck

Five units (sessions) per

lifetime.

Q3031

Collagen skin test To be administered and

evaluated over a four week

period.

95028

Intracutaneous (intradermal) tests with

allergenic extracts, delayed type

reaction, including reading, specify

number of tests

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: CONSULTATIONS—SECOND OPINIONS

DESCRIPTION

A consultation is the rendering of a medical opinion by a physician regarding evaluation

or management of a specific condition requested by another physician. It requires the

consulting physician to examine the patient, unless the applicable standard of care does

not require a physical examination.

Second or third opinions (confirmatory consultation) may be requested for members

having a procedure for which a choice of treatment modalities may be applicable, such as

surgical procedures.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs (IHCP) policies regarding this service. More specific information may be

found in the IHCP provider manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

The following four subcategories of consultations are covered by the IHCP.

 Office or other outpatient consultation

 Confirmatory consultation

 Initial inpatient consultation

 Follow-up inpatient consultation

Reimbursement for an initial consultation is limited to one per consultant, per member,

per inpatient hospital or nursing facility admission. The IHCP will not reimburse

consultation codes when a member is referred for management of a condition or the

consulting physician assumes management of the member’s care.

The medical record must contain written documentation of the request for consultation by

the requesting physician, if a consultation code is billed. This documentation should be

maintained in the member’s medical record by both the physician requesting a

consultation and the physician providing the consultation.

01/31/2007 Consultations – Second Opinions

Medical Policy Manual

101

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Reimbursement is available for consultative pathology and radiology services. These

consultations do not require the consulting physician to examine the member.

Office Consultation (CPT codes 99241 – 99245)

A consulting physician may initiate diagnostic or therapeutic services. An office or other

outpatient consultation must address a specific condition not previously diagnosed or

managed by the consulting physician. If an additional request for an opinion or advice

regarding the same or a new problem is received from the attending physician and

documented in the medical record, the office consultation codes may be used by the

consulting physician again. If the consulting physician initiates a follow-up visit, the

follow-up visit is reported using the appropriate office or other outpatient code for

established patients (CPT codes 99211-99215).

Confirmatory Consultation

A confirmatory consultation must be specifically requested by the member or the IHCP

contractor and is used for second and third opinions or advice only. A confirmatory

consultation to substantiate medical necessity may be required as part of the prior

authorization (PA) process.

Initial Inpatient Consultation (CPT codes 99251 – 99255)

Only one initial consultation may be reported by a consultant per admission. The request

for consultation must be documented. These codes are used to report consultations

provided to hospital inpatients, residents of nursing facilities, or patients in a partial

hospital setting. These codes should be utilized by the consulting physician for the initial

encounter with the patient and then subsequent hospital care codes for additional

encounters thereafter.

Follow-up Inpatient Consultation

A follow-up consultation is a subsequent visit needed to complete the initial consultation

or subsequent consultative visits requested by the attending physician. These

consultative visits include monitoring progress, recommending management

modifications, or advising on a new plan of care in response to changes in the patient’s

status. If the consulting physician has initiated treatment at the initial consultation, and

participates thereafter in the patient’s management, the codes for subsequent hospital care

should be used (CPT codes 99231 – 99233).

Pathology Services

Consultative pathology services are reimbursable if they are requested by the member’s

attending physician in writing and meet the following criteria.

• The consult relates to a test result that lies outside the clinically significant normal

or expected range in view of the condition of the member

• The consultant provides a written narrative report to be included in the member’s

medical record

• Medical judgment is required by the consulting physician.

01/31/2007 Consultations – Second Opinions

Medical Policy Manual

102

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Dental Services

The American Dental Association (ADA) has indicated that a consultation is to be used

as a second opinion. When billing for a dental consultation, providers are to report CDT

code D9310, Consultation (diagnostic service provided by dentist or physician other than

practitioner providing treatment), or one of the oral evaluation codes, not both on the

same date of service, for the same member, by the consulting dentist. Please refer to the

MP Manual fact sheet on Dental Services for further information.

Podiatry Services

A second or third opinion substantiating the medical necessity or approach may be

required for bunionectomy procedures and all surgical procedures involving the foot. A

confirmatory consultation is required regardless of the setting in which the surgery is

performed, including ambulatory surgical centers, hospitals, clinics, or in the office.

Please refer to the MP Manual fact sheet on Podiatry for further information.

Consultation services rendered by a podiatrist in a nursing facility are not covered when

performed on members on a routine basis for screening purposes, except in those cases

where a specific foot ailment is involved. Documentation must be maintained in the

member’s medical record. Please refer to the MP Manual fact sheet on Podiatry Services

for further information.

PRIOR AUTHORIZATION

The CPT codes for evaluation and management (E&M) services that are used to report

second opinion and consultative services and that also require prior authorization after 50

visits per member per provider per rolling calendar year are listed in Table 1 – Services

Requiring PA After 50 Visits per Member per Rolling Calendar Year. The Billing

Requirements section of this fact sheet provides information regarding appropriate use of

the codes listed in Table 1 for reporting second opinion and consultation services

provided to IHCP members.

Table 1 - Services Requiring PA

After 50 Visits per Member per Rolling Calendar Year*

CPT Code Ranges

for E&M Services

Description

99201-99205

Office or other outpatient visit for the evaluation and management

of a new patient

99211-99215

Office or other outpatient visit for the evaluation and management

of an established patient

99241-99245

Office or other outpatient consultation for a new or established

patient

99271-99275 Confirmatory consultation for a new or established patient

*This table contains the E&M codes used for second opinion and consultative services

and is not meant to be inclusive of all E&M codes.

01/31/2007 Consultations – Second Opinions

Medical Policy Manual

103

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

The Hoosier Healthwise PrimeStep member’s primary medical provider (PMP) must

make a referral for a second opinion if requested by the member. Hoosier Healthwise

members may choose a qualified Hoosier Healthwise provider from whom they desire to

seek a second opinion. The PMP certification code is required for the consultative

physician services to be reimbursed. Any subsequent treatment by the second opinion

provider, if necessary, requires a separate referral.

Hoosier Healthwise members enrolled in Risk-Based Managed Care (RBMC) are

allowed to receive a second medical opinion and consultative services. Hoosier

Healthwise members that are enrolled in RBMC are the financial responsibility of the

managed care organization (MCO) in which the member is enrolled. The MCO may

have its own requirements for authorization of second opinion and consultative services;

therefore, providers must contact the MCO for further information regarding the referral

process.

BILLING INFORMATION

Using the appropriate modifier, consultations and second opinions may be reimbursed

according to Medicaid guidelines. Documentation may be requested to determine

medical necessity for the claim to be paid. In the claim note information on the

electronic 837 claim, the provider can indicate the medical reason for a second opinion

during the 15 days before or after the billed consultation.

Consultation codes should not be used for the evaluation of a self-referred or non-

physician referred patient. A consultation implies collaboration between a requesting and

a consulting physician. Follow-up visits in the consultant’s office or other outpatient

facility initiated by the consulting physician are reported using office visit codes for

established patients, 99211-99215. If an additional request for an opinion or advice about

a new problem is received from the attending physician and documented in the medical

record, the office consultation codes may be used again.

A physician providing a confirmatory consultation (CPT codes 99271–99275) is expected

to provide an opinion and/or advice only. Any services provided subsequent to the

opinion are coded at the appropriate level of office visit, established patient, or

subsequent hospital care.

The IHCP provides reimbursement to providers billing CPT codes 99251-99255 for

initial inpatient consultations with new or established patients in the inpatient hospital

setting. The IHCP recognizes CPT codes 99261-99263 for follow-up inpatient

consultations.

01/31/2007 Consultations – Second Opinions

Medical Policy Manual

104

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RELATED MEDICAL TOPICS

Dental Services

Diagnostic Studies

Evaluation and Management Services

Physician Services

Podiatry Services

Surgery – Surgical Services

RULES, CITATIONS, AND SOURCES

405 IAC 5-8 - Consultations and Second Opinions

405-IAC 5-9-1 - Evaluation and Management Services, Limitations

405 IAC 5-18-4 - Nonanatomical laboratory procedures

405 IAC 5-26-2 (4) – Podiatric Services, General restrictions

405 IAC 5-26-10 – Surgical Procedures; Confirmatory Consultations

Hoosier Healthwise Manual for Primary Medical Providers and Office Staff, January,

2003

Indiana Health Coverage Programs Provider Manual

1999

Version 5.1, March 2005

Indiana Health Coverage Programs Provider Bulletins

BT200262 - PrimeStep PMP Certification Code Changes

BT200511 – HIPAA Modifications

Origination Date: 12/31/2000

Revisions and

Review

Reason Date

470 IAC 5-9-8;

5-9-9

Transferred

Consultations; Second Opinions 7/1/91

405 IAC 1-7-8;

1-7-9 Repealed

8/24/97

Consultation And Second Opinions 1/1/92

405 IAC 5-8 Consultations and Second Opinions 8/24/97

Review Scheduled 7/29/05

01/31/2007 Consultations – Second Opinions

Medical Policy Manual

105

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Consultations – Second Opinions

Medical Policy Manual

106

APPLICABLE INDIANAAIM EDITS AND AUDITS:

6006 – Only 1 New Patient Visit Per Three (3) Years

6011 – Therapeutic or Diagnostic Injections

6012 – Medical Services 30 per year

6014 – Global Payable at a Reduced Fee When Component Paid

6019 – Initial/Established Visits Not Payable Same Day of Service

6028 – Initial and Periodic Visits Not Payable Same Day of Service

6041 – E&M Codes Not Reimbursable With Prenatal Codes

6042 – Prenatal Codes Not Reimbursable with E&M Codes

6064 – Components Not Payable When Global Paid Medical System

6069 – Office Visits 50 per Year

6090 – Office Visits Limited to One per Year – Podiatrist

6091 – One Initial Office Visit per Recipient - Podiatrists

6096 – The CPT/HCPCS Code Billed is Not Payable According to the PPS

Reimbursement Methodology

6098 – Chiropractic Services Limited to Procedure and Diagnosis

6099 – Reimbursement is Limited to 50 Chiropractic Services

6101 – Chiropractic Restrictive Office Visit Codes (NP)

6102 – Chiropractic Office Visits Limited to 5 per year

6111 – Chiropractic Office Visits Limited to Five per Year

6122 – Chiropractic Therapeutic Physical Medicine Treatment

6150 – Consultation Billed 15 Days Before or After Another

6151 – Consultation Billed 7 Days Before or After Surgery

6152 – Surgery Payable at Reduced Amount When Consult Paid

6236 – Dental Services Limited $600 for 21 and Over

6238 – Dental Services Limited $600 for 21 and Over

6610 – Routine Vision Exam Limit to 1/12 Months Age 1-18 years

6611 – Routine Vision Exam Limited to 1/24 Months Ages 19-999 years

6637 – Drug Administration is Not Payable on the Same Day of Service

6649 – Surgery Payable at Reduced Amount When Related POS

6652 – Multiple Surgeries Must Be Billed on the Same Claim

6653 – Post Op Care Within 00-90 Days of Surgery

6654 – Pre-Operative Care Within 1 day of Surgery

6655 – Surgery Payable at Reduced Amount When Pre-op Care

6656 – Post-Op Care Within 10 Days of Select Surgery

6657 – Pre-Op Care on Day of Surgery

6658 – Surgery Payable at Reduced Amount When Pre-Op Care

6659 – Surgery Payable at Reduced Amount When Related POS

6660 – Pre/Post-Operative Care Billed with Unlisted Surgery

6903 – PCCM Limits Office Visits Greater Than 30 Visits

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: DENTAL SERVICES

DESCRIPTION:

Dental services include diagnostic, preventive, or corrective procedures provided by or under the

supervision of a dentist in the practice of his or her profession. These include treatment of the

teeth and associated structures of the oral cavity, disease, injury, or impairment that may affect

the oral or general health of the member. Other services include those offered by dental

specialists, such as endodontists, orthodontists and periodontists.

COVERAGE CRITERIA

Procedure Code Multiple Units

The Indiana Health Care Programs (IHCP) accepts multiple units per service line for applicable

dental procedure codes. The dental provider will be able to submit multiple units on one claim

service line. For example, D1110, Prophylaxis, adult, is not appropriate for submitting multiple

service units; however, D4341, Periodontal scaling and root planning, four or more contiguous

teeth or bounded teeth spaces, per quadrant, can be submitted with up to four units on one

service line with the number of quadrants treated on the date of service.

The multiple units must be rendered on the same date of service and a single service line cannot

span more than one date. All procedure code limitations remain in place and services that exceed

these limitations are reduced to the unit limitation allowed for the procedure code. This change is

effective for dates of service November 14, 2003, and after.

Dental Extractions

Effective for dates of service on or after January 1, 2004, the following billing requirements and

reimbursement policies apply to tooth extractions. Only one tooth number is allowed 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 59 on the American Dental Association (ADA) 2000 Dental Claim form.

The IHCP will pay 100 percent of the maximum allowed amount or the billed amount,

whichever is less, for the initial extraction. For multiple extractions within the same quadrant on

the same date of service, the IHCP will pay 90 percent of the maximum allowed amount for

procedure code D7140 or the billed amount, whichever is less.

01/31/2007 Dental Services

Medical Policy Manual

107

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Dental Cap

Effective March 1, 2003, The Office of Medicaid Policy and Planning (OMPP) established a $600

cap for members 21 years of age and older. The affected procedures are limited to a total of $600

of services per member, per calendar year. Dental services included in the dental cap are

considered non-covered when the cap is reached for that calendar year. For years 2004 and

beyond, the calendar year for the dental cap will begin on January 1 and end December 31. If

additional dental services are needed for a member beyond the $600 cap during a specific calendar

year, providers can hold members financially responsible. For a list of codes included in the $600

dental cap, please refer to Table 8.86 in Chapter 8, Section 4 of the IHCP Provider Manual.

The dental cap applies only to the IHCP paid dental services provided in a dental office. Dental

services for root planing and scaling, intravenous sedation provided in conjunction with oral

surgery, and osseous surgery are excluded from the dental cap.

In certain circumstances, providers can bill their usual and customary charge, provided that the cap

has been exhausted. However, if the service is partially paid by the IHCP because of the cap limit,

the member can only be billed for the difference between what the IHCP would have reimbursed to

the provider and what the IHCP actually paid.

Diagnostic and Preventative

IHCP members are eligible for diagnostic and preventive services; however, many of the

services offered to IHCP members are included in the $600 dental cap.

Currently, a member can receive one (1) periodic oral evaluation (D0120) every six (6) months.

Likewise, D0150, Comprehensive oral evaluation, and D0160, detailed and extensive oral

evaluation, are limited to two visits per member per year. Other diagnostic and preventive

services that members are eligible to receive include, D0140, limited oral evaluation-problem

focused and D0170, Re-evaluation-limited, problem focused (established; patient; not post

operative visit).

Prophylaxis is a covered IHCP service, but is limited to the following restrictions. The program

allows for one (1) application of prophylaxis every six months, for non-institutionalized

members twelve (12) months of age up to their twenty first birthday. One (1) unit of prophylaxis

is allowed, every 12 months, for non-institutionalized members that are twenty-one (21) years of

age and older. Institutionalized members may receive up to one unit of prophylaxis every six

months, regardless of age. Members 12 months of age and younger are not eligible for

prophylaxis service.

Prophylaxis and fluoride that is provided on same date of service, should be billed under one

code—D1201, topical application of fluoride. Likewise D1110, prophylaxis-adult, and D1204,

topical application of fluoride (prophylaxis not included), are no longer separately reimbursed.

D1204 is a non-covered procedure code. Providers should be billing this joint service using

either D1201 for children up to the age of 12 and D1205 for children 13 up to age 21, when

fluoride and prophylaxis are provided on the same day.

01/31/2007 Dental Services

Medical Policy Manual

108

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Either full mouth series radiographs or panorex x-rays are limited to one (1) set per member

every three (3) years. Bitewing, intraoral, and extraoral radiographs are limited to one (1) set per

recipient every twelve months. One (1) set of bitewings is defined as a total of four (4) single

films.

Restorative

IHCP reimburses for dentures and partials once every six years, but only with prior authorization

(PA) and if medically necessary. IHCP also reimburses for reline and repairs to dentures and

partials, provided PA is obtained and that the service is for members 21 years of age and older.

Repairs and relines are only approved to extend the useful life of a prosthesis that is at least six

(6) years old. Eight posterior teeth in occlusion, four maxillary and four mandibular teeth in

functional contact with each other, are considered adequate for functional purposes. If a member

is taking parenteral/enteral nutritional supplements, dentures and partials will not be approved

unless the dentist submits a plan of care with the PA request that indicates dentures or partials

are needed to wean the member from the nutritional supplements.

Local codes for complete and partial dentures were eliminated effective January 1, 2004.

Reimbursement rates for dentures are determined by the age of the member. Complete and

partial dentures do not require PA for members under twenty-one (21), while those 21 and older

do require PA. Repairs and relines require PA and are only approved to extend the life of the

prosthesis that is at least six years old.

Providers must submit D7999 to denote supernumerary tooth extractions. A claim attachment

(note of explanation) is required with the ADA Claim Form when billing D7999. The attachment

should indicate the type of extraction performed and whether it is an erupted or an impacted

tooth. An impacted tooth must be documented as to whether it is soft tissue, partially bony,

completely bony, with unusual complications, and so forth.

IHCP provider bulletin BT200433, published December 23, 2004, stated that procedure code

D7283, placement of a device to facilitate eruption of an impacted tooth, was a covered service

effective January 1, 2005. Further review indicates that this procedure is performed as an

orthodontic service. The IHCP covers comprehensive orthodontic services with PA, as outlined

in IHCP provider bulletin BT200230, published June 19, 2002. Procedure code D7283 includes

placement of an orthodontic bracket or band to facilitate eruption of an unerupted tooth after

surgical exposure. Placement of an orthodontic bracket is included in the reimbursement for

comprehensive orthodontic services; therefore, procedure code D7283 is not separately

reimbursed.

Resin crown codes D2336, D2337, D2335, and D2932 are covered by IHCP. IHCP will also pay

for resin fillings, amalgam fillings and steel crowns.

Dentures and the $600 Dental Cap

Dentures are subject to the annual $600 dental cap for members age 21 or older. Services subject

to the dental cap that are provided after the cap has been reached are not covered by the IHCP. If

the member has exceeded the annual $600 dental cap, the provider must inform the member of

01/31/2007 Dental Services

Medical Policy Manual

109

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

the non-covered services as described in the IHCP Provider Manual. If the member has been

informed of the amount of the non-covered charge(s) prior to the service being rendered, the

provider can charge the member the usual and customary fee for the service(s).

If the member exhausted the cap during the course of treatment, the member is responsible only

for the Medicaid allowed amount over the annual $600 dental cap. The following scenario

demonstrates the correct method for charging a member when the dental cap is exhausted during

treatment. The member receives dental services that exhaust $400 of the dental cap. During the

same year, the member requires a complete upper denture, a service that is also included in the

dental cap. The current IHCP maximum reimbursement for a complete upper denture (D5110) is

$391.25. Therefore, the member will exceed the $600 cap and the member will be responsible

for $191.25, if notified of the charges prior to the delivery of the dentures. The provider must

maintain documentation to substantiate member notification of the member’s portion of financial

responsibility prior to providing the service. The IHCP Provider Manual, Chapter 4, Section 5,

describes the policy for charging members for non-covered services.

Example:

$600 cap - $400 cap exhausted = $200 cap remaining

$391.25 maximum fee - $200 cap remaining = $191.25 billable to the member

The service of providing dentures to any patient is not complete until the completed denture has

been delivered to the patient. The date of the provision of the finished product is the date of

service that must be used for claims filing and must be supported by record documentation. The

provider must bill the IHCP according to when the services are rendered. The IHCP requires that

provider records be maintained in accordance with 405 IAC 1-5-1. Per 405 IAC 1-5-1(b)(4), the

medical record must contain the date when the service was rendered. In addition, according to

405 IAC 1-1-4, denial of claim payment can occur if the services claimed are not documented in

accordance with 405 IAC 1-5-1.

If the member is no longer eligible, the former member can be charged for the dentures. The

IHCP policy for charging members for non-covered services does not apply if the member is no

longer eligible; therefore, a non-covered services waiver is not required.

Providers are responsible for verifying member eligibility prior to rendering services. Providers

are urged to advise members that if their eligibility is terminated prior to the dentures being

completed, the cost of the dentures will be the member’s responsibility. If the provider has

verified that the member is no longer eligible, the provider can charge the member according to

the provider’s usual practices for other customers not enrolled in the IHCP.

Members Under Twenty One

Reimbursement is available for treatment of dental caries, extraction of teeth, and space

maintenance in children with deciduous molar teeth. General anesthesia, nitrous oxide analgesia,

and pre-anesthetic medication are also covered under IHCP reimbursement for general

anesthesia provided in the dentist’s office and available only for members under twenty-one (21)

years of age.

01/31/2007 Dental Services

Medical Policy Manual

110

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

IHCP offers reimbursement for monitored sedation ‘provided in the dentist’s office’ for

recipients under the age of twenty-one (21). Monitored sedation is the administration of either

subcutaneous, intramuscular, intravenous or oral sedation, in combination with monitoring of the

patient’s vital signs.

Prophylaxis is a covered IHCP service, but is limited to the following restrictions. The program

allows for one (1) application of prophylaxis every six months, for non-institutionalized

members twelve (12) months of age, up to their twenty first birthday. One (1) unit of prophylaxis

is allowed, every 12 months, for non-institutionalized members that are twenty-one (21) years of

age and older. Institutionalized members may receive up to one unit of prophylaxis every 12

months. Members 12 months of age and younger are not eligible for prophylaxis service.

Prophylaxis and fluoride that is provided on same date of service, should be billed under one

code—D1201, topical application of fluoride. Likewise, D1110, prophylaxis-adult and D1204,

topical application of fluoride (prophylaxis not included) are no longer separately reimbursed.

Providers should be billing this joint service using either D1201 for children up to the age of 12

and D1205 for children 13 up to age 21, when fluoride and prophylaxis are provided on the same

day.

Periodontics

D4341, scaling and root planing is limited to four quadrants per lifetime for members 21 years of

age and older who are not institutionalized. Institutionalized members are restricted to four (4)

quadrants every two years. Providers billing D4341 must attach documentation that demonstrates

that the member has periodontal disease by showing pocket markings, or evidence of attachment

loss, and that the procedure was necessary for the removal of cementum and dentin that is rough,

permeated by calculus, or contaminated with toxins or micro-organisms.

Periodontics surgery is a covered service for cases of drug-induced periodontal hyperplasia; prior

authorization is required. Admission of a member to a hospital for performing any elective

dental service, or any elective dental service performed on an inpatient basis, requires prior

authorization. IHCP providers shall be required, based upon the facts of the case, to obtain a

second or third opinion substantiating the medical necessity or approach for maxillofacial surgery

related to diseases and conditions of the jaws and contiguous structures.

Orthodontics and Oral Surgery

Orthodontic procedures for IHCP are covered only for members younger than 21 years old. The

OMPP requires PA, effective August 5, 2002 for all orthodontic services. Prior authorization

requests must be submitted on the IHCP Medical Prior Authorization Form not the IHCP Prior

Authorization Dental Request Form.

The patient must be diagnosed by a member of a recognized craniofacial anomalies team, such as

a member of the American Cleft Palate-Craniofacial Association. The patient must be treated by

a licensed practitioner, who minimally accepts routine craniofacial patients for orthodontic

services, such as those patients with the cleft lip and palate.

01/31/2007 Dental Services

Medical Policy Manual

111

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

A signed statement from the practitioner, who is a member of a hospital based craniofacial team,

must certify the correct craniofacial diagnosis and malocclusion. The diagnosis must include

information descriptive of facial and soft tissue, skeletal, dental/occlusal, functional, and

applicable medical or other conditions. Documentation for orthodontic services must be

maintained in the patient’s dental or medical record, as required by 405 IAC 1-5-1, Medical

records; contents and retention.

Procedure code D8680, Orthodontic retention-removal of appliances, construction and

placement of retainer(s) is non-covered and is included in the reimbursement for orthodontic

treatment. Procedure codes D8691, Repair of orthodontic appliance, and D8692, Replacement of

lost or broken retainer are also non-covered. These services are included in the reimbursement

for orthodontic treatments and will not be separately reimbursed.

General anesthesia is covered for adults only if the procedure is performed in a hospital (in-

patient or outpatient) or an ambulatory surgical center. Reimbursement for IV sedation and

nitrous oxide analgesia is available to all members, regardless of age.

Mobile Dental Services

Effective July 1, 2002, 828 IAC 4-1-1 requires providers of mobile dental services to be licensed

as a mobile dental facility. Providers of mobile dental services should contact the Health

Professions Bureau at (317) 234-2010 for an application and forward a copy of the mobile dental

license to EDS Provider Enrollment.

Dental Forms and Provider Billing Issues

Dental providers wishing to submit paper claims must do so only on the ADA 2000 approved

claim form. Effective January 1, 2004, dental providers will be using CDT-4 codes exclusively

for billing.

During the week of June 6, 2005, the IHCP identified a high number of claim denials for edit

1008, rendering provider must have an individual number. This error occurs when a provider

submits a billing group number in the detail line. According to IHCP provider bulletin

BT200511, published June 1, 2005, all group providers must use their rendering provider

numbers. To expedite claims, providers should follow these guidelines:

• Group provider using a paper claim – Enter the group number and location codes in

field 44A. Enter the individual rendering numbers in the Administrative column adjacent

to each detail submitted.

• Group provider using Web InterChange – Enter the group number and location code

in the provider number field. Enter the individual rendering number in the rendering

provider field.

• Individual billing provider using a paper claim – Enter the individual billing number

and location code in field 44A. Enter the individual billing number in the Administrative

column adjacent to each detail submitted.

01/31/2007 Dental Services

Medical Policy Manual

112

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Individual billing provider using Web InterChange – Enter the individual billing

number and location code in the provider number field. Enter the individual billing

number in the rendering provider field.

Dental Rendering Provider Information at the Service Line Level

For all dental claims, dental providers are required to submit rendering provider information at

the service line level when the billing provider is a group. Rendering providers are required to be

associated with the billing provider’s group. The requirement to record the individual dentist

performing the service is an added HIPAA requirement. The IHCP captures the rendering

provider information at the service line level.

The provider must include rendering provider number in the administrative column on the ADA

2000 Dental Claim form. Providers may also submit dental rendering provider information via

Web InterChange. Dental rendering provider information is contained in the 835 transaction.

Identification of Supernumerary Tooth Extractions

If using the claim note segment, the provider should identify the affected tooth by one of the

following:

• Adult – Designate the tooth ID by the appropriate tooth number followed by an A

• Child – Designate the tooth ID by the appropriate tooth letter followed by a 1

RBMC Carve Out Dental Guidelines

Dental services, which are performed by the following dental specialists and billed on the ADA

1999 Version 2000 Dental Claim Form (ADA 2000) or the 837 Health Care Claim: Dental (837D)

electronic transaction, are carved out or excluded from the responsibility of Hoosier Healthwise

Risk-based Managed Care (RBMC). The specialties include:

Endodontists

General Dentistry Practitioners

Oral Surgeons

Orthodontists

Pediatric Dentists

Periodontists

Mobile Dentists

Prosthodontists

Dental Clinic

All dental services billed using CDT-5 procedure codes must be submitted to EDS using either

the ADA 2000 claim form or the 837D transaction.

Dental providers that provide treatment for medical conditions may be billing the E/M codes,

and these services may include treatment of sleep apnea or Temporomandibular joint (TMJ)

syndrome. The scope of practice, defined in IC 25-14-1-23, allows for diagnosis or treatment of

the human oral cavity, teeth, gums, maxillary or mandibular structures.

01/31/2007 Dental Services

Medical Policy Manual

113

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

When dental services will be provided in an inpatient, outpatient hospital setting, or an ASC for

an RBMC member, the dental providers must first contact the member’s managed care

organization (MCO) before rendering services to determine whether prior authorization 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-92 claim form. Dental services provided

in an inpatient, outpatient, or ASC setting can be billed with CDT-5 codes on a dental claim

form. These services are carved out of RBMC, and must be billed to EDS using the ADA 2000

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.

Package E Dental Provider Notice

Dental providers may have received inappropriate reimbursement for non-emergency services

rendered to Package E members. With the assistance of the Dental Advisory Panel (DAP), the

IHCP created a table of the CDT-5 codes that are allowed for reimbursement of emergency

services provided to Package E members.

CDT-5 Codes Allowed for Package E Members

CDT-5

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

D0274 Bitewing– 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

01/31/2007 Dental Services

Medical Policy Manual

114

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

CDT-5 Codes Allowed for Package E Members

CDT-5

Description

Code

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)

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)

Radiographs must only be billed when the member presents with symptoms that warrant the

diagnostic service. In addition, providers are encouraged to refer to the IHCP Provider Manual

and IHCP provider newsletters NL200410 and NL200504 for related information.

NL200410 reminded dental providers of the importance of eligibility verification prior to

rendering services to IHCP members. It is important to verify eligibility prior to each visit, as

eligibility can change, be terminated, or include service limitations dependent on the program in

which the member is enrolled.

NL200504 reiterated the policy stated in the IHCP Provider Manual about field 53 of the ADA

Dental Claim Form. Field 53 is a required field and must be used to specify if the services

01/31/2007 Dental Services

Medical Policy Manual

115

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

performed were for emergency care. Providers must indicate “Yes” for all emergency care. All

services are subject to post-payment review and documentation must support medical necessity

for the services performed.

MCO Billing Codes

Refer to Table 6.4, Dental Related Anesthesia, Surgery, Radiology, and Laboratory CPT

Codes for a list of CPT codes that may be billed to a member’s managed care organization

(MCO). Dental providers should only bill the codes listed in Table 6.4 when a CDT-5 is not

appropriate.

Table 6.4

Dental Related Anesthesia, Surgery, Radiology, and Laboratory CPT Codes

Code Description

00100– 00352 Anesthesia (Head and Neck)

10021– 11646 Removal of Lesions or Skin Tags

12001– 16036 Wound Repair, Skin Grafts and Flaps, Burns

17000– 17999 Lesions

20150– 20694 TMJ Treatments, Biopsy

20900– 20926 Grafts

20999 Unlisted Procedure, Musculoskeletal System, General

21010– 21499 Musculoskeletal System Repairs

29800– 29804 Arthroscopy, TMJ

40490– 42999 Oral Surgery (above Esophagus)

64716 Neuroplasty and/or Transposition; Cranial Nerve

70100– 70380 Radiology

71010 Radiological Exam, Chest, Single View, Frontal

72020 Radiological Exam, Spine, Single View, Specify Level

72040 Radiological Exam, Spine, Cervical; Two or Three Views

72072 Radiological Exam, Spine, Thoracic, Three Views

72146 MRI, Spinal Canal and Contents, Thoracic

72285

Diskography, Cervical or Thoracic, Radiological Supervision

and Interpretation

76100

Radiological Exam, Single Plane Body Section, other than with

Urography

76536

Ultrasound, Soft Tissues of Head and Neck, B-Scan, and/or

Real Time with Image

80048– 89399 Pathology and Laboratory Codes

Note: If a member is enrolled in the PCCM delivery system, the PMP must authorize services

rendered in an inpatient, outpatient, or ASC setting for providers to receive reimbursement.

01/31/2007 Dental Services

Medical Policy Manual

116

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

The MCOs are responsible for determining which services require PA for its members. The

MCOs’ decisions to authorize, modify, or deny a given request is based on medical necessity,

reasonableness, and other criteria. A provider must make requests for reviews and appeals by

contacting the appropriate MCO.

RELATED MEDICAL TOPICS

Anesthesia Services

EPSDT - HealthWatch

Locum Tenens

Radiology

Surgery– Surgery and Anesthesia by the Same Provider

Surgery Surgical Services

RULES, CITATIONS, AND SOURCES

42 CFR 440.100 Dental Services

42 CFR 440.50 Physicians' services and medical and surgical services of a dentist

42 CFR 440.120 Prescribed drugs, dentures, prosthetic devices, and eyeglasses

405 IAC 5-14 Dental Services

405 IAC 5-1-5 Global fee billing; codes

405 IAC 5-2-2 Definitions

405 IAC 5-13-4 Intermediate Care Facilities for the Mentally Retarded

IHCP Provider Bulletin BT200511

IHCP Provider Bulletin BT200433

IHCP Provider Bulletin BT200326

IHCP Provider Bulletin BT200324

IHCP Provider Bulletin BT200321

IHCP Provider Bulletin BT200318

IHCP Provider Bulletin BT200313

IHCP Provider Bulletin BT200311

IHCP Provider Bulletin BT200302

IHCP Provider Bulletin BT200250

IHCP Provider Bulletin BT200230

IHCP Provider Bulletin BT200227

IHCP Provider Bulletin BT200141

IHCP Provider Bulletin BT200142

IHCP Provider Bulletin BT200003

Indiana Medicaid Update Bulletin 98-32

Indiana Medicaid Update Bulletin 98-23

Indiana Medicaid Update Bulletin 98-07

Indiana Medicaid Update Bulletin 98-03

Indiana Medicaid Update Bulletin 95-21

01/31/2007 Dental Services

Medical Policy Manual

117

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

IHCP Provider Banner BR200532

IHCP Provider Banner BR200526

IHCP Provider Banner BR200318

IHCP Provider Banner BR200310

IHCP Provider Banner BR200309

IHCP Provider Banner BR200308

IHCP Provider Banner BR200305

IHCP Provider Banner BR200245

IHCP Provider Banner BR200243

IHCP Provider Banner BR200241

IHCP Provider Banner BR200224

IHCP Provider Banner BR200219

IHCP Provider Banner BR200213

IHCP Provider Banner BR200208

IHCP Provider Banner BR200207

IHCP Provider Banner BR200206

IHCP Provider Banner BR200149

IHCP Provider Banner BR200104

IHCP Provider Banner BR200049

IHCP Provider Banner BR200045

IHCP Provider Banner BR200038

IHCP Provider Banner BR200226

IHCP Provider Banner BR199945

IHCP Provider Banner BR199905

IHCP Provider Banner BR199903

Indiana Medicaid Banner Page 1/19/99

Indiana Medicaid Banner Page 1/12/99

Indiana Medicaid Banner Page 1/5/99

Indiana Medicaid Banner Page 8/11/98

Indiana Medicaid Banner Page 8/4/98

Indiana Medicaid Banner Page 7/28/98

Indiana Health Coverage Programs Provider Manual 2003

HealthWatch Manual

01/31/2007 Dental Services

Medical Policy Manual

118

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1 Sources For Policy Issues and Updates

Revisions and

Review

Reason Date

Indiana State

Department of Public

Welfare Medical

Policy Manual 1991

Dental; second opinion procedures, dental;

out-of-state medical services; intermediate

care facilities for the mentally retarded;

7/1/91

470 IAC 5-8-8

Transferred

Dental services

7/1/91

405 IAC 1-6-8

Repealed 8/24/97

Coverage of dental services

1/1/92

Indiana Medicaid

Update Bulletin 95-21

(DATED 5/2/95)

IndianaAIM Medicaid Medical Policy

Update- Dental Services Requiring

Anesthesia on an Outpatient Hospital or

Ambulatory Surgical Center (ASC)

2/20/95

Indiana Medicaid

Update Bulletin 94-42

(dated 9/6/94)

Dental Services

10/5/94

405 IAC 5-13-4 Intermediate care facilities for the

mentally retarded

8/24/97

405 IAC 5-14 Dental services policy

8/24/97

405 IAC 5-1-5 Global fee billing; codes

8/24/97

405 IAC 5-2-2 Definitions—ADA

8/24/97

42 CFR 440.100 Dental services

10/1/97

42 CFR 440.50 Physicians' services and medical and

surgical services of a dentist.

10/1/97

42 CFR 440.120 Prescribed drugs, dent-rues, prosthetic

devices, and eyeglasses.

10/1/97

828 IAC 4-1-1 Licensing of Mobile Dental Units

7/1/02

405 IAC 5-14-2

405 IAC 5-14-4

405 IAC 5-14-6

405 IAC 5-14-11

405 IAC 5-14-15

405 IAC 5-14-16

405 IAC 5-14-17

405 IAC 5-14-18

Covered Services

Topical Fluoride

Prophylaxis

Analgesia

Anesthesia

Periodontics; surgical

Oral surgery

Hospital Admission

2/10;03

2/10/03

405 IAC 5-14-1 $600 Dental Cap

3/1/03

Indiana Medicaid

Update Bulletin 94-42

Dental services

10/5/94

01/31/2007 Dental Services

Medical Policy Manual

119

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Revisions and

Reason Date

Review

Indiana Medicaid

Update Bulletin 95-21

IndianaAIM Medicaid medical policy

update—dental services requiring

anesthesia in an outpatient hospital or

ambulatory surgical center (ASC)

2/20/95

Indiana Medicaid

Update Bulletin 98-03

Dental Services

9/1/97

Indiana Medicaid

Update Bulletin 98-07

Dental services and managed care organ-

izations

8/1/98

Indiana Medicaid

Update Bulletin 98-23

Dental changes: Rate Increase

PA Lifted RBMC Changes

5/1/98

9/1/97

8/1/98

Indiana Medicaid

Update Bulletin 98-32

Update on dental procedure codes

6/5/98

IHCP BT199933 Smoking Cessation TX

10/27/99

IHCP BT200003 Coverage of dentures and partials

1/14/00

IHCP BT200141 Dental claim instructions

11/01/01

IHCP BT200142 D7999, D9999

12/17/01

IHCP BT200201 Locum Tenens Policy

1/18/02

01/31/2007 Dental Services

Medical Policy Manual

120

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Revisions:

Revisions and

Review

Reason Date

IHCP BT200227 Dental code changes

7/29/02

IHCP BT200230 Criteria for orthodontic services

8/05/02

IHCP BT200250 End dating and limitations of dental codes 11/01/02

10/15/02

IHCP BT200301 Implementation of the $600 dental cap

1/15/03

IHCP BT200302 Implementation of the $600 dental cap

1/15/03

IHCP BT200310 $600 dental limit for members 21 and

older

3/1/03

IHCP BT200311 Delayed implementation of the $600

dental cap

3/1/03

IHCP BT200313 New 2003 HCPCS Coding Systems.

4/1/01

IHCP BT200318 Change in method of filing RHC and

FQHC claims.

3/07/03

IHCP BT200321 Correct Codes for Billing of IHCP Dental

Services

4/1/01

IHCP BT200324 Changes to the $600 Dental Cap

06/01/03

ICHP BT200326 Change in Dental Coverage

5/31/03

APPLICABLE INDIANAAIM EDITS AND AUDITS

0261, Tooth number missing

0262, Tooth number invalid

0263, One or more of the tooth surface codes billed is invalid

0266, Insufficient number of valid tooth surface codes

3011, Out-of-state provider requires prior authorization- rendering provider

4211, Tooth number/procedure code combination invalid

5010, Exact duplicate- tooth surface

5011, Possible duplicate- tooth surface

6000, Manual pricing required

6032, Extraction/surgical procedures payable at reduced amount when suturing paid

6033, Prophylaxis limited to two treatments every six months- institutionalized

6036, Oral surgery payable at reduced rate when apicoectomy previously paid

6199, Fluoride limited to one treatment every six months

6200, Panoramic/full mouth versus bitewings/periapical

6201, More than one reline/rebase/repair of dentures within three years

6202, Palliative versus other emergency services

6203, Relines and rebases vs. initial denture lower placement

6204, Pulpotomy versus root canal therapy

01/31/2007 Dental Services

Medical Policy Manual

121

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Dental Services

Medical Policy Manual

122

6205, Apicoectomy versus oral surgery

6208, Occlusal films limited to two units

6209, Full mouth or panoramic x-rays limited to once every three years

6210, Prophylaxis limited to one treatment every six months for non-institutionalized age 18

months to 21 years.

6211, Periodic/limited oral evaluation limit one every six months

6212, Fluoride treatments limited to one every six months for members ages 18 months

through 18 years of age

6213, Prosthodonic adjustment

6214, Root canal payable at reduced amount when pulpotomy paid

6216, Lower denture relines limited to one per 36 months

6217, Gingival curettage payable at a reduced amount

6218, One pulp cap per tooth per lifetime

6219, Periodontal scaling and planing- two quadrants per day

6220, Replacement greater than three teeth- denture partial or complete

6221, Periodontal root planing and scaling limited to four treatments every two years

non-instituionalized

6222, Periodontal root planing and scaling limited to four treatments every two years

member regardless of age

6223, Periodontal root planing & scaling non-institutionalized member 21 years or older

limited to 4 treatments per lifetime

6224, One tooth extraction per tooth per lifetime

6225, One sealant per tooth per lifetime/21 years or younger

6226, Comprehensive/extensive oral examination limited to one per lifetime

6227, Emergency services versus palliative treatment

6228, Denture reline versus denture repair

6229, Relines and rebases versus initial denture upper replacement

6232, Prophylaxis- adult will be limited to one treatment every six months for

institutionalized members 13 years old and older

6234, Suturing versus extractions and surgical procedures

6235, Prophylaxis non-institutional 21 years or older limited to 1 (one) per 12 months

6236, Dental services limited to $600 for members 21 years old or older

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: DERMATOLOGY

DESCRIPTION

As defined in Dorland’s Medical Dictionary, Edition 28, 1994, dermatology is the

medical specialty concerned with the diagnosis and treatment of diseases of the skin.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding this service. More specific information may be

found in the IHCP Provider Manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

The IHCP will provide for reimbursement for dermatology services billed with an

appropriate procedure code when medically necessary. Generally, prior authorization

(PA) is not required; however, specific procedure codes may require PA. Documentation

in the medical record must support medical necessity. According to Indiana

Administrative Code (IAC) citation 405 IAC 5-29-1, the following are noncovered

services :

• Dermabrasion surgery for acne pitting or marsupialization

• Scar removals or tattoos removals by excision or abrasion

• Removal of keloids from pierced ears when they are less than 3 centimeters or they

obstruct fifty percent of the ear canal

PRIOR AUTHORIZATION

Generally, prior authorization is not required.

01/31/2007 Dermatology

Medical Policy Manual

123

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for more specific guidelines. Refer to the

Provider Manual, Chapter 1, for detailed information about the fee-for-service (FFS),

Primary Care Case Management (PCCM), and Risk Based Managed Care (RBMC)

delivery systems.

IHCP members enrolled in Medicaid Select PCCM receive the same benefit coverage,

and are subject to the same limitations as traditional Medicaid FFS. Refer to the

Medicaid Select Manual for Primary Medical Providers and Office Staff for further

information.

BILLING REQUIREMENTS

Providers must bill for dermatology services using the established billing guidelines.

RELATED MEDICAL TOPICS

Consultations - Second Opinion

Evaluation and Management Services

Physician Services

RULES, CITATIONS, AND SOURCES

405 IAC 5-29-1 Noncovered services

Indiana Health Coverage Programs Provider Manual

Version 5.1, March 2005

Origination Date: 12/31/2000

Revisions and

Review

Reason Date

470 IAC 5-9-1

Transferred

Global Billing Fee 07/01/1991

405 IAC 1-7-1

Repealed 8/24/97

Global Fee Billing 01/01/1992

405 IAC 1-6-1;

1-6-9; 1-6-15; 1-

7-15; Repealed

8/24/97

Noncovered Services 01/01/1992

405 IAC 5-1-5 Global Billing Fee 08/24/1997

405 IAC 5-29-1 Noncovered Services 08/24/1997

01/31/2007 Dermatology

Medical Policy Manual

124

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Dermatology

Medical Policy Manual

125

Revisions and

Review

Reason Date

405 IAC 5-29-1

Amended

Noncovered Services 10/27/1999

Review Scheduled 10/31/2006

APPLICABLE INDIANAAIM EDITS AND AUDITS

6649 – Surgery Payable at Reduced Amount When Related POS

6651 – Surgical Cutback Procedure – 50%

6653 – Post Op Care Within 00-90 Days of Surgery

6654 – Pre-Operative Care Within 1 Day of Surgery

6655 – Surgery Payable at Reduced Amount When Pre-Op Care

6656 – Post Op Care Within 10 Days of Select Surgery

6657 – Pre-Operative Care on Day of Surgery

6658 – Surgery Payable at Reduced Amount When Pre-Op Care

6659 – Surgery Payable at Reduced Amount When Related POS

6660 – Pre/Post-Operative Care Billed with Unlisted Surgery

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: DIABETES SELF-MANAGEMENT TRAINING

DESCRIPTION

Indiana Health Coverage Programs’ (IHCP) diabetes self-management training services

are intended to enable or enhance the member’s ability to properly manage their diabetic

condition. The purpose of these services is to optimize personal therapeutic treatment

regimens.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding this service. More specific information may be

found in the IHCP Provider Manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

The IHCP will provide reimbursement for diabetes self-management training services

when medically necessary, ordered in writing by a physician or podiatrist, and provided

by a health care professional licensed under applicable Indiana law. The health care

professional providing the service must have specialized training in the management of

diabetes. Some examples of the training include, but would not be limited to, instruction

regarding the diabetic disease state, nutrition, exercise and activity, medication

counseling, blood glucose self-monitoring training, insulin injection training, foot, skin,

eye, and dental care.

The IAC citation, 405 IAC 5-36 mandates coverage limitations of diabetes self-

management training to a total of sixteen units with each unit equaling 15 minutes. IHCP

reimbursement of diabetes self-management training services is limited to a total of eight

units of G0108, Diabetes outpatient self-management training services, individual, per

30 minutes, and G0109, Diabetes self-management training services, group session (2 or

more), per 30 minutes, for diabetes self-management training services per member, 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 insured’s

symptoms or condition

• Re-education or refresher training

01/31/2007 Diabetes Self-Management Training

Medical Policy Manual

126

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Practitioners, both ordering and rendering, are to maintain sufficient documentation of

the diabetes self-management training services provided to substantiate medical necessity

and the provision of the service itself. Examples of documentation that are to be

maintained by the provider include, but are not limited to, the following.

• Written order(s) for the service

• Date of service

• Amount of time used for the training session

• General content of the training session

• Units of service billed and charge amount

• Pertinent patient history and clinical data

• Practitioner notes from the training sessions

PRIOR AUTHORIZATION

Prior authorization is NOT required for initial units of diabetes self-management training

services that do not exceed the established limits for the service. However, additional

units may be authorized through the standard prior authorization request process.

Documentation must be maintained to provide evidence of medical necessity for

additional units requested.

It is the responsibility of the ordering physician or podiatrist to ensure that initial and all

subsequent orders for diabetes self-management training are fully substantiated by

medical necessity of the service.

MANAGED CARE

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for more specific guidelines. Refer to the

Provider Manual, Chapter 1, for detailed information about the fee-for-service (FFS),

Primary Care Case Management (PCCM), and RBMC delivery systems.

IHCP members enrolled in Medicaid Select PCCM receive the same benefit coverage,

and are subject to the same limitations as traditional Medicaid FFS. Refer to the

Medicaid Select Manual for Primary Medical Providers nd Office Staff for further

information.

BILLING REQUIREMENTS

Providers must bill for diabetes self management training service on the HCFA 1500

claim form or 837P electronic transaction, utilizing HCPCS procedure codes G0108,

Diabetes outpatient self-management training services, individual, per 30 minutes, and

G0109, Diabetes self-management training services, group session (2 or more), per 30

minutes. Fractional units of service can be billed on the CMS 1500 with allowance for

01/31/2007 Diabetes Self-Management Training

Medical Policy Manual

127

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Diabetes Self-Management Training

Medical Policy Manual

128

two decimal places when submitting partial units. The IHCP does not provide

reimbursement for a diabetes self-management training service which is provided to the

general public at no charge, including diabetes self-management training services.

RELATED MEDICAL TOPICS

Endocrinology – Insulin

Nursing Services

Podiatry

RULES, CITATIONS, AND SOURCES

Indiana Senate Enrolled Act No. 184, IC 27-8-14.5, effective January 1, 1998

Indiana Medicaid Update Bulletin 98-05

Indiana Health Coverage Programs Provider Manual

Version 5.1, March 2005

Medicaid Select Manual for Primary Care Providers and Office Staff, 2003

Origination Date: 12/31/2000

Revisions and Reviews Reason Date

Indiana SEA No. 184,

IC 27-8-14.5; Indiana

Medicaid Update

Bulletin 98-05

Diabetes Self-Management Training 01/01/1998

Revision 405 IAC 5-36 Amended 10/27/1999

Review Scheduled 10/31/2006

APPLICABLE INDIANAAIM EDITS AND AUDITS

6096 – The CPT/HCPCS Code Billed is Not Payable

6652 – Multiple Surgeries Must Be Billed on Same Claim

6798 – Services Not Covered for Telemedicine

6920 – Diabetes Management Limited to 8 Units in 12 Months

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: DIAGNOSTIC STUDIES

DESCRIPTION:

Diagnostic Studies are invasive and non-invasive tests completed to determine the

probable cause of the patient’s signs and symptoms. These studies can be done as an

inpatient or outpatient, dependent on the severity of the signs and symptoms and the

treatment they require.

SUMMARY OF CURRENT POLICY:

Medical diagnostic services may not be fragmented and billed separately.

MEDICAL TOPICS CROSS-REFERENCES:

Consultations – Second Opinion

Endocrinology - Insulin

Gastroenterology

Hematology

Mental/Behavioral Health – Inpatient Services

Mental/Behavioral Health – Outpatient Services

Obstetric Care

Oncology

Physician Services – Visits/New patient vs. Established Patient Visits: Office, Home,

Nursing Facility, Emergency Room

Urology

RULES, CITATIONS, AND SOURCES:

405 IAC 5-28-2

Indiana State Department of Public Welfare Medical Policy Manual 1991

Indiana Health Coverage Programs Provider Manual

01/31/2007 Diagnostic Studies

Medical Policy Manual

129

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Diagnostic Studies

Medical Policy Manual

130

Initial Policy Issue

Effective

Date

Implementation

Date

Retroactive

Date

470 IAC 5-9-1

Transferred

Global Fee Billing

7/1/91

405 IAC 1-7-1

Repealed 8/24/97

Coverage of

Diagnostic

Procedures

1/1/92

Revisions:

405 IAC 5-28-1

Diagnostic Studies 8/24/97

405 IAC 5-28-2

Diagnostic Studies 8/24/97

APPLICABLE INDIANAAIM EDITS AND AUDITS:

6001

6011

6014

6024

6025

6026

6064

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: EMERGENCY MEDICINE—CARDIOPULMONARY

RESUSCITATION (CPR)

DESCRIPTION

Cardiopulmonary Resuscitation is the process used to return the patient presenting with

sudden cardiac arrhythmia and/or sudden respiratory failure to normal respiratory and

cardiac function.

SUMMARY OF CURRENT POLICY

Cardiopulmonary Resuscitation is a covered service. It is an all inclusive procedure and

includes central venous pressure catheterization, insertion of arterial lines, endotracheal

intubation, and cardioversion.

MEDICAL TOPICS CROSS-REFERENCESRELATED MEDICAL TOPICS

Emergency Medicine – Emergency Room

Emergency Medicine – Emergency Services

Hospital Outpatient

Physician Services – Visits/New patient vs. Established Patient Visits: Office, Home,

Nursing Facility, Emergency Room

Surgery – Office Visits

RULES, CITATIONS, AND SOURCES

405 IAC 5-10-3 Anesthesia Services

Indiana State Department of Public Welfare Medical Policy Manual 1991

ORIGINATION, REVISIONS, AND REVIEWS

Origination Date: 12/31/00

Revisions and Reviews Reason Date

405 IAC 5-10-3 Anesthesia Services 8/24/97

Reviewed Without Revision Scheduled Review 4/30/04

01/31/2007 Emergency Medicine – Cardiopulmonary Resuscitation (CPR)

Medical Policy Manual

131

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Emergency Medicine – Cardiopulmonary Resuscitation (CPR)

Medical Policy Manual

132

APPLICABLE INDIANAAIM EDITS AND AUDITS

COVERAGE CRITERIA

Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary resuscitation (92950) is an all inclusive procedure. Therefore, separate

charges for central venous pressure catheterization (36488, 36489), insertion of arterial

lines (36620), endotracheal intubation (31500), and cardioversion (92960) will be denied

as included in the charge for CPR. Additional charges for care of the member on the

same day by the same physician (for example, intensive care visits, hospital visits,

emergency room visits) will also be denied as included in the charge for the

cardiopulmonary resuscitation.

1. Payment in full is allowed for a Swan-Ganz in addition to the CPR charge.

2. These guidelines apply when the same physician bills separately for CPR and any of

the above components. Physicians other than the primary physician will be paid for

services they provide during the cardiopulmonary resuscitation.

3. These guidelines apply when the same physician bills separately for CPR and any of

the above components. Physicians other than the primary physician should be paid

for services that they provide during the cardiopulmonary resuscitation.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: EMERGENCY MEDICINE—EMERGENCY ROOM

DESCRIPTION

Emergency services are services provided in the emergency department of a hospital.

Emergency services include services provided to an Indiana Heath Coverage Programs

(IHCP) member after the sudden onset of a medical condition manifesting itself by acute

symptoms of sufficient severity that the absence of immediate medical attention could

reasonably be expected to result in placing the member's health in serious jeopardy;

serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

SUMMARY OF CURRENT POLICY

Reimbursement is available for emergency department services provided by IHCP

enrolled providers. Emergency services (as described above) do not require prior

authorization. Emergency services are excluded from co-payment requirements.

However, non-emergency services treated in an emergency department setting are subject

to co-payments. Members on restricted utilization may receive treatment without a

referral from the authorized provider if the diagnosis is an emergency diagnosis.

Members enrolled in the RBMC component of Hoosier Healthwise can seek emergency

care from providers not contracted with the managed care organization without prior

authorization, subject to the prudent layperson standard for emergency medical

conditions. This means that a layperson with an average knowledge of health and

medicine could reasonably expect the absence of immediate medical attention to result in

(a) serious jeopardy to the health of the individual or, in the case of a pregnant women,

the health of the woman or her unborn child; (b) serious impairment to bodily functions,

or (c) serious dysfunction of any bodily organ or part.

The Primary Care Case Management (PCCM) component of the Hoosier Healthwise

managed care program does not require Primary Medical Provider (PMP) authorization

for federally required medical screening examinations performed by a physician in the

emergency department of a hospital. CPT codes reflecting the appropriate level of

screening exam must be billed on a HCFA 1500 form:

99281

Emergency Department Visit for evaluation and management;

presenting problem(s) are self limiting or minor

99282

Emergency Department Visit for evaluation and management;

presenting problem(s) are low to moderate severity

01/31/2007 Emergency Medicine – Emergency Room

Medical Policy Manual

133

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

99283

Emergency Department Visit for evaluation and management;

presenting problem(s) are of moderate severity

99284

Emergency Department Visit for evaluation and management;

presenting problem(s) are high severity; require urgent evaluation

by physician but do not pose immediate threat to life or

physiologic function

99285

Emergency Department Visit for evaluation and management;

presenting problem(s) are high severity and pose immediate threat

to life or physiologic function

Related services that do not have an emergency diagnosis and emergency indicator on the

claim will be denied if the claim does not contain the PMP authorization.

If a physician uses an emergency room as a substitute for his or her office for non-

emergency services, these visits should be billed as office visits and will be reimbursed as

such.

RELATED MEDICAL TOPICS

Emergency Medicine – Cardiopulmonary Resuscitation (CPR)

Emergency Medicine – Emergency Services

Hospital Outpatient

Physician Services – Visits/New patient vs. Established patient visits: Office, Home,

Nursing Facility, Emergency Room

Out-of-State Services

RULES, CITATIONS, AND SOURCES

IC 12-15-15-2.5 Payment for physician services provided in the emergency department of

a hospital

405 IAC 5-2-9 “Emergency service” defined

405 IAC 5-3-12 Prior authorization; exceptions

Indiana Medicaid Update Bulletin 96-36

Indiana Medicaid Update Bulletin 95-51

Indiana Medical Assistance Program Provider Manual 1994

Indiana Health Coverage Programs Provider Manual 1999

Indiana Health Coverage Programs Provider Manual 2003

01/31/2007 Emergency Medicine – Emergency Room

Medical Policy Manual

134

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Origination Date 7/1/91

REVIEW AND REVISIONS REASON DATE

470 IAC 5-9-1 Transferred Global Fee Billing 7/1/91

405 IAC 1-7-1 Repealed 8/24/97 Global Fee Billing 1/1/92

Indiana Medicaid Update Bulletin

95-51

Medical Screening

Exams in the

Emergency Room

1995

Indiana Medicaid Update Bulletin

96-36

COPAYMENTS

FOR

EMERGENCY

ROOM VISITS

1/1/97

IC 12-15-15-2.5

Payment for

Physician Services

Provided in the

Emergency

Department of a

Hospital

5/13/97

405 IAC 5-2-9

"Emergency

Service" Defined

8/24/97

405 IAC 5-3-12

Prior

Authorization;

Exceptions

8/24/97

405 IAC 5-9-2

Evaluation and

Management

Services--

Restrictions

8/24/97

IC 12-15-15-2.5(f)

Payment for

Physician Services

Provided in the

Emergency

Department of a

Hospital

7/1/99

405 IAC 5-3-12

AMENDED

Prior

Authorization;

Exceptions

10/27/99

Review

Scheduled

7/30/04

01/31/2007 Emergency Medicine – Emergency Room

Medical Policy Manual

135

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Emergency Medicine – Emergency Room

Medical Policy Manual

136

APPLICABLE INDIANAAIM EDITS AND AUDITS:

440

6514

Provider Type and Specialty List

PROVIDER TYPE Provider Specialty

31 Physician 315 Emergency Medicine Practitioner

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: EMERGENCY MEDICINE—EMERGENCY SERVICES

DESCRIPTION

Emergency services include unscheduled episodic services provided to IHCP members

who require immediate medical attention.

SUMMARY OF CURRENT POLICY

IHCP reimbursement is available for emergency services provided to IHCP members. As

defined by the prudent layperson provision in the Omnibus Budget Reconciliation Act

(OBRA) of 1986, an emergency may be perceived by the sudden onset of a medical

condition manifesting itself by acute symptoms of such severity that the absence of

immediate medical attention could reasonably be expected to result in (1) placing the

patient’s health in serious jeopardy, (2) serious impairment to bodily functions, and (3)

serious dysfunction of any bodily organ or part.

Hoosier Healthwise Package E members (aliens, non-citizens) receive only emergency

services and the services are reimbursed as fee for service. Package E services must meet

emergency criteria as noted in the paragraph above. In the case of pregnant women eligible

for coverage under Package E, labor and delivery services are also considered emergency

medical conditions.

Providers must denote that a provided service was emergent by indicating such in the

appropriate field on submitted claim forms.

COVERAGE CRITERIA

IHCP provides reimbursement for emergency services; guidelines for these services are

subject to the member’s program enrollment. Hoosier Healthwise Programs A and B

enrollees are required to pay a copayment for non-emergency services provided in the

emergency department. Per federal regulations, IHCP providers may not deny services to

any member due to the member’s inability to pay the copayment on the date of service.

This federal requirement 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 that he or she cannot afford to pay the

copayment on the date of service. The provider may bill the member for copayments not

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

137

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

made on the date of service. The following information discusses emergency services by

program area, as applicable.

Cardiopulmonary Resuscitation

The IHCP reimburses cardiopulmonary resuscitation. Refer to the Medical Policy fact

sheet on Emergency Services – Cardiopulmonary Resuscitation for specific coverage

information.

Emergency Dental Services

The IHCP reimburses medically necessary emergency dental services. Hoosier

Healthwise Package E members are eligible only for services to treat an emergency

medical condition. Preventive treatments such as sealants, prophylaxis, and fluoride

treatments do not meet the definition of an emergency medical condition. Package E

members who seek dental services that are non-emergencies are responsible for payment

of such services.

Field 53 on the ADA dental claim form must be used to specify if the services performed

were for emergency care. Providers must indicate Yes for emergency care rendered to

Package E members. All services are subject to post-payment review, and documentation

must support medical necessity for the services performed.

Palliative treatment of facial pain, such as an abscess incision and drainage is limited to

emergency treatment only. HCPCS code D0140 can be billed for the emergency exam.

If the procedure for the palliative care has a corresponding ADA code, the code for the

procedure is billed rather than the code for palliative care.

Emergency Services Related to Hospice

When an IHCP member elects the IHCP hospice benefit, care for the terminal condition

comes under the supervision of the IHCP hospice provider. The IHCP covers the IHCP

hospice member’s medical care for conditions not related to the terminal illness.

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 hospice and

transportation charges associated with all emergency services. If the emergency services

are unrelated to the terminal illness, the IHCP covers transportation and facility services

associated with the emergency services according to the member’s program enrollment,

(i.e. Fee-for-Service and Hoosier Healthwise). Refer to the Indiana Health Coverage

Programs Hospice Provider Manual and the Medical Policy fact sheet on Hospice

Services for specific coverage information.

Inpatient Services

Inpatient services for diagnoses reimbursed under the level of care payment methodology

and emergency substance abuse require prior authorization (PA). Emergency inpatient

admissions for these diagnoses must be reported to PA within forty-eight hours of

admission, not including Saturdays, Sundays, or legal holidays in order to receive IHCP

reimbursement.

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

138

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Pharmacy Services

Pharmacy services are exempt from copayment requirements when emergency services

are provided in a hospital, clinic, office, or other facility equipped to furnish emergency

care.

In accordance with federal law, the IHCP allows for the provision of at least a 72 hour

supply of a prescribed drug in an emergency situation, without otherwise applicable PA

(such as, on a weekend, holiday, and so forth). Pharmacy providers should document the

circumstances that support providing the emergency supply and are subject to post

payment review. Providers should refer to the Medical Policy fact sheet on Pharmacy

Services for specific coverage and billing information.

Emergency Department Physicians

ICHP reimbursement is available to emergency department physicians who render

medically necessary emergency service to IHCP members. PCCM members are not required

to obtain a PMP authorization for the federally required medical screening examinations

performed by a physician in the emergency department of a hospital. One of the CPT

codes listed below, reflecting the appropriate level of screening exam, must be billed on

the CMS 1500 claim form or the 837P transaction.

 99281 – Emergency department visit for evaluation and management,

usually, presenting problem(s) are self limiting or minor

 99282 – Emergency department visit for evaluation and management,

usually, presenting problem(s) are of low to moderate severity

 99283 – Emergency department visit for evaluation and management,

usually, presenting problem(s) are of moderate severity

 99284 – Emergency department visit for evaluation and management,

presenting problem(s) of high severity, require urgent

evaluation by the physician, do not pose significant threat to

life/physiologic function

 99285 – Emergency department visit for evaluation and management,

presenting problem(s) of high severity, pose immediate

significant threat to life/physiologic function

Psychiatric Services

The physician or HSPP must be available for emergencies and must either see the patient

or review the information obtained by the mid-level practitioner within seven days of the

intake process. IHCP reimbursement is available for emergency mental health admissions

in cases of a sudden onset of a psychiatric condition manifesting in acute symptoms of

such severity that the absence of immediate medical attention could reasonable be

expected to result in danger to the member or to others. Refer to the Medical Policy fact

sheets for Mental and Behavioral Health Services for inpatient hospitalization and

outpatient services for specific coverage information.

Transportation Services

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

139

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Emergency transportation services are covered by the IHCP. Refer to the Medical Policy

Fact sheet on Transportation Services for specific coverage information.

BILLING REQUIREMENTS

Facility payments for services rendered in the emergency department are the same for

emergent and non-emergent care. Under federal regulations (42 CFR 447.53), emergency

services are excluded from copayment requirements.

Revenue codes 70X, 71X, 72X, and 76X are reimbursed at a flat rate regardless of the

diagnosis code on the claim. For a service to be considered an emergency, an applicable

emergency diagnosis code must be entered as the principal diagnosis in Locator 67 on the

UB-92.

Providers submitting claims for reimbursement of services to Hoosier Healthwise Package E

members must indicate emergency in the proper form locator on the claim form. The

diagnosis codes must include an appropriate code from the comprehensive list of codes

considered as emergencies, located in the Provider Manual, Chapter 8, entitled

“Emergency Department Diagnosis Codes.”

PRIOR AUTHORIZATION

Prior authorization (PA) is not required for emergency services.

Emergency inpatient admissions for diagnoses reimbursed under the level of care

payment methodology and emergency substance abuse inpatient admissions must be

reported to PA within forty-eight (48) hours of admission, not including Saturdays,

Sundays, or legal holidays, in order to receive IHCP reimbursement. IHCP reimbursement is

available for emergency mental health admissions only in cases of a sudden onset of a

psychiatric condition manifesting in acute symptoms of such severity that the absence of

immediate medical attention could reasonably be expected to result in danger to the

member or to others.

Continuation of inpatient treatment and hospitalization, following out-of-state emergency

services is subject to prior authorization requirements. Refer to the Medical Policy fact

sheet for Out-of-State Services for further information.

MANAGED CARE

IHCP members enrolled in Hoosier Healthwise programs are encouraged to take

responsibility for the choices they make in seeking medical care, particularly with regard

to use of the emergency room. Each Hoosier Healthwise member has chosen or been

assigned to a primary medical provider (PMP) who is available 24 hours a day to give

medical advice. Members are educated to contact their PMP prior to seeking treatment in

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

140

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

the emergency room except in cases of true emergencies. Members are encouraged to

seek emergency room treatment only when it is appropriate. Thus, to the extent

permitted by federal and state regulations, a copayment is charged when there is not a

true emergency and the emergency room setting was chosen without the authorization of

the PMP.

While authorization is not required for emergencies, non-authorized services, such as

facility charges, labs, and x-ray services, rendered to a PCCM member without an

emergency diagnosis may not be covered. These claims may be suspended for review to

determine if the prudent layperson standard (see page 1 of this fact sheet) for an

emergency medical condition has been met. If the review results in the determination

that the prudent layperson standard has not been met, the claim will be denied. If the

prudent layperson standard has been met, then only revenue code 45X will be paid, as

long as the eight digit PMP license number is indicated in Field 83B of the UB-92 claim

form. As noted previously on page 3, a PMP authorization is not required for a federally

required medical screening examination performed by a physician in the emergency

department of a hospital.

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s MCO for more specific guidelines. Refer to the Provider Manual, Chapter 1,

for detailed information about the fee-for-service (FFS), Primary Care Case Management

(PCCM), and RBMC delivery systems.

RELATED MEDICAL TOPICS

Dental Services

Emergency Medicine – Emergency Room

Emergency Medicine – Cardiopulmonary Resuscitation

Hospice Services

Hospital Outpatient

Mental Health Services – Inpatient

Out-of-State Services

Physician Services – Visits/New patient vs. Established patient visits: Office, Home,

Nursing Facility, Emergency Room

Transportation Services

RULES, CITATIONS, AND SOURCES

42 CFR 447.15 – Member copayment

405 IAC 5-2-9 – “Emergency service” defined

405 IAC 5-3-12 – Prior authorization; exceptions

405 IAC 5-4-2 – Provider agreement requirements for transportation services

405 IAC 5-17-3 – Emergency; weekend inpatient admissions

405 IAC 5-20-6 – Emergency admissions

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

141

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Indiana Medicaid – Update Bulletins

95-17, 96-36, and 98-04

Indiana State Department of Public Welfare Medical Policy Manual 1991

Indiana Health Coverage Programs Hospice Provider Manual, March 2004, Version 4.0

Indiana Health Coverage Programs Provider Bulletin BT200311 – Package E Dental

Services

Indiana Health Coverage Programs Provider Newsletter NL200410 – Dental Services

Indiana Health Coverage Programs Provider Manuals

1999

July 2004, Version 5.0

ORIGINATION, REVISIONS AND REVIEWS

Origination Date: 12/31/2000

Revisions and Reviews Reason Date

Indiana State Department

of Public Welfare Medical

Policy Manual 1991

Emergency Services 7/1/91

Indiana Medicaid Update

Bulletin 95-17

MCOs’ Coverage Of Emergency Services 3/28/95

Indiana Medicaid Update

Bulletin 96-36

Copayments For Urgent And Nonemergency

Services Provided In An Emergency Room

1/97

405 IAC 5-2-9 "Emergency service" defined 8/24/97

Indiana Medicaid Update

Bulletin 98-04,

Emergency Room Transportation 2/9/98

Indiana Health Coverage

Programs BT 200311

Package E Dental Services 2/7/03

Review Scheduled 4/29/05

APPLICABLE INDIANAAIM EDITS AND AUDITS

440 – Emergency Indicator Invalid

4090 – Drug and Supply Codes are Included in Treatment

4091 – Add-on Service was Billed Without a Treatment Room

6514 – No More than One Emergency Room Visit per Day

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

142

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

EMERGENCY MEDICINE – EMERGENCY SERVICES

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the Emergency Medicine – Emergency Services Fact Sheet. The information

in this addendum will be incorporated into the fact sheet at the next review.

Provider Notification: BR200539 Publication Date: 09/27/2005

Subject: Emergency Department Diagnosis Codes

Date Added to Manual: 10/31/2005

Text of Publication

Beginning October 1, 2005 please use the following updated International Classification

of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The new, revised,

and discontinued codes may be viewed at

http://www.cms.hhs.gov/medlearn/icd9code.asp. To ensure Health Insurance Portability

and Accountability Act (HIPAA) compliance, the 90-day grace period no longer applies

to ICD-9-CM updates. Providers must use the appropriate ICD-9-CM diagnosis and

procedure codes that are valid for the date of service. Codes not valid for the dates of

service will deny. The ICD-9-CM diagnosis and procedure codes are billable and

reimbursable October 1, 2005.

The following new ICD-9-CM diagnosis codes will be added to Table 8.13 – Emergency

Department Diagnosis Codes in the IHCP Provider Manual, Chapter 8, Section 2. These

codes are effective October 1, 2005.

ICD-9-CM Diagnosis Codes Added to Table 8.13 Emergency Department Diagnosis

Codes

276.50 567.38 651.70 770.12 770.86 996.44

276.51 567.39 651.71 770.13 779.84 996.45

276.52 567.81 651.73 770.14 799.01 996.46

567.21 567.82 760.77 770.15 799.02 996.47

567.22 567.89 760.78 770.16 996.40 996.49

567.23 585.6 763.84 770.17 996.41 V46.14

567.29 599.60 770.10 770.18 996.42 V62.84

567.31 599.69 770.11 770.85 996.43

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

143

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Emergency Medicine – Emergency Services

Medical Policy Manual

144

The following ICD-9-CM diagnosis codes will be removed from Table 8.13 – Emergency

Department Diagnosis Codes in the IHCP Provider Manual, Chapter 8, Section 2

effective October 1, 2005. These codes are no longer valid codes.

ICD-9-CM Diagnosis Codes Removed from Table 8.13 Emergency Department

Diagnosis Codes

276.5 567.2 567.8 599.6 770.1 799.0 996.4

The following new ICD-9-CM diagnosis codes will be added to Table 8.63 – High Risk

Pregnancy – ICD-9-CM Diagnosis Codes in the IHCP Provider Manual, Chapter 8,

Section 3. These codes are effective October 1, 2005.

ICD-9-CM Diagnosis Codes Added to Table 8.63 High Risk Pregnancy – ICD-9-CM

Diagnosis Codes

276.50 291.82 567.38 585.5 V46.13 V85.25 V85.37

276.51 362.07 567.39 585.6 V46.14 V85.30 V85.38

276.52 426.82 567.81 585.9 V62.84 V85.31 V85.39

278.02 567.21 567.89 599.60 V85.0 V85.32 V85.4

287.30 567.22 585.1 599.69 V85.21 V85.33

287.31 567.23 585.2 651.70 V85.22 V85.34

287.33 567.29 585.3 651.71 V85.23 V85.35

287.39 567.31 585.4 651.73 V85.24 V85.36

The following ICD-9-CM diagnosis codes will be removed from Table 8.63 High Risk

Pregnancy – ICD-9-CM Diagnosis Codes in the IHCP Provider Manual, Chapter 8,

Section 3 effective October 1, 2005. These diagnosis codes are no longer valid.

Invalid ICD-9-CM Diagnosis Codes Removed

from Table 8.63 High Risk Pregnancy – ICD-9-CM Diagnosis Codes

287.3 585

The following new ICD-9-CM procedures are not covered by the IHCP. According to the

Indiana Administrative Code (IAC) 405 IAC 5-29-1 (3), experimental treatment or

procedures are not covered by the IHCP.

ICD-9-CM Non-Covered ServicesCode Description

37.41 Implantation of prosthetic cardiac support device around the heart

84.58 Implantation of interspinous process decompression device

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: EPSDT/HEALTHWATCH

DESCRIPTION

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, referred

to as HealthWatch in Indiana, is a federally mandated preventive health care program

designed to improve the overall health of eligible infants, children and adolescents.

Special emphasis is given to early detection and treatment since these efforts can reduce

the risk of more harmful and costly treatment or hospitalization, when detection is

delayed. IHCP members from birth to age twenty-one (21) may participate in the

program on a voluntary basis. Division of Family and Children staff from each of the 92

counties are responsible for HealthWatch program outreach and for informing IHCP

eligible persons about the availability of HealthWatch services. The Hoosier Healthwise

program plays a significant role in the administration of the EPSDT program. Hoosier

Healthwise enrollees must consult their managed care organization (MCO) for outreach

and information on EPSDT services.

SUMMARY OF CURRENT MEDICAL POLICY

EPSDT program services covered by the IHCP are subject to certain coverage limita-

tions. The purpose of EPSDT is to facilitate the introduction of young IHCP members

into a continuing health care system that will detect abnormalities before such

abnormalities become chronic or debilitating.

An initial screening is performed by the EPSDT screening provider when referred by the

Office of Medicaid Policy and Planning (OMPP) or its designee or upon the initial

request of the member for EPSDT services. The initial screening and subsequent,

periodic screenings must be performed in accordance with the HealthWatch Periodicity

and Screening Schedule (periodicity schedule) shown on Table 1. A comprehensive

health and developmental history includes assessment of both physical and mental health

development and a comprehensive unclothed physical exam. Provisions are outlined for

other services such as nutritional assessment, developmental assessment, appropriate vision

and hearing testing, dental screening, health education, including anticipatory guidance,

and include administration of or referral for any other test, procedure or immunization that

is medically necessary or clinically indicated.

Any treatment found necessary to correct or ameliorate defects and physical and mental

illnesses and conditions as a result of a diagnosis identified during an initial or periodic

screening may be provided subject to any prior authorization requirements for the services.

If a service is not covered by the IHCP, it is still available to EPSDT eligible members,

only if it is necessary to correct or ameliorate defects and physical or mental illnesses and

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

145

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

conditions discovered by the screening services, subject to prior authorization requirements

of 405 IAC 5-4

Table 1: HealthWatch/EPSDT Periodicity and Screening Schedule

RELATED MEDICAL TOPICS

Immunizations

Laboratory Services

Pediatrics

Screening Services – Newborn screening

Speech and Hearing

RULES, CITATIONS, AND SOURCES

405 IAC 5-15 Early and Periodic Screening, Diagnostic, and Treatment Services

405 IAC 5-14-19 Prior authorization for early and periodic screening, diagnostic, and

treatment covered services

405 IAC 5-14-2 Covered services

405 IAC 5-23-3 Covered vision care services

Department of Health and Human Services Health Care Financing Administration

Transmittal No. 12 September 1998

HealthWatch EPSDT Provider Manual, Version 1.0, February 2002

Indiana Health Coverage Programs Provider Manual, July 2004

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

146

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

ORIGINATION, REVISIONS, AND REVIEWS

Origination Date: August 25, 1997

Revisions and Reviews Reason Date

405 IAC 5-2-10 “EPSDT” defined 8/25/97

405 IAC 5-15

Early and Periodic Screening, Diagnostic, and

Treatment Services

8/25/97

405 IAC 5-14-19 Prior Authorization 8/25/97

405 IAC 5-14-2 Covered Services 8/25/97

HealthWatch EPSDT

Provider Manual

Provider Manual 2/2002

BT 200207 New HCPCS Codes 2/15/02

BR200217 RHC and FQHC Coding Change 4/23/02

BT 200353

Elimination of Local Codes

X3067 (Missed Appointment)

8/15/03

IHCP Provider Manual Vaccines for Children 7/04

Review Schedule Routine Review 10/04

APPLICABLE INDIANAAIM EDITS AND AUDITS:

6028 – Initial and periodic visits not payable on same date of service

6702 – Newborn screening limited to one per lifetime

9050 – EPSDT pricing

COVERAGE CRITERIA

Member Requirements

Hoosier Healthwise Primary Care Case Management (PCCM) or risk-based managed

care (RBMC) enrollees receive HealthWatch/EPSDT screening examinations from

physicians enrolled in the IHCP as Hoosier Healthwise primary medical providers

(PMPs). Children who are not enrolled in PCCM or RBMC can receive screenings from

any IHCP provider. EPSDT screenings for children not enrolled in Hoosier Healthwise

are provided at designated federally qualified health centers (FQHC) and rural health

clinics (RHC).

HealthWatch Screening Examinations

The primary goal of the HealthWatch/EPSDT program is to ensure that all IHCP eligible

children receive necessary, age-appropriate, comprehensive, preventive services.

Components of the screening examinations and recommended frequency of the screens

are listed in the periodicity schedule. The periodicity schedule is listed in the Indiana

Administrative Code (IAC) 405 IAC 5-15-8. These screenings or any portion of the

screening is not required when lack of medical necessity is documented by the provider.

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

147

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

However, when a member receives components of an EPSDT screening or is referred

elsewhere for these components, they must be accurately reflected in the member’s

medical record.

Any treatment found necessary as a result of a diagnosis reached during an initial or

periodic screening may be provided subject to any prior authorization requirement for the

specified service. If a service is not covered by the IHCP, it is still available to a

HealthWatch/EPSDT-eligible member if it is necessary to correct or improve a physical

or mental illness or condition discovered during a screening subject to prior authorization

requirements.

HealthWatch/EPSDT screens are reimbursed at a higher rate than other child exams.

Reimbursement for the initial patient exam is limited to the first screen performed by the

screening provider during the member’s lifetime. In order to claim a higher

reimbursement, the following components of the screening must be provided and

documented in the member’s medical record.

• A health and developmental history, including assessment of both physical

and mental health development

• An unclothed physical exam

• A nutritional assessment

• A developmental assessment

• Vision observation at each screening and direct referral to an optometrist or

ophthalmologist starting when objective screening methods indicate a referral

is warranted

• Hearing observation at each screening and objective testing with audiometer

at four years, administered or referred

• Dental observation at each screening. Direct referral to a dentist starting at 24

months old. Dental referrals may be made as early as 12 months old when

indicated.

• Laboratory tests, including blood lead level assessment appropriate for age

and risk factors

• Immunizations administered or referred, if needed at time of the screening

• Health education, including anticipatory guidance

Further details of the components of HealthWatch/EPSDT screenings are available in the

HealthWatch EPSDT Provider Manual.

Billing HealthWatch/EPSDT Screening Examinations

HealthWatch/EPSDT visits are billed on the CMS-1500 claim form or 837P transaction.

HealthWatch/EPSDT claims billed to the IHCP must be coded with the following.

• The appropriate patient examination code (99381-99395, 99391-99395) must

be included on the first detail line of the medical claim form

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

148

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• The preventive health diagnosis code, V20.2 (Routine infant or child health

check), as the primary diagnosis. Physicians are encouraged to include all

applicable diagnosis codes (up to four) and procedure codes on the claim for

each HealthWatch/EPSDT visit

• The appropriate EPSDT reimbursement rate for the initial or established

patient exam billed.

The required examination codes providers are to use vary by the age of the member. The

appropriate examination procedure codes are listed in Table 2 by age.

Table 2: EPSDT Screening Examination Codes

Age Initial Patient Exam Established Patient Exam

Less than one year 99381 99391

One to four years 99382 99392

Five to 11 years 99383 99393

12 to 17 years 99384 99394

18 to 20 years 99385 99395

HealthWatch/EPSDT screening services are not subject to third party liability (TPL).

Providers do not have to submit EPSDT claims for TPL payment prior to submitting the

claim to IHCP

Providers may bill and be reimbursed for services provided in addition to the EPSDT

visit. In this instance, the problem-oriented exam can be billed separately, with the -25

modifier (separately significantly identifiable E/M service). The visit must require

additional moderate level evaluation to qualify as a separate service on the same date.

IHCP reimbursement will be at the lesser of the submitted charge or the maximum fee for

each additional service.

Members who miss HealthWatch/EPSDT appointments or follow-up appointments must

be identified and their names forwarded to the Hoosier Healthwise Helpline or the

Hoosier Healthwise benefit advocate. Claim submission for missed appointments is not

required and reimbursement will not be made for missed appointments. Providers may

not bill IHCP members for missed appointments.

Required EPSDT Referrals

HealthWatch/EPSDT providers are required to make dental, vision, hearing, and lead

screening referrals when screening results indicate a problem. Providers may refer

members for dental services beginning at 24 months old or as early as 12 months, if

indicated in the screening. Vision referrals must be made when objective screening

methods indicate a problem is present. Newborns with hearing deficit identified under

the universal newborn screening program must be referred to the First Steps program.

Older members in need of additional testing should be referred for additional testing and

treatment when screening results indicate a possible hearing deficit. Tables 2, 3, and 4

show the schedules for dental, vision and hearing observation and screenings

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

149

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 3: Periodicity Schedule for HealthWatch/EPSDT

Dental Observation and Screening

Age of Child

Recommended (S) or

Required (R)

Services

12 to 24 months S

Direct referral to a dentist if

necessary

24 months R

Direct referral to a dentist

for examination, preventive

dental care, and anticipatory

guidance

24 months through 20 years R

Regular dental assessments

at intervals defined by the

dentist, approximately

every six months. The

individual member

assessment should include

examination, preventive

dental care, and anticipatory

guidance.

Table 4: Periodicity Schedule for HealthWatch/EPSDT

Vision Observation and Screening

Age of Child

Recommended (S) or

Required (R)

Services

Up to 3 years S

Visual observation with an

external eye examination;

subjective screening by

history. Refer child to an

appropriate specialist if

abnormality is suspected.

3 to 5 years R

Annual objective screening

test by standard testing

method. If warranted, refer

child to an appropriate

specialist.

6,8,14,16,18 years S

Visual observation with an

external eye examination;

subjective screening by

history. Refer child to an

appropriate specialist if

abnormality is suspected.

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

150

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 4, con’t.

Age of Child

Recommended (S) or

Required (R)

Services

10, 12, 18 R

Objective screening test by

a standard testing method.

If warranted, refer child to

an appropriate specialist.

Table 5: Periodicity Schedule for HealthWatch/EPSDT

Hearing Observation and Screening

Age of Child

Recommended (S) or

Required (R)

Services

Newborn S

Newborn hearing screening

via fully automated brain

stem response, if available

Newborn R

All members considered to

be at risk for hearing deficit

should be screened at this

time.

Under 12 months S

Subjective screening, by

history and/or other infant

screening using standard

testing method. Refer those

at risk or suspected of

hearing deficit to a

specialist, if warranted.

12 months through 3 years R

As early as possible,

perform an objective

screening using standard

testing method. Refer those

at risk or suspected of

hearing deficit to a

specialist.

4-5 years R

Audiometric screening with

an audiometer or

audioscope (refer to

audiologist if necessary).

Refer child at risk or

suspected of hearing deficit

to an appropriate specialist.

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

151

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 5, con’t.

Age of Child

Recommended (S) or

Required (R)

Services

4, 8, 14, 16, 20 years S

Subjective screening, by

history and/or other

method; refer child with

suspected hearing deficit to

an appropriate specialist.

10, 12, 18 years R

Objective hearing screening

by a standard testing

method; (hearing tests are

given by Indiana Dept. of

Education in grades 1, 4,7,

and 10 – several schools

also test kindergarten

students). Do not duplicate

school screenings unless a

child is considered at risk

and rescreening is

warranted.

Blood lead screenings must be performed at the nine-month, 12 month, and 24 month

visits. If the member is at high risk for lead exposure, the initial screening should be

done at the six-month visit. The OMPP recommends that blood samples drawn for lead

screening be sent to labs participating in the Indiana Childhood Lead Poisoning

Prevention Program (ICLPPP). Providers that send blood samples to ISDH/ICLPPP

laboratories can use code 36415, collection of venous blood by venipuncture, to indicate

that blood draws were made. Sending blood samples to a participating lab ensures that

the results are recorded in the ILCPPP database. The three ILCPPP laboratories are the

Vanderburgh County Department of Health, Marion County Department of Health, and

the Indiana State Department of Health in Marion County. The ILCPPP provides

medical supplies, mailing containers and postage for providers registered in the program

and tracks blood lead screening results geographically to identify areas at risk. The IHCP

will not reimburse a conveyance fee for sending samples to the lab if the ILCPP postage

paid kit is used. Providers that send blood sample to private labs should use the codes in

Table 2, as appropriate.

Table 6: CPT Codes for Blood Samples Sent to Private Labs

CPT

Code

Definition

36415 Collection of venous blood by venipuncture

99000

Handling and/or conveyance of specimen for transfer from

physician’s office to a laboratory

99001

Handling and/or conveyance of specimen for transfer from the patient in other

than a physician’s office to laboratory (distance may be indicated)

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

152

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Vaccines for Children

The Vaccines for Children (VFC) program is a federally funded program that works to

raise childhood immunization levels in the United States by supplying health care

providers with free vaccines for children 18 years old and younger. To be eligible for the

VCF program, a child must meet one of the following criteria.

• Enrollment in IHCP

• Without health insurance

• Identified by parent or guardian as American Indian or Alaskan native

• Underinsured, for example, the child has health insurance that does not

cover immunizations

The VFC program currently offers free vaccines against the following diseases.

• Diphtheria

• Hemophilus influenza type B (Hib)

• Hepatitis B(HepB)

• Measles, mumps and rubella (MMR)

• Pertussis (Whooping cough)

• Polio

• Tetanus

• Varicella (Chickenpox)

• Pneumoccocal disease

IHCP providers are not required to participate in this program. If a provider chooses not

to participate in this program, they must provide appropriate vaccine referrals, patient

follow-up, and documentation of immunization history. If a Hoosier Healthwise provider

chooses not to participate in the program, they must have a mechanism in place to ensure

that members under their care are immunized.

VFC vaccines provided by fee-for-service providers are reimbursed at the lesser of the

submitted charge or the current VFC administration fee. Reimbursement under the

RBMC delivery system is administered by the managed care organizations.

To bill the IHCP for VFC vaccine administration ICD-9 code V20.2 must be the primary

diagnosis and the appropriate procedure code for the specific vaccine being administered.

Providers are not to bill for more than the VFC vaccine administration time on the date of

service. The IHCP only allows one vaccine administration fee per encounter, regardless

of the number of vaccines given at one time. If the only service provided during the

encounter is vaccine administration, the provider may not bill for an office visit. An

office visit can only be billed if a separate, identifiable service is performed during the

same visit Table 7 shows the procedure codes for vaccines covered in the VFC program.

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

153

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 7: Procedure Codes for VFC Vaccines

Procedure

Code

Vaccine

90645

Hemophilus influenza b vaccine (Hib), HbOC conjugate

(4 dose schedule), for intramuscular use

90647

Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate

(3 dose schedule), for intramuscular use

90648

Hemophilus influenza b vaccine (Hib) PRP-T conjugate

(4 dose schedule), for intramuscular use

90655

Influenza Virus Vaccine, split virus, preservative free, for children 6-35

months dosage, for IM or jet injection use, per 0.25 ml

90656

Influenza Virus Vaccine, split virus, preservative free, for children and

adults three years of age and above, dosage for IM or jet injection use,

per 0.5 ml

90657

Influenza Virus Vaccine, split virus, for children 6-35 months dosage, for

IM or jet injection use, per 0.25 ml

90658

Influenza Virus Vaccine, split virus, for children and adults three years

of age and above, dosage for IM or jet injection use, per 0.5 ml

90660 Influenza virus vaccine, live, for intranasal use

90669

Pneumoccocal Conjugate, polyvalent, for children under 5 years for

intramuscular use

90700 DTaP

90702 DT

90707 MMR

90713 Inactivated Polio Vaccine (e-IPV)

90716 Varicella

90718 Td

90721 DTaP-HIB

90723 DTaP-IPV-HepB, brand name Pedirix

90744 HEP B-Ped

90748 HepB-Hib combination, brand name Comvax

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

154

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

EPSDT-HEALTHWATCH FACT SHEET

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the EPSDT-Healthwatch Fact Sheet. The information in this addendum will

be incorporated into the fact sheet at the next review.

Provider Notification: NL200506 Publication Date: 06/2005

Subject: Vaccines for Children and Injectables

Date Added to Manual: 07/29/2005

Text of Publication

Provider-Purchased Vaccine

When a provider administers immunizations using the provider’s private stock, refer to

IHCP provider bulletin, BT200151, for use of the administration code 90788, as

appropriate, for the additional $2.75 rate.

Administration Fee

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 90788. When billing for privately purchased

vaccine, bill an administration code in addition to the CPT code to obtain reimbursement

for both vaccine and its administration. Do not bill an administration CPT code when

billing for VFC vaccine. VFC vaccines must be billed with the CPT code for the vaccine

and the provider’s charge (not to exceed $8) for VFC vaccine administration. Medicaid

maximum fee information can be found on the www.indianamedicaid.com 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 submitting RHC and FQHC claims to track encounters (such claims will be

denied), 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 providerpurchased meningococcal vaccine. All

immunization dollars should be included and totaled on the line specific for

immunizations in cost reports submitted to Myers & Stauffer.

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

155

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 EPSDT – Health Watch

Medical Policy Manual

156

EPSDT-HEALTHWATCH FACT SHEET

ADDENDUM B

Note: This addendum contains provider notifications that have been published since the

review of the EPSDT Healthwatch Fact Sheet. The information in this addendum will be

incorporated into the fact sheet at the next review.

Provider Notification: BR200539 Publication Date: 09/27/2005

Subject: EPSDT Annual Exam or Well-Baby Exam

Date Added to Manual: 10/31/2005

Text of Publication

This notification clarifies the policy and billing requirements regarding problem-oriented

exams rendered on the same date as an EPSDT annual exam or well-baby exam. The

HealthWatch Provider Manual states, “If a patient is evaluated and treated for a problem

during the same visit as an EPSDT annual exam or well child service, the problem-

oriented exam can be billed separately accompanied by the -25 modifier (separate

significantly identifiable E&M service). The problem must require additional moderate

level evaluation to qualify as a separate service on the same date.”

Some have interpreted this statement from the manual to mean that Evaluation and

Management (E&M) codes 99211, 99212, or 99213 could not be reimbursed if provided

on the same date as the EPSDT annual or well baby exam. This is incorrect.

IHCP reimburses for all E&M codes billed by a physician who is providing a problem-

oriented exam on the same date as the EPSDT annual or well-baby exam. This includes

E&M codes 99211 through 99215. These services should be billed with modifier -25 to

identify a separate significantly identifiable E&M service.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: EVALUATION AND MANAGEMENT SERVICES

DESCRIPTION

Evaluation and management (E&M) services are those that are provided for the

assessment of a member’s health or condition and direction of a member’s health care.

E&M services must include the following three components: (1) obtaining a medical and

social history, (2) a physical examination, and (3) medical decision making.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs (IHCP) policies regarding this service. More specific information may be

found in the IHCP provider manual, program notices, the Indiana Administrative Code

(IAC) or other appropriate sources. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

E&M services must be appropriate to the diagnosis and treatment given, and providers

are advised to select the CPT code that most closely describes the services rendered, and

includes the three components listed above. IHCP reimbursement is available for office

visits, limited to a maximum of 50 per year, per member, without prior authorization

(PA). If a physician uses an emergency room as a substitute for the physician’s office for

nonemergency services, such services should be billed as office visits with the site of

service indicated.

New patient office visits are limited to one per member, per provider within the last three

years. A new patient is one who has not received any professional services from a

provider within the same specialty and group practice, within the preceding three years.

If a surgical procedure is performed during the course of an office visit, the surgical fee

includes the medical visit unless the member has never been seen by the provider prior to

the surgical procedure, or the determination to perform surgery is made during the

evaluation of the member. If an evaluation of a separate clinical condition is performed

on the same day as the surgery, both the evaluation and the surgery may be billed

separately.

The IHCP will provide reimbursement for eye examinations that are reported using an

appropriate E&M code. Providers are advised to select the most descriptive code for the

01/31/2007 Evaluation and Management Services

Medical Policy Manual

157

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

service rendered from the E&M codes listed in Table 1. Refer to the Medical Policy fact

sheet for Ophthalmological Services for further information.

Table 1 – Evaluation and Management Services to Report Eye Examinations

CPT Code Description

92002 – 92014 Ophthalmological services: medical examination and evaluation with

initiation of diagnostic treatment program

99201 – 99205 Office or other outpatient visit for the evaluation and management of a

new patient

99211 – 99215 Office or other outpatient visit for the evaluation and management of an

established patient

99241 – 99245 Office consultation for a new or established patient

99251 - 99255 Initial inpatient consultation for a new or established patient

99261 - 99263 Follow-up inpatient consultation for an established patient

99271 - 99275 Confirmatory consultation for a new or established patient

An initial prenatal visit can be reported with the appropriate E&M codes (CPT codes

99201 through 99215), and the appropriate trimester modifier and the expected date of

delivery. Additionally, outpatient office visits rendered to pregnant members, if related

to a concurrent medical condition requiring medical care or consultative referral, are to be

reported with the appropriate E&M codes. Medical problems that complicate labor and

delivery management may require additional resources that are reported utilizing an

appropriate E&M code. Refer to the Medical Policy fact sheet for Obstetrical Services

for further information.

PRIOR AUTHORIZATION

E&M services as described in Table 2, which exceed 50 visits, per rolling calendar year,

per member require prior authorization (PA). Additionally, PA is required for any

physician service that is rendered during an inpatient hospital stay and reimbursed using a

level-of-care methodology, such as psychiatric, rehabilitation, and burn treatment.

Table 2 – Evaluation and Management Services Requiring PA After 50 Visits Per

Member Per Rolling Calendar Year

CPT Code Description

99201 – 99205 Office or other outpatient visit for the evaluation and management of a new patient

99211 – 99215 Office or other outpatient visit for the evaluation and management of an established

patient

99241 – 99245 Office consultation or a new or established patient

99271 - 99275 Confirmatory consultation for a new or established patient

99381 – 99387 Initial comprehensive preventive medicine evaluation and management of an

individual

99391 – 99397 Periodic comprehensive preventive medicine reevaluation and management of an

individual

01/31/2007 Evaluation and Management Services

Medical Policy Manual

158

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for guidelines about E&M codes specific to

the MCO. Refer to the Provider Manual, Chapter 1, for detailed information about the

fee-for-service (FFS), Primary Care Case Management (PCCM), and Risk Based

Managed Care (RBMC) delivery systems.

IHCP members enrolled in Hoosier Healthwise PrimeStep (PCCM) receive the same

benefit coverage, and are subject to the same limitations as traditional Medicaid FFS.

Refer to the Hoosier Healthwise Manual for Primary Medical Providers and Office Staff

for further information.

Hoosier Healthwise providers must report family planning office visits with the

appropriate E&M codes for the initial and each established patient office or outpatient

visit. Appropriate documentation should be maintained in the member’s medical record

to support the level of coding appropriate to the service rendered.

BILLING REQUIREMENTS

Professional services rendered during the course of a hospitalization must be submitted

on the CMS-1500 or via an 837P electronic transaction. If a physician uses an emergency

department as a substitute for the physician’s office for nonemergency services, these

visits should be billed with a CPT code used for a visit in the office with the site of

service indicated. Providers who perform procedures in an outpatient setting or place of

service 22, 23, or 62, which are normally provided in a physician's office, are subject to a

site of service payment adjustment, which is 80 percent of the practice expense

component of the statewide RBRVS IHCP Fee Schedule. The IHCP does not provide

reimbursement for E&M codes reported with treatment room or emergency room revenue

codes 45X, 51X, 52X, 70X, 71X, 72X, and 76X.

New patient office visits are limited to one visit per member, per provider, within the last

three years. A new patient is one who has not received any professional services from a

provider within the same specialty and group practice, within the preceding three years.

If a surgical procedure is performed during the course of an office visit, the surgical fee

includes the medical visit unless the member has never been seen by the provider prior to

the surgical procedure, or the determination to perform surgery is made during the

evaluation of the member. If an evaluation of a separate clinical condition is performed

on the same day as the surgery, both the evaluation and the surgery may be billed

separately. Providers are advised to report the appropriate E&M code with Modifier 25,

Significant, separately identifiable evaluation and management service by the same

physician on the same day of the procedure or other service, to indicate that there was a

significant, separately identifiable E&M service by the same physician on the same day

of a procedure. Modifier 57, Decision for surgery, is to be reported to indicate that an

01/31/2007 Evaluation and Management Services

Medical Policy Manual

159

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

E&M service resulted in the initial decision to perform surgery. Appropriate documentation must

be included in the medical record to substantiate the need for an office visit code in

addition to the procedure code on the same date of service.

The first prenatal visit can be billed with E&M codes, CPT codes 99201 through 99215,

with the appropriate trimester modifier and the expected date of delivery indicated on the

CMS-1500 or 837P electronic transaction.

RELATED MEDICAL TOPICS

Chiropractic Services

Clinic Services – FQHC and Rural Health Clinic Services

Consultations – Second Opinion

Emergency Medicine – Emergency Services

EPDST

Family Planning

Hospital Inpatient

Hospital Outpatient

Obstetric Services

Ophthamological Services

Podiatry

RULES, CITATIONS, AND SOURCES

405 IAC 5-9-1 - Evaluation and Management Services

Hoosier Healthwise Manual for Primary Medical Providers and Office Staff

January 2003

Hoosier Healthwise EPSDT Provider Manual

Version 1.0, February 2002

Indiana Health Coverage Programs Provider Manual

1999

Version 5.1, March 2005

Indiana Health Coverage Programs Provider Bulletins

BT199916 – Changes in Policy and Billing of Vision Services

BT200136 – Outpatient Hospital and Ambulatory Surgical Centers

01/31/2007 Evaluation and Management Services

Medical Policy Manual

160

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Origination Date: 12/31/2000

Revisions and

Review

Reason Date

Revision

407 IAC 5-9-9 Transferred - Second

Opinions

470 IAC 5-9-10; 5-9-11 Transferred -

Office Visits

7/1/91

Revision

405 IAC 1-7-9 - Second Opinions -

Repealed 8/24/97

405 IAC 5-9 - Evaluation and

Management Services

1/1/92

Review Scheduled Review 10/31/05

APPLICABLE INDIANAAIM EDITS AND AUDITS:

4108 – No ASC on file.

6004 – Established Intermediate Office Visit (One Every 30 Days)

6005 – Established Extended Office Visit (One Every 60 Days)

6006 – Only One New Patient Visit per Three Years

6009 – Medical Versus Medical Overlaps Previous In-Hospital Care

6010 – Excessive Physical Exam/One Physical Exam (Same Provider Within 12 Months)

6012 – Medical Services 30 per Rolling Calendar Year

6013 – Multiple In-Hospital Visits Same Day Same Provider

6014 – Global Payable at a Reduced Fee When Components Paid – Respiratory System

6019 – Initial or Established Visits Not Payable Same Date of Service as W6511 or

W6512

6027 – Select Medical Services Reimbursable Only Once per Day

6028 – Initial and Periodic Visits Not Payable Same DOS (EPSDT)

6041 – E&M Codes Not Reimbursable with Prenatal Codes

6042 – Prenatal Codes Not Reimbursable with E&M Codes

6064 – Components Not Payable When Global Paid – Medical System

6069 – Office Visits 50 per Year

6082 – Nursing Facility Visits Versus DME Service

6090 – Office Visits Limited to One per Year - Podiatrist

6091 – One Initial Office Visit per Member - Podiatrist

6096 – CPT/HCPCS Code Billed is Not Payable According to the PPS Reimbursement

Methodology

6098 – Chiropractic Services Limited to Procedure and Diagnosis Codes Identified

6099 – Reimbursement is Limited to 50 Chiropractic Services

6101 – Chiropractic Restrictive Office Visits Codes (New Patient)

6102 – Chiropractic Office Visit Limited to Five per Year

6111 – Chiropractic Office Visits Limited to Five (5) per Calendar Year

6150 – Consultation Billed 15 Days Before or After Another Consultation

6151 – Consultations Billed Seven Days Before or After Surgery

01/31/2007 Evaluation and Management Services

Medical Policy Manual

161

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Evaluation and Management Services

Medical Policy Manual

162

6152 – Surgery Payable at Reduced Amount When Consultation Paid Days Before or

After Surgery

6211 – Periodic/Limited Oral Eval Limit One Every Six Months

6508 – Same Day Discharge

6610 – Routine Vision Exam Limited to One Exam per Twelve (12) Months for ages 1-

18 years

6611 – Routine Vision Exam Limited to One Exam per Twenty-four (24) Months for

ages 19-999 years

6637 – Drug Administration is Not Payable on the Same DOS

6649 – Surgery Payable at Reduced Rate Amount When Related Postoperative Care Paid

6650 – Lifetime Procedures are Limited to One per Lifetime

6653 – Postoperative Care Within Zero to 90 Days of Surgery

6654 – Preoperative Care Within One Day of Surgery

6655 – Surgery Payable at Reduced Amount When Preoperative Care Paid

6656 – Postoperative Care Within 10 Days of Select Surgery

6657 – Preoperative Care on Day of Surgery

6658 – Surgery Payable at Reduced Amount When Preoperative Care Paid Same Date of

Service

6659 – Surgery Payable at Reduced Amount When Related Postoperative Care Paid

6660 – Preoperative and Postoperative Care Billed With Unlisted Surgeries Requires

Review

6858 – Excessive Nursing Home Visits – More Than One per 27 Days

6903 – PCCM Office Visits Greater than 30 Visits per Member per Year Requires PA

6911 – Therapeutic or Diagnostic Injection

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: FAMILY PLANNING

DESCRIPTION

Family planning services are those services provided to individuals of childbearing age to

temporarily or permanently prevent or delay pregnancy. Such 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 examinations

♦ 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 ligations, Essure sterilization procedure

♦ Vasectomies

♦ Abortions, in accordance with 405 IAC 5-28-7 (consult the MP fact sheet entitled

“Abortion.”)

SUMMARY OF CURRENT POLICY

Indiana Health Coverage Programs (IHCP) reimbursement is available for family

planning services rendered by IHCP enrolled providers, including but not limited to

physicians, certified nurse-midwives, family planning clinics, and hospitals. The IHCP

does not place any restrictions on access to family planning services for members of

childbearing age and who desire such services and supplies. Hoosier Healthwise

members may obtain information about accessing family planning services from their

Primary Medical Provider (PMP).

PAP smears are included as a family planning service if performed according to the

United States Preventative Services Task Force Guidelines. The Task Force has

01/31/2007 Family Planning

Medical Policy Manual

163

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

concluded that most cases of cervical cancer occur in women who are not screened

adequately. The guidelines recommend cervical cancer screening every one to three

years, based on the presence of risk factors such as early onset of sexual intercourse and

multiple sexual partners. However, PAP smear annual frequency may be reduced if three

or more annual smears are normal.

IHCP reimbursement for abortions is available only if the procedure is performed to

preserve the life of the pregnant woman or in other circumstances when the abortion is

required to be covered by Medicaid under federal law. The IHCP reimburses for medical

abortion by oral ingestion of medication using the same coverage criteria applicable to

surgical abortions. For more information on abortion guidelines, please consult the MP

fact sheet entitled “Abortion.”

RELATED MEDICAL TOPICS

Abortion

Clinic Services – FQHC and Rural Health Clinic Services

EPDST

Gynecology – Pelvic Exam under Anesthesia

Gynecology – Services Requiring Prior Authorization

Pharmacy

Sterilization

RULES, CITATIONS, AND SOURCES

42 CFR 441.20 Family Planning Services

42 CFR 431.51(b)(2) Free Choice of Providers

IC 12-15-5 Services Provided

IC 16-36-1-3 – Consent to own health care; minors

405 IAC 5-24-7 Pharmacy Services-- Copayment for legend and nonlegend drugs

405 IAC 5-22-3 Nursing and Therapy Services-- Certified nurse midwife services

State Medicaid Plan 08/01/95

Social Security Act, Section 1905 (a)(4)(C)

Indiana Medicaid Update Bulletin 95-17

Indiana Medicaid Update Bulletin 96-38

Indiana Medical Assistance Program Provider Manual 1994

Indiana Health Coverage Programs Provider Manuals 1999, 2002, and 2004

HealthWatch EPSDT Provider Manual, Version 1.0, February 2002

Hoosier Healthwise Manual for Primary Medical Providers and Office Staff, January

2003

Indiana Health Coverage Programs Newsletter NL200403

Indiana Health Coverage Programs Newsletter NL200405 – Essure Sterilization

Indiana Health Coverage Programs Bulletin BT200433

01/31/2007 Family Planning

Medical Policy Manual

164

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Indiana Health Coverage Programs Newsletter NL200412

State of Indiana Request for Proposals (RFP) 4-79 –“Solicitation for Managed Care

Organization Services”

ORIGINATION, REVIEWS, AND REVISIONS

Origination date: 12/31/2000

Review and Revisions Reason Date

Revision –Bulletin 96-38

MCO’s coverage of Family

Planning

7/1/91

Revision - 470 IAC 5-8-19

Transferred

Nursing and Therapy Services 7/1/91

Revision - 405 IAC 1-6-20 Repealed

08/24/97

Nursing and Therapy Services 1/1/92

Revision - 405 IAC 1-6-21.1

Repealed 08/24/97

Family Planning and Pharmacy

Services

11/4/93

Revision - State Medicaid Plan

Family Planning and Copay

exemptions

8/1/95

Revision - 405 IAC 5-24-7

Pharmacy Services-- Copayment

For Legend And Nonlegend

Drugs

8/24/97

42 CFR 441.20 Family Planning Services

405 IAC 5-22-3

Nursing And Therapy Services--

Certified Nurse Midwife Services

8/24/97

IC 12-15-5-1 Services Provided

Public Law 2-1992, SEC. 9;

Amended by Public Law 24-

1997, SEC. 48; Public Law 149-

2001, SEC.1.

405 IAC 1-8-4 Client copayment

12/02/93,

readopted

6/27/01

Review and Revision

Scheduled review, Essure

Sterilization Procedure, Medical

Abortion by Oral Medication

1/31/05

APPLICABLE INDIANAAIM EDITS AND AUDITS

1011 – Member’s PMP Is Missing

6704 – Family Planning/One Within 12 Months

6998 – Sterilization Consent Form Improperly Completed

01/31/2007 Family Planning

Medical Policy Manual

165

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

COVERAGE CRITERIA

Contraception

Norplant and related services are reimbursable once per member, per five years. If

removal and re-implantation at the same or different incision site is performed prior to

five years from the previous implantation, reimbursement is available for the removal

only. Specific information for reimbursement of the Norplant system is available in the

Provider Manual, Chapter 8.

Condoms are considered medically necessary for men and women in the prevention of

pregnancy and to reduce the risk of sexually transmitted disease. Therefore,

reimbursement is available for HCPCS code A4267, Contraceptive supply, condom, male

for both male and female IHCP members.

Sterilization (Essure device)

The IHCP covers the Essure implant device as a sterilization option. Essure is an implant

device providing a non-incision permanent sterilization option. The implant can be

performed by a medical doctor (MD) or a doctor of osteopathy (DO) trained in the

procedure and can be performed in the office, at an outpatient hospital facility, or in an

Ambulatory Surgical Center (ASC).

An outpatient hospital facility or ASC must adhere to the following billing instructions to

receive reimbursement in addition to the outpatient ASC rate. No additional

reimbursement is available if the service is performed in an inpatient setting.

♦ Outpatient hospitals and ASCs must bill for the device using HCPCS code A9900,

Miscellaneous supply, accessory, and or service component of another HCPCS

code on the CMS-1500 claim form under their professional number or durable

medical equipment (DME) number.

♦ Outpatient hospitals and ASCs must submit a cost invoice with the claim to

support the actual cost of the device. Reimbursement will be the lesser of the

following amounts.

- 130 percent of the amount listed on the cost invoice

- The provider’s usual and customary charge

- The Statewide maximum

♦ Providers must submit a valid, signed Sterilization Consent Form with the

claim.

♦ Providers must enter ICD-9-CM V25.2 – Sterilization as the primary

diagnosis on the claim.

♦ Providers must print “Essure Sterilization” in the body of the claim form or on

the accompanying invoice.

The following instructions must be followed when the procedure is performed in the

office.

01/31/2007 Family Planning

Medical Policy Manual

166

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Providers must submit the professional service on the CMS-1500 claim form

using Current Procedural Terminology (CPT) code 58565, Hysteroscopy,

surgical; with bilateral fallopian tube cannulation to induce occlusion by

placement of permanent implants.

♦ Providers must submit the signed Sterilization Consent Form with the claim.

♦ Providers must bill the device on a separate line item on the claim using HCPCS

code A9900.

♦ Providers must submit a cost invoice with the claim to support the actual cost of

the device. Reimbursement is the lesser of the following amounts.

- 130 percent of the amount listed on the cost invoice

- The provider’s usual and customary charge

- The statewide maximum

Sexually Transmitted Diseases (STDs)

Based on CMS’ policies, initial diagnosis and treatment of STDs, HIV testing and

counseling provided during a family planning encounter are considered 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. Referral to the primary medical provider

should be made for ongoing treatment and follow up of chronic STDs to maintain

continuity of patient care.

BILLING INFORMATION

Services and supplies not classified as drugs or biologicals must be billed using the CMS

claim form 1500 or 837P. These services should be billed using appropriate CPT or

HCPCS codes and appropriate ICD-9-CM diagnosis codes for the services rendered or

the condition treated.

Physicians and family planning clinics using the appropriate NDCs on the IFSSA Drug

Claim Form can bill for contraceptive pills, devices, and supplies, including Norplant.

For specific information regarding claims filing, refer to the IHCP Provider Manual,

under Family Planning Services.

Family planning services and supplies furnished to members of child-bearing age are

exempt from the pharmacy services co-payment requirement, including oral

contraceptives. Pharmacy services provided to RBMC members follow the specific

guidelines of the appropriate MCO.

Specific billing information for the Essure device is available in the Coverage Criteria

section of this fact sheet.

01/31/2007 Family Planning

Medical Policy Manual

167

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Hoosier Healthwise/Risk Based Managed Care

Family planning services under Federal regulation 42 CFR 431.51(b)(2) require a

freedom of choice of providers and access to family planning services and supplies.

Family planning services are those services provided to individuals of childbearing age to

temporarily or permanently prevent or delay pregnancy including, but not limited to, birth

control pills. Hoosier Healthwise members may not be restricted in choice of a family

planning service provider. The IHCP Provider Manual provides a complete and current

list of family planning services.

The MCOs participating in Hoosier Healthwise must allow their members to obtain birth

control pills on a self-referral basis. OMPP recognizes the need for appropriate

management of prescription medication in the interest of the member’s health; however,

OMPP also recognizes the importance of removing barriers to family planning services.

To reduce potential barriers to obtaining birth control pills, which may include, but may

not be limited to, transportation to pharmacies for periodic refills, the MCOs must, at a

minimum, reimburse for the dispensation of up to a 90 calendar day supply for birth

control pills at one time per member, if prescribed.

For more information on family planning in the Risk Based Managed Care program,

please consult the individual MCO.

Hoosier Healthwise/Primestep

The Hoosier Healthwise Manual for Primary Medical Providers (PMPs) and Office Staff

Section 4.12, Family Planning, page 23, indicates family planning is covered in the

following manner.

Members may seek family planning services from any qualified IHCP enrolled provider

without PMP authorization. However, if a family planning provider diagnoses a

particular condition in a member and subsequently initiates treatment (i.e. sexually-

transmitted diseases) the family planning provider must refer the patient back to the PMP

if treatment continues for more than one month. At that time, the PMP will assume case

management and determine whether or not further treatment is medically necessary. If

additional treatment is required, the PMP may either continue treatment at the PMP site

or authorize the family planning provider to do so.

01/31/2007 Family Planning

Medical Policy Manual

168

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Family Planning

Medical Policy Manual

169

FAMILY PLANNING FACT SHEET

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the Family Planning Fact Sheet. The information in this addendum will be

incorporated into the fact sheet at the next review.

Provider Notification: BR200539 Publication Date: 09/27/2005

Subject: HCPCS code J7303, Contraceptive supply, hormone

containing vaginal ring, each, and J7305, Contraceptive

supply, hormone containing patch, each

Date Added to Manual: 10/31/2005

Text of Publication

This article advises providers that the Indiana Health Coverage Programs (IHCP) has

approved coverage of Healthcare Common Procedure Coding System (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 they

are more specific to the service being supplied. HCPCS code J7303 reimburses a max fee

rate of $41.48 and HCPCS code J7304 reimburses a max fee rate of $14.31. Direct

questions about this article to customer assistance at (317) 655-3240 in the Indianapolis

local area or 1-800-577-1278.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: GASTROENTEROLOGY

DESCRIPTION

Gastrointestinal disorders are disorders that affect the digestive system including, but not

limited to, the esophagus, stomach, small intestines, and large intestines. Such disorders often

simultaneously affect multiple digestive organs. Symptoms associated with these disorders

include, but are not limited to, abdominal pain, flatulence, bleeding, difficulties swallowing,

poor appetite, nausea, and vomiting.

Diagnostic procedures utilized to determine appropriate treatment methods include endoscopy,

computed tomography (CT)/magnetic resonance imaging (MRI), and manometry. Below are

brief descriptions of these diagnostic procedures.

• Endoscopy

This procedure utilizes a flexible tube to view different internal structures. Evidence of

abnormalities such as inflammation, infection, or tumors may be detectable.

Laparoscopy is an examination of the abdominal cavity with an endoscope. Other uses

for this procedure include obtaining tissue samples and reparative procedures.

• Computed Tomography (CT)/Magnetic Resonance Imaging (MRI)

A magnetic field allows cross-sections of organs to be evaluated. The visual image

contains scans of the underlying organs. These diagnostic procedures determine size and

location of abnormalities in organs such as tumors, changes in the path and size of blood

vessels, and inflammation.

• Manometry

A tube connected to pressure gauges is inserted in the esophagus. This test determines

whether the muscle contractions of the esophagus are adequate for swallowing purposes.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs (IHCP) policies regarding this service. More specific information may be found in

the IHCP provider manual, program notices, the Indiana Administrative Code (IAC) or other

sources as appropriate. See the “Rules, Citations, and Sources” section of this document for

further information.

COVERAGE CRITERIA

IHCP reimbursement is available for medically necessary gastrointestinal services for the

evaluation, diagnosis, and treatment of such disorders.

01/31/2007 Gastroenterology

Medical Policy Manual

170

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

PRIOR AUTHORIZATION

Services must be medically reasonable and necessary and required for the care and well-being

of the member. Services must be provided in accordance with generally accepted standards of

medical or professional practice. Gastroplasty and gastrointestinal surgeries require prior

authorization (PA). Services rendered without appropriate PA are noncovered. Refer to the

medical topics cross reference section of this fact sheet and the IHCP Provider Manual for

specific procedure requirements and limitations.

The following information describes the coverage for the diagnostic examinations

computerized tomography and upper gastrointestinal studies. Services rendered outside

of these guidelines are noncovered.

Computerized tomography

Diagnostic examinations performed by computerized tomography (CT) scanners

are covered services and do not require PA. These examinations are subject to the

following guidelines.

• The scan should be reasonable and necessary for the individual member.

• The use of a CT scan must be found to be medically appropriate considering

the member’s symptoms and preliminary diagnosis.

• Reimbursement will be made for CT scans performed with equipment

certified by the Food and Drug Administration.

• CT scans for the treatment of cancer, whole abdomen or whole pelvis areas

(greater than 20 cuts), are reimbursable.

Upper gastrointestinal studies

Medicaid reimbursement is available for upper gastrointestinal (GI) studies when

performed for the detection and evaluation of diseases of the esophagus, stomach,

and duodenum.

• An upper GI study is not a covered service for a patient with a history of

duodenal or gastric ulcer disease unless recently symptomatic.

• An upper GI study is not a covered service in the preoperative

cholecystectomy patient unless symptoms indicate an upper GI abnormality

in addition to the cholelithiasism or if the etiology of the abdominal pain is

uncertain.

BILLING REQUIREMENTS

Multiple diagnostic and operative procedures billed on the same day, by the same provider, are

subject to the IHCP multiple surgery and reimbursement guidelines.

MANAGED CARE ORGANIZATIONS

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for more specific guidelines. Refer to the IHCP

01/31/2007 Gastroenterology

Medical Policy Manual

171

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Provider Manual, Chapter 1, for detailed information about the fee-for-service (FFS), Primary

Care Case Management (PCCM), and RBMC delivery systems.

IHCP members enrolled in Medicaid Select receive the same benefit coverage, and are subject

to the same limitations as Traditional Medicaid FFS. Refer to the Medicaid Select Provider

Manual for Primary Medical Providers and Office Staff for further information.

MEDICAL TOPICS

Anesthesia Services

Bariatric Services

Consultations – Second Opinion Services

Diagnostic Services

Emergency and Evaluation Management Services

Home Health Services

Inpatient Hospital Services

Managed Care Organization Services

Nursing Services

Outpatient Hospital Services

Pharmacy Services

Radiology

Surgery Services

Transplant Services

Weight Reduction Services

RULES, CITATIONS, AND SOURCES

Indiana Administrative Code (IAC)

405 IAC 5-3-13 – Services requiring prior authorization

405 IAC 5-1-5 – Global Fee Billing

405 IAC 5-27-3 – Computerized tomography; general

405 IAC 5-27-5 – Upper gastrointestinal studies

405 IAC 5-28-1 – Medical and Surgical Services; Reimbursement limitations

405 IAC 5-28-2 – Medical and Surgical Services; Medical diagnostic procedures

405 IAC 5-29-1 – Services Not Covered by Medicaid; Noncovered services

Indiana Health Coverage Programs Banner (BR)

BR200513 – Gastrointestinal Tract Imaging

Indiana Health Coverage Programs Bulletin (BT)

BT200306 – All Pharmacy Providers and Prescribing Practitioners

Indiana Health Coverage Programs (IHCP) Provider Manual

1994

1999

2005

01/31/2007 Gastroenterology

Medical Policy Manual

172

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Gastroenterology

Medical Policy Manual

173

Origination Date: 12/31/2000

Revisions and

Reviews

Reason Date

Revision

470 IAC 5-9-1 Transferred

Global Fee Billing

07/01/1991

Revision

405 IAC 1-7-1 Repealed 08/24/1991

Global Fee Billing

01/01/1992

Review

405 IAC 1-7-19 Repealed 08/24/1997

Radiology Services-Upper GI studies

01/01/1992

Review

405 IAC 5-27-5 Radiology Services Upper

gastrointestinal studies

08/24/1997

Review

405 IAC 5-29-1 Services Not Covered By

Medicaid—Noncovered Services

08/24/1997

Revision 405 IAC 5-1-5 Global Fee Billing; Codes 08/24/1997

Review

405 IAC 5-29-1Amended Services Not

Covered By Medicaid—Noncovered Services

10/27/1999

Review Scheduled 10/31/2006

APPLICABLE INDIANAAIM EDITS AND AUDITS

6022– Components not billable when global fee paid

6023– Global payable at a reduced fee when components paid

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: GENETIC TESTING – BRCA1 AND BRCA2 FOR

BREAST AND OVARIAN CANCER

DESCRIPTION

Two genes (BRCA1 and BRCA2)

are associated with susceptibility to breast and

ovarian cancer. Often, family members of those diagnosed with breast or ovarian cancer

share a gene mutation. Therefore, testing of the diagnosed individuals and family

members can identify those family members at higher risk of developing breast or

ovarian cancer. Presence of a gene mutation does not predict the certainty of cancer, but

indicates the individual is at higher risk for developing breast or ovarian cancer and can

utilize increased surveillance and screening measures, as well as make appropriate

lifestyle changes to decrease the likelihood of developing a malignancy.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding this service. More specific information may be

found in the IHCP provider manual, program notices, the Indiana Administrative Code

(IAC) or other sources, as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

The IHCP provides reimbursement for BRCA1 and BRCA2 genetic testing when

determined to be medically necessary for women with a personal history of breast cancer,

developing contralateral disease (disease in the opposite breast), or families with history

of breast and ovarian cancer. IHCP members referred to an oncologist or geneticist for

BRCA1 and BRCA2 testing must have a completed personal and family cancer history

that should include three generations on both maternal and paternal sides of the family in

the member’s medical record to include the following.

a. relatives with breast, ovarian, and other relevant cancers, such as prostate

and colon cancer

b. age at diagnosis in affected family members

c. other significant factors, such as ethnic background

The acronym BRCA has been given to the genes that are specific to breast and ovarian cancer.

01/31/2007 Genetic Testing – BRCA1 and BRCA2 for Breast and Ovarian Cancer

Medical Policy Manual

174

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

PRIOR AUTHORIZATION

Prior authorization will be given for BRCA1 and BRCA2 genetic testing, utilizing the

HCPCS codes listed in Table 1, when medically necessary in the following

circumstances.

1. Clinically affected individuals (invasive breast cancer or ovarian cancer at any

age) meeting at least one of the following criteria.

a. One or more first (mother, father, sister, or daughter) or second-degree

(aunt, uncle, grandmother, niece, or granddaughter) relatives with

invasive breast cancer diagnosed before age 50

b. One or more first or second-degree relatives with ovarian cancer

c. One or more first or second-degree relatives with male breast cancer

2. Individuals with a personal history of at least one of the following (no family

history required).

a. Invasive breast cancer before age 50

b. Ovarian cancer at any age

c. Both invasive breast cancer and ovarian cancer at any ages

d. Male breast cancer at any age

3. Individuals with a family member (related by blood) with a known BRCA1 or

BRCA2 mutation.

4. Individuals with Ashkenazi (Eastern European) Jewish ancestry with invasive

breast cancer at any age, or meeting any of the above listed (1-3) criteria.

Table 1–HCPCS Codes for Reporting BRCA Genetic Testing

HCPCS

Code

Description Comments

S3818

Complete gene sequence

analysis; BRCA1 gene

S3819

Complete gene sequence

analysis; BRCA2

S3818 and S3819 are not covered for ICD-9-CM

diagnosis codes in Table 2. (Refer to S3820.)

However, reimbursement may be available for

testing for other types of cancer, such as

pancreatic carcinoma.

S3820

Complete BRCA1 and

BRCA2 gene sequence

analysis for susceptibility to

breast and ovarian cancer

S3820 encompasses the testing for all the

genetic variations involving BRCA1 and

BRCA2. 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

BRCA1 or BRCA2 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 known to have BRCA1 or BRCA2

mutation.

01/31/2007 Genetic Testing – BRCA1 and BRCA2 for Breast and Ovarian Cancer

Medical Policy Manual

175

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1–HCPCS Codes for Reporting BRCA Genetic Testing

HCPCS

Description Comments

Code

S3823

Three-mutation BRCA1 and

BRCA2 analysis for

susceptibility to breast and

ovarian cancer in Ashkenazi

individuals

S3823 reports genetic testing for individuals of

Ashkenazi Jewish descent. Since there are

known to be fewer and more specific changes in

this population group, the amount of testing

required is significantly less than the general

population.

Men rarely develop breast cancer and, thus, there may not be an affected first-degree

relative, and the size of the family may not permit analysis of possible autosomal

dominant inheritance.

BRCA testing of men with breast cancer is considered medically

necessary for either of the following indications.

1. To assess the man’s risk of recurrent breast cancer; or

2. To assess the breast cancer risk of a female member where the affected male is a

first or second degree blood relative of that member. BRCA1 and BRCA2

testing to assess the risk of breast or prostate cancer in men without breast cancer

is considered not medically necessary.

MANAGED CARE

Hoosier Healthwise members enrolled in risk-based managed care (RBMC) are allowed

to receive genetic testing services for breast and ovarian cancer that are determined to be

medically necessary. Hoosier Healthwise members that are enrolled in RBMC are the

financial responsibility of the managed care organization (MCO) in which the member is

enrolled. The MCO may have its own requirements for authorization of genetic testing

services; therefore, providers must contact the MCO for further information.

BILLING REQUIREMENTS

The IHCP provides reimbursement for BRCA1 and BRCA2 genetic testing billed with

the appropriate HCPCS codes, noted in Table 1, and with the appropriate ICD-9-CM

diagnosis code, reflected in Table 2 on the next page.

HCPCS codes S3820, S3822, and S3823 are limited to once per lifetime. If the member

has S3820 completed, the IHCP will not provide reimbursement for S3822 and S3823.

HCPCS codes S3818 and S3819 will not be covered for the ICD-9-CM diagnosis codes

noted in Table 2. S3818 and S3819 are components of S3820.

This is a type of genetic inheritance which can be inherited form a single affected parent. Sons and

daughters have an equal chance of inheriting the gene.

01/31/2007 Genetic Testing – BRCA1 and BRCA2 for Breast and Ovarian Cancer

Medical Policy Manual

176

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 2 – 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

174.9 Malignant neoplasm of female breast; unspecified

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

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 of breast

V10.43 Personal history of malignant neoplasm of ovary

V16.3 Family history of malignant neoplasm of breast

V16.41 Family history of malignant neoplasm of ovary

RELATED MEDICAL TOPICS

Laboratory Services

Oncology – Breast and Ovarian Cancer

RULES, CITATIONS, AND SOURCES

Indiana Administrative Code

405 IAC 5-3-13

Indiana Health Coverage Programs Provider Manual

Version 5.1, March 2005

Indiana Health Coverage Programs Provider Notifications

BT200605 – Billing Requirements and PA Criteria

01/31/2007 Genetic Testing – BRCA1 and BRCA2 for Breast and Ovarian Cancer

Medical Policy Manual

177

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Genetic Testing – BRCA1 and BRCA2 for Breast and Ovarian Cancer

Medical Policy Manual

178

Origination Date: April 28, 2006

Revisions and

Review

Reason Date

APPLICABLE INDINAAIM EDITS AND AUDITS

6177 – S3818, S3819, S3822, S3823 Not Allowed if S3820 Pd

6178 – S3820, S3822, and S3823 Are Limited to Specific Dx

6179 – Genetic Testing Codes not Reimbursed with Specific Dx

6650 – Lifetime Procedures Are Limited to 1 per Lifetime

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: GYNECOLOGY SERVICES

DESCRIPTION

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding gynecologic services. More specific information

may be found in the IHCP provider manual, program notices, the Indiana Administrative

Code (IAC) or other sources as appropriate. See the “Rules, Citations, and Sources”

section of this document for further information.

As defined by Stedman’s Electronic Medical Dictionary , V.5.0

, gynecology is the medical

specialty concerned with diseases of the female genital tract, as well as endocrinology and

reproductive physiology of the female. Many gynecologic conditions create infertility.

CURRENT COVERAGE

A. Pelvic Exam Under Anesthesia

A pelvic exam performed under anesthesia may be done as part of another gynecological

surgical procedure or as a single procedure. The IHCP provides reimbursement when the

member requires anesthesia/conscious sedation to enable the practitioner to complete

the exam. Based on accompanying documentation, medically necessary care

provided prior to surgery will be reimbursed. If the examination is completed in

adjunct with a surgical procedure, it will be included in the global fee schedule with

the appropriate reduction applied.

Procedures requiring prior authorization (PA) cannot be rendered before acquiring

PA. For such services, reimbursement will be denied if PA is not obtained. Prior

authorization must be requested for emergency procedures within 48 hours of the

admission or on the next business day if on a weekend or holiday.

B. Laminaria

Laminaria is derived from a perennial kelp plant, Laminaria digitata, which is

hydrophilic. When placed in the cervical canal, laminaria gradually absorbs moisture,

swells, and gently dilates the cervix. Laminaria is most frequently used to induce

abortion and can be utilized to assist the dilatation of the cervix when labor is

induced.

The IHCP will provide reimbursement for the laminaria, when it is used for induction

of labor and the delivery is paid. When the HCPCS CPT code 59200, Insertion of

cervical dilator (eg, laminaria, prostaglandin) (separate code) appears with a code

01/31/2007 Gynecology Services

Medical Policy Manual

179

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

indicating an abortion procedure, the claim will be denied and documentation of

medical necessity will be requested.

C. Hysterectomy

Hysterectomy is a covered service only when the member has given her informed

consent. The member must have been informed orally and in writing that this

procedure will render her permanently incapable of reproducing, and has signed a

written acknowledgement of receipt of that information. The IHCP does not provide

reimbursement for a hysterectomy performed solely for the purpose of rendering an

individual permanently incapable of reproducing, whether performed as a primary or

secondary procedure.

The “acknowledgement requirement”, which must be signed by the member or

member’s representative, is NOT required in the following situations.

1. The member is already sterile.

2. A life-threatening emergency situation exists for which the physician determines

prior acknowledgement is not possible.

However, in the situations noted above, the physician performing the hysterectomy

must certify one of the following in writing.

1. The member was already sterile at the time the hysterectomy was performed, and

states the cause of the sterility at the time of the hysterectomy.

2. The hysterectomy was performed under a life-threatening emergency situation

and that prior acknowledgement was not possible. The physician must also

include a description of the nature of the emergency.

Retroactive Eligibility

The IHCP will provide reimbursement for hysterectomies performed during a period

of a member’s retroactive Medicaid eligibility, if the physician, who performed the

hysterectomy, certifies in writing one of the following.

1. The member was informed before the operation that the hysterectomy would

make her permanently incapable of reproducing.

2. The member was already sterile before the hysterectomy.

3. The member requires a hysterectomy because of a life-threatening emergency

situation in which the physician determined that prior acknowledgment is not

possible. The physician who performed the hysterectomy must also include a

description of the nature of the emergency.

Documentation Requirements

No specific format is mandated and examples are provided in the IHCP Provider

Manual including the information necessary to satisfy IHCP documentation and

certification requirements for hysterectomy procedures. The sterilization consent

form cannot be used for hysterectomy procedures under any circumstances.

01/31/2007 Gynecology Services

Medical Policy Manual

180

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

PRIOR AUTHORIZATION

The IHCP advises providers to report the appropriate CPT code that describes the service

provided. Table 1 lists CPT codes used to report services that include total or partial

hysterectomies. This list may not be inclusive and PA requirements are as noted.

Table 1 – CPT Codes for Reporting Total or Partial Hysterectomy

CPT

Code

Description

Requirement

51925 Closure of vesicouterine fistula; with hysterectomy No

58150

Total abdominal hysterectomy (corpus and cervix), with or without

removal of tube(s), with or without removal of ovary(s)

Yes

58152

Total abdominal hysterectomy (corpus and cervix), with or without

removal of tubes(s), with or without removal of ovary(s); with

colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz type)

Yes

58180

Supracervical abdominal hysterectomy (subtotal hysterectomy),

with or without removal of tube(s), with or without removal of

ovary(s)

Yes

58200

Total abdominal hysterectomy, including partial vaginectomy, with

para-aortic and pelvic lymph node sampling, with or without

removal of tube(s), with or without removal of ovary(s)

58210

Radical abdominal hysterectomy, with bilateral total pelvic

lymphadenectomy and para-aortic lymph node sampling (biopsy),

with or without removal of tube(s), with or without removal of

ovary(s)

58260 Vaginal hysterectomy, for uterus 250 grams or less Yes

58262

Vaginal hysterectomy for uterus 250 grams or less; with removal of

tubes(s), and/or ovary

Yes

58263

Vaginal hysterectomy for uterus 250 grams or less; with removal of

tubes(s), and/or ovary, with repair of enterocele

Yes

58267

Vaginal hysterectomy, for uterus 250 grams or less; with colpo-

urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type)

with or without endoscopic control

Yes

58270

Vaginal hysterectomy, for uterus 250 grams or less; with repair of

enterocele

Yes

58275 Vaginal hysterectomy, with total or partial vaginectomy Yes

58280

Vaginal hysterectomy, with total or partial vaginectomy; with repair

of enterocele

Yes

58285 Vaginal hysterectomy, radical (Schauta type operation) No

58290 Vaginal hysterectomy, for uterus greater than 250 grams Yes

58291

Vaginal hysterectomy, for uterus greater than 250 grams; with

removal of tube(s) and/or ovary(s)

Yes

58292 Vaginal hysterectomy, for uterus greater than 250 grams; with Yes

01/31/2007 Gynecology Services

Medical Policy Manual

181

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1 – CPT Codes for Reporting Total or Partial Hysterectomy

CPT

Code

Description

Requirement

removal of tube(s) and/or ovary(s), with repair of enterocele

58293

Vaginal hysterectomy, for uterus greater than 250 grams; with colp-

urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type)

with or without endoscopic control

Yes

58294

Vaginal hysterectomy, for uterus greater than 250 grams; with repair

of enterocele

Yes

58550

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250

grams or less

Yes

58552

Laparoscopy surgical, with vaginal hysterectomy, for uterus 250

grams or less; with removal of tube(s) and/or ovary(s)

Yes

58553

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater

than 250 grams

Yes

58554

Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater

than 250 grams; with removal of tube(s) and/or ovary (s)

Yes

58951

Resection of ovarian, tubal or primary peritoneal malignancy with

bilateral salpingo-oophorectomy and omentectomy; with total

abdominal hysterectomy, pelvic and limited para-aortic

lymphadenectomy

58953

Bilateral salpingo-oophorectomy with omentectomy, total

abdominal hysterectomy and radical dissection for debulking

58954

Bilateral salpingo-oophorectomy with omentectomy, total

abdominal hysterectomy and radical dissection for debulking; with

pelvic lymphadenectomy and limited para-aortic lymphadenectomy

58956

Bilateral salpingo-oophorectomy with total omentectomy, total

abdominal hysterectomy for malignancy

59525

Subtotal or total hysterectomy after cesarean delivery (List

separately in addition to code for primary procedure)

Prior authorization will be granted for members with documentation supporting one of

the following.

1. Non-malignant uterine tumor causing abnormal pressure or bleeding (lasting >

eight days for > two cycles, requiring additional bleeding protection defined as

large clots and gushes, limiting activity).

2. Non-malignant uterine tumor causing one of the following.

• Uterus of 12 week gestational size or larger, with ill defined adnexa (<12

week gestational size, or <8 cm could have vaginal procedure).

• Post-menopausal enlargement (>12 week gestational size necessitates

abdominal procedure).

• Rapid uterine growth over last six months.

• Pressure on adjacent organs.

3. Cervical intraepithelial neoplasia (CIN) III diagnosed by endocervical curettage

uncontrolled by conservative surgery, such as laser excision, loop electrosurgical

01/31/2007 Gynecology Services

Medical Policy Manual

182

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

excision procedure (LEEP), large loop excision of transformation zone (LLETZ),

or loop surgical excision.

4. Fibroids in premenopausal woman with both of the following.

• Uterus >12 weeks size or documentation of need for abdominal, rather than

vaginal, approach.

• And one of the following.

 Abnormal bleeding.

 Uterus size doubled within one year.

 Ureteral compression by ultrasound (US) or intravenous pyelogram

(IVP).

 Other symptoms, such as pelvic or abdominal pain or discomfort

without other explanation, urinary frequency or urgency, or

dyspareunia.

5. Fibroids in postmenopausal woman with all of the following.

• Uterus >12 weeks size or documentation of need for abdominal rather than

vaginal approach.

• And one of the following.

 Uterus size doubled within any time period.

 Ureteral compression by US or IVP.

 Other symptoms, such as pelvic or abdominal pain or discomfort

without other explanation, urinary frequency or urgency, or

dyspareunia.

 Papanicolaou (PAP) smear within six months.

6. Dysfunctional uterine bleeding with all of the following.

• Premenopausal woman.

• Abnormal bleeding uncontrolled by conservative therapy, such as hormonal

therapy.

• No evidence of cancer demonstrated by hysteroscopy, endometrial biopsy,

Dilation and Curettage (D&C) or transvaginal ultrasound.

• PAP smear within six months.

7. Postmenopausal bleeding with all of the following.

• Abnormal bleeding continued after change in or discontinuation of hormone

replacement therapy.

• No evidence of cancer demonstrated by hysteroscopy, endometrial biopsy,

D&C or transvaginal ultrasound.

• PAP smear within six months.

8. Pelvic inflammatory disease with one of the following.

• Suspected rupture or leakage of pelvic abscess.

• Unsuccessful management with antibiotics for 10-14 days.

• Surgery for residual, inactive but symptomatic, disease if conservative therapy

not possible.

• Chronic Pelvic Inflammatory Disease (PID) with both of the following.

 Chronic pelvic pain.

 Adhesions, scarring, or hydrosalpinx.

9. Recurrent abnormal uterine bleeding (lasting > eight days for > two cycles,

requiring additional protection defined as large clots and gushes, with limitations

01/31/2007 Gynecology Services

Medical Policy Manual

183

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

of normal activity) and benign endometrial biopsy after failed medication therapy

[excluding members on birth control pills or with an Intrauterine Device (IUD)].

10. Chronic incapacitating pelvic pain, unresponsive to conservative therapy, such as

analgesics, and evidence of normal gastrointestinal/genitourinary (GI/GU)

evaluations.

• A four to six month failed trial of oral contraceptives, diuretics, anti-

inflammatories, or induced amenorrhea.

• Negative examinations of urinary tract (UT), GI tract, and musculoskeletal.

• Psychological and psychosexual counseling reveals no etiology of pain.

11. Post-menopausal bleeding > one year after last menstrual period (LMP), (with

D&C or endometrial biopsy within past six months). Positive cytology of cervix

requires abdominal procedure (cervical intra-epithelial neoplasia including

carcinoma-in-situ).

12. Pre-malignant adenomatous hyperplasia or adenocarcinoma of the endometrium,

confirmed by pathology report.

13. Post-menopausal (> one year) with benign or malignant ovarian tumor and/or

cyst.

14. Abdominal procedure when associated with abdominal procedure for correction

of urinary stress incontinence or vaginal repair of cystocele, rectocele, enterocele,

or uterine prolapse.

15. Uncontrolled postpartum bleeding within six hours of delivery uncontrolled by

drug therapy (e.g., Pitocin, Methergine, or Prostaglandin therapy) or D&C.

16. Endometriosis uncontrolled by hormonal therapy (e.g., depot

medroxyprogesterone, oral contraceptives, GnRH agonist, or danazol), surgical

ablation, or excision.

17. Tubo-ovarian abscess.

18. Urinary incontinence due to fistula into vagina, uterus, or perineum, and fistula

demonstrated by cystoscopy, radiological examination, visual inspection, or

probing.

19. Uterine prolapse, second or third degree and one of the following.

• Pain.

• Pelvic pressure.

• Stress incontinence.

• Ulceration of vaginal mucosa or cervix with bleeding or spotting.

• Vaginal splinting.

BILLING REQUIREMENTS

The appropriate documentation must be attached to the claim form, or sent separately to

the Electronic Claims and Attachments address for claims submitted electronically. All

providers rendering hysterectomy related services (e.g. anesthesiologist, etc.) must attach

an EXACT photocopy of the appropriate sterilization acknowledgement or physician

certification statement(s) to the claim(s). To ensure timely reimbursement, the primary

service provider is advised to forward copies of the sterilization acknowledgement or

physician certification statement(s) to these related service providers.

01/31/2007 Gynecology Services

Medical Policy Manual

184

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

For members enrolled in Risk Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for specific guidelines. Refer to the IHCP

Provider Manual, Chapter 1, for detailed information about fee-for-service (FFS),

Primary Care Case Management (PCCM), and Risk Based Managed Care (RBMC)

delivery systems.

IHCP members enrolled in Hoosier Healthwise PrimeStep (PCCM) receive the same

benefit coverage, and are subject to the same limitations as traditional Medicaid FFS.

Refer to the Hoosier Healthwise Manual for Primary Medical Providers and Office Staff

for further information.

RELATED MEDICAL TOPICS

Abortion

Anesthesia Services

Case Management Services – Pregnant Women

Clinic Services – FQHC and Rural Health Clinic Services

Family Planning

Hospital Inpatient Services

Hospital Outpatient Services

Obstetric Services

Pathology Services

Surgery-Multiple Procedures/Same Operative Session

Surgery-Office Visits

Surgery-Surgeon and Assistant Surgeon, Same Provider

Surgery-Surgery and Anesthesia By the Same Provider

Surgery-Surgical Services

Surgery-Suture of Wounds

RULES, CITATIONS, AND SOURCES

Code of Federal Register 42 CFR 441.255

Indiana Administrative Code

405 IAC 5-17 – Hospital Services

405 IAC 5-28 – Medical and Surgical Services

405 IAC 5-28-7 – Abortion

Indiana State Department of Public Welfare Medical Policy Manual 1991

Indiana Health Coverage Programs Provider Manual

1999

01/31/2007 Gynecology Services

Medical Policy Manual

185

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

March 2005, Version 5:1

Indiana Medical Assistance Program Provider Manual 1994

Indiana Health Coverage Programs Provider Notifications

Banner Page 8/19/97

Origination Date: 12/31/2000

Revisions and

Review

Reason Date

470 IAC 5-9-1 – Global Fee Billing

470 IAC 5-9-3 – Prior Authorization

5-9-9 – Second Opinions

470 IAC 5-9-12 – Medical Services

Surgical Services

470 IAC 5-9-14 – Surgical Services

Specifically Gynecology Transferred

7/1/91

Indiana State Department of Public

Welfare Medical Policy Manual 1991 -

Laminaria or Dilateria

7/1/91

405 IAC 1-7-1 – Global Fee Billing

405 IAC 1-7-3 – Services Requiring

Prior Authorization

405 IAC 1-7-9 – Second Opinions

405 IAC 1-7-12 & 14 – Surgical

Services

1/1/92

405 IAC 5-1-5 – Global Fee Billing

405 IAC 5-3 – Prior Authorization

405 IAC 5-8 – Consultations and

Second Opinions

405 IAC 5-17-2 – Hospital Services-

Prior Authorization

405 IAC 5-17-3 – Hospital Services-

Emergency, Weekend Inpatient

Admissions

405 IAC 5-28 – Medical and Surgical

Services

8/24/97

Revision

Combination of Gynecology –

Hysterectomy, Laminaria, and Pelvic

Under Anesthesia

01/31/06

01/31/2007 Gynecology Services

Medical Policy Manual

186

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Gynecology Services

Medical Policy Manual

187

APPLICABLE INDIANAAIM EDITS AND AUDITS

4012 – Abortion Diagnosis/Procedure Indicated

4073 – Hysterectomy Requires Manual Review

6002 – Any Two Anesthesiology Providers Same Procedure Requires Review

6003 – Manual Pricing for Split Care Billing

6023 – Global Payable at a Reduced Fee When Components Paid – Digestive System

6034 – Global Surgery Payable at Reduced Amount When Components of Surgical Care

Paid

6035 – Components of Surgical Care Not Payable When Global Surgery Paid

6037 – Only One Assistant Surgeon Allowed for Select Surgeries

6039 – Assistant Surgeon Not Payable When Co-Surgeon Paid

6040 – Co-Surgeon Paid at Reduced Amount When Assistant Surgeon

6061 – Components Not Payable When Global Paid – Urinary/Reproductive Systems

6096 – The CPT / HCPCS Code Billed Is Not Payable According to the PPS

Reimbursement Methodology

6649 – Surgery Payable at Reduced Amount When Related Postoperative Care Paid

6650 – Lifetime Procedures Are Limited to One Per Lifetime

6652 – Multiple Surgeries Must be Billed on Same Claim

6653 – Postoperative Care Within Zero to 90 Days of Surgery

6654 – Preoperative Care Within One Day of Surgery

6655 – Surgery Payable at Reduced Amount When Postoperative Care Paid

6656 – Postoperative Care Within 10 Days of Select Surgery

6657 – Preoperative Care on Day of Surgery

6658 – Surgery Payable at Reduced Amount When Preoperative Care Paid Same Date of

Service

6659 – Surgery Payable at Reduced Amount When Related Postoperative Care Paid

6660 – Preoperative and Postoperative Care Billed with Unlisted Surgeries Requires

Review

6706 – Global Payable at a Reduced Fee When Components Paid – Genital

Urinary/Reproductive Systems

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HIV/AIDS CARE COORDINATION

DESCRIPTION

According to the Centers for Disease Control and Prevention, the Human

Immunodeficiency Virus (HIV) is a viral infection that gradually destroys the immune

system. The compromised immune system leaves the body vulnerable to a variety of

life-threatening illnesses. Common bacteria, yeast, parasites, and viruses, that ordinarily

do not cause serious disease in people with fully functional immune systems, can cause

fatal illnesses in people with HIV. People with severely compromised immune systems

are diagnosed with Acquired Immune Deficiency Syndrome (AIDS). AIDS is the final

and most serious stage of the HIV viral infection.

HIV/AIDS can be transmitted from person to person in several manners. Blood, semen,

vaginal secretions, and breast milk have been the only proven secretions to transmit the

diseases. Most transmissions of HIV/AIDS occur by sexual contact, blood transfusion,

needle sharing, mother to fetus through shared blood circulation, and mother to infant

through breastfeeding. Other transmission methods are rare and include accidental

needle injury, artificial insemination with donated semen, and through a donated organ.

Treatment for HIV/AIDS may delay the progression of diseases for many years and

improve the quality of life. Most treatments are used to strengthen the immune system

and increase the T-cell counts.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs (IHCP) policies regarding this service. More specific information may be

found in the IHCP provider manual, program notices, the Indiana Administrative Code

(IAC), or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

HIV/AIDS care coordination is a specialized form of case management for members with

HIV/AIDS diagnoses. Care coordination consists of goal-oriented activities that

facilitate, coordinate, and monitor the full-range of HIV-related health and human

services including, but not limited to, medical, psychological, social, and educational

services. To assure freedom of choice, members sign a Freedom of Choice/Intent to

Participate Form acknowledging an understanding of the services provided and

identifying the chosen care coordination provider.

01/31/2007 HIV Care Coordination

Medical Policy Manual

188

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

PRIOR AUTHORIZATION

Prior authorization is not required for this service. Refer to the following sections

outlining member eligibility, member services, and provider enrollment for other relevant

information.

Member Eligibility

To be eligible for HIV/AIDS care coordination services, members must be a Traditional

Medicaid member, a Hoosier Healthwise member, or a Medicaid Select member with a

documented HIV viral infection/AIDS diagnosis. Medical documentation or verification

of a related medical diagnosis must be maintained in the member’s care coordination file.

The diagnosis may be verified with the following types of documentation.

• Confidential positive HIV test result

• Physician's statement

• Hospital discharge statement or other medical reports which verify the

diagnosis

• Medical prescription for Azidothymidine (AZT), Didanosine (ddl), or

Zalcitabine (ddC)

• Copy of approval for participation in the AIDS Drug Assistance Program

(ADAP) or the Early Intervention Program (EIP)

The provider must verify that the member is eligible for Medicaid services during the

specific month in which services are provided. Failure to do so may result in denial of

payment. The member’s name must appear on the claim form exactly as it appears on the

eligibility file. Eligibility must be checked each time that a service is rendered.

HIV/AIDS Care Coordination Services

HIV/AIDS care coordination providers must maintain written documentation of all

services provided. Documentation is subject to post-payment review by the Office of

Medicaid Policy and Planning (OMPP) or its agent. The following records must be

available in each member’s file and updated annually, if applicable.

• Determination of eligibility

• Documentation of verified diagnosis of HIV/AIDS diagnosis

• Intake form

• Assessment and re-evaluations of the member’s presenting problems,

indications of medical/physical status, indications of psychological status,

quality of social supports, living arrangements, and status on 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

01/31/2007 HIV Care Coordination

Medical Policy Manual

189

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Providers must comply with all regulations delineated by OMPP and the Division of

Disability, Aging, and Rehabilitative Services (DDARS). The following information

outlines these guidelines.

• Providers must permit access and examination of records by persons

authorized by the OMPP, its agent, and Federal personnel. Records must be

maintained for seven years. Record destruction must be done in a confidential

manner such as burning or shredding of documents.

• Providers must obtain input from members on service satisfaction and

summarize this input at least annually. This information must be available for

review.

• Providers are required to provide quarterly reports to the DDARS on the

approved forms.

• Providers must have data collection and analysis capability required to prepare

monthly statistical reports concerning member demographics, including but not

limited to, age, race, gender, risk exposure category, and other relevant data in

a format approved by the DDARS.

• Providers must develop and maintain a current listing of support services in the

community and the established referral process.

• Providers will be required 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 regarding the member is confidential

information.

• Providers may not use any information obtained about the member in any

manner except as necessary for the proper discharge of responsibilities. All

information, personal facts and circumstances concerning the member, must be

treated as privileged communication and may not be divulged without the

written consent of the member or the member’s legal representative.

• Providers will assure that services will be available to all eligible members

regardless of age, race, gender, sexual/affectional orientation or preference,

ethnicity, religion, national origin, or handicap.

• Providers must comply with licensing and accreditation standards as required

by the OMPP or its agent.

• Providers will determine if a member is eligible for receipt of services in

accordance with OMPP and the DDARS established policies and procedures.

• Providers will comply with procedures for administrative review of appeals for

applicants and members.

There are specific services with limitation that must be followed when care coordinators

provide services to eligible members. The following information outlines the HIV/AIDS

care coordinator services provided to IHCP members.

A. Intake and Assessment

The care coordinator completes a Freedom of Choice/Intent to Participate Form

and an Assessment of Care Coordination/Worksheet for Data Entry Form. As

01/31/2007 HIV Care Coordination

Medical Policy Manual

190

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

determined by the Assessment of Intensity of Care Coordination/Worksheet for

Data Entry Form, care coordination services may not exceed a maximum of 128

units (32 hours), per calendar quarter (three month period), per member. This form

should be completed at the beginning of each quarter to determine the maximum

number of hours allowed per member. It is expected that most members will

require between 6.6 and 9 hours per quarter with some using less. Furthermore, it is

anticipated that few members will require more than nine hours per quarter. This

form describes the supporting factors for the number of care coordination hours

used. Supporting factors must be substantiated through self-report, medical records,

caregiver records, other agency reports, and physical observation. Substantiation of

services must be documented in each member’s file. Sections of the assessment

must contain information regarding presenting problems, medical/physical status,

indicators of psychosocial status, indicators of developmental and intellectual

status, living arrangements, and other relevant factors.

Once the maximum number of hours allowed is determined in a given quarter, the

need for additional hours will require the submission of a new and updated

Assessment of Intensity of Care Coordination/Worksheet for Data Entry Form.

B. Plan of Care Development

Based upon the information gathered in the assessment, the care coordinator and the

member develop a comprehensive plan of care. Services are structured and time is

goal oriented. The plan of care must be developed on or before the 30

day

following the date of the initial intake. The following factors must be considered in

the development of the plan.

• Prioritizing the needs that were identified in the assessment

• Developing outcome goals that will address the identified needs

• Identifying factors that may impinge upon the implementation of the plan of

care

• Proposing and discussing preliminary strategies for meeting outcome goals and

obtaining signed approval forms from the member or representative

• Specifying the time frame for meeting outcome goals

• Developing evaluation criteria to measure whether outcome goals are met

• Identifying specific services, costs, and sources of payment

• Contracting with the member or representative to apportion the rights and

responsibilities between the member and the care coordinator

• Developing procedures for emergency situations

01/31/2007 HIV Care Coordination

Medical Policy Manual

191

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

C. Implementation

To implement the plan of care, the care coordinator negotiates agreements with

service providers, coordinates delivery of service, and maintains the member’s

record. In addition, the care coordinator acts as a facilitator in resolving access

problems that arise in implementing the plan of care, as well as, advocating for the

development of new services. It is the responsibility of the care coordinator to

ensure services are cost effective and not duplicated.

D. Monitoring

The care coordinator assures 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.

E. Evaluation

The care coordinator periodically engages in the following activities to measure the

quality and effectiveness of the plan of care. The following describes the

evaluation process.

• Analysis of information generated through monitoring the quality and

effectiveness of interventions, appropriateness of goals and strategies, the

member’s or representative’s commitment to participate in the plan of care,

and the member’s or representative's satisfaction with the plan of care

• Comparison of plan of care objectives with actual outcomes of intervention

F. Re-evaluation

The care coordinator schedules plan of care re-evaluations to determine continuing

or changing needs the member may have. Evaluations and re-evaluations require

ongoing contact with the member. The Assessment of Care

Coordination/Worksheet for Data Entry Form should be completed from the date of

the initial intake and the beginning of every quarter, as part of the re-evaluation

process. Where there is a change in a member’s needs, the care coordinator will do

one of the following.

• Revise plan of care outcome goals

• Re-evaluate the priority of member needs

• Revise plan of care strategies

• Realign technical service resources

• Propose and discuss new strategies for meeting outcome goals subject to the

member’s or representative’s approval

• Specify new time frames for meeting outcome goals

• Enter into a new contract with the member or representative to reapportion the

rights and responsibilities of the member and the care coordinator

G. Termination

Upon re-evaluation of the plan of care, the care coordinator and the member or

representative determines whether services should continue. The decision will be

made based on the following information.

01/31/2007 HIV Care Coordination

Medical Policy Manual

192

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• HIV/AIDS care coordination services are still required

• Member or representative elects to continue care coordination services

• Member or representative is upholding the contracted agreement set forth in

the plan of care

• Member or representative is cooperating with agreed upon plan of care

• Member is aggressive or non-cooperative with the care coordinator

HIV/AIDS Care Coordinator Eligibility

In order to receive reimbursement for HIV/AIDS care coordination services, the service

provider must be enrolled as an IHCP provider. In addition, the care coordinator must

meet the following minimum qualifications described below.

• Registered Nurse licensed in Indiana with a minimum of one year case

management experience

• Master of Social Work/Master of Social Sciences or equivalent degree with a

minimum of one year case management experience

• Bachelor of Social Work or equivalent degree with a minimum of one year

case management experience

• Master of Science in Nursing or equivalent master's nursing degree with a

minimum of one year case management experience

• Bachelor of Science in Nursing or equivalent nursing degree with a minimum

of one year case management experience

All HIV/AIDS care coordinators are required to enroll and complete a State-approved

HIV/AIDS specific care coordination training course prior to certification. If training is

not available within six weeks of the provider's letter of intent to enroll, the provider may

request a temporary waiver for this training. If the waiver is granted, the training will

need to be completed within three months of the conditional enrollment. The request to

waive may be made under these circumstances.

• If the provider has at least one year of documented HIV/AIDS care

coordination experience

• If the provider is under the supervision of a currently enrolled HIV/AIDS care

coordinator

Once minimum qualifications are met, the provider may complete enrollment documents

and submit them to the Medicaid Waiver Unit. These documents may be requested from

the following address.

Medicaid Waiver Unit

P.O. Box 7083

Indianapolis, IN 46207-7083

(317) 232-5710

Once the enrollment process is completed, the provider will be notified in writing of the

assigned care coordinator provider number. Additionally, the provider will receive the

appropriate provider manual along with an initial supply of forms. All changes in status,

location, or personnel should also be reported in writing to the Medicaid Waiver Unit.

01/31/2007 HIV Care Coordination

Medical Policy Manual

193

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MANAGED CARE

HIV/AIDS care coordination services are self-referral services under the Hoosier

Healthwise and Medicaid Select managed care programs. Providers serving members in

the risk-based managed care (RBMC) delivery system should contact the appropriate

managed care organization to file claims.

HIV/AIDS care coordination claims are not subject to managed care edits; therefore,

there is no requirement for a PMP certification code or a provider number on the HCFA-

1500 claim form.

BILLING REQUIREMENTS

HIV/AIDS care coordinator, provider specialty 211, is reimbursed for the Healthcare

Common Procedural Coding System (HCPCS) code G9012, Coordinated care fee, risk

adjusted maintenance, other specified care management. Effective October 1, 2004, this

code is the only procedure code that will be reimbursed. Additionally, providers must

use primary diagnosis code 042, Human Immunodeficiency virus {HIV} disease, for

billing purposes. Each unit of the HCPCS code G9012 is equal to 15 minutes of services.

Non-billable Services

Non-billable services include time spent completing or reviewing claim forms for care

coordination, implicit paperwork, and activities not related to a particular member.

Administrative expenses are not billable; however, these expenses are included in the

reimbursement rate. Transporting members and general provider recruitment are not

billable.

Early and Periodic Screening, Diagnosis, and Treatment/HealthWatch Program

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)/HealthWatch services

may be provided to IHCP members younger than 21 years old. Primary Medical

Providers (PMP) are not required to provide or authorize HIV/AIDS targeted case

management services. Reimbursement for case management services is on a fee-for-

service basis.

Targeted Case Management Services for Pregnant Women

HIV-related targeted case management services for pregnant women are limited to 60

hours per quarter. Coverage is limited to services related to pregnancy, including

prenatal, delivery, and postpartum services, as well as, conditions which may complicate

the pregnancy or urgent care services. The following Current Procedural Terminology

(CPT) codes must be used for HIV testing and screening.

• CPT code 86701, HIV-1

• CPT code 86689, HIV antibody confirmatory test (e.g., Western Blot)

01/31/2007 HIV Care Coordination

Medical Policy Manual

194

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RELATED MEDICAL TOPICS

Early and Periodic Screening, Diagnosis, and Treatment/HealthWatch Services

Inpatient Hospital Services

Laboratory Services

Managed Care Services

Obstetric Care

Outpatient Hospital Services

Screening Services–Newborn Screening

Targeted Case Management Services for Pregnant Women

Waiver Services

RULES, CITATIONS, AND SOURCES

Indiana Administrative Code (IAC)

405 IAC 5-15 – Early and Periodic Screening, Diagnosis, and Treatment Services

Indiana Code (IC)

IC 16-41-6 – Communicable Disease: Mandatory Testing of Individuals with

Communicable or Dangerous Diseases

Indiana Health Coverage Programs Provider Manual

1999

2005 Version 5.1

Medicaid Provider Manual for Waiver Providers

Indiana Health Coverage Programs Provider Banner (BR)

BR200510 – IHCP Policy for Billing HIV Care Coordination Services

BR200433 – HIV Care Coordinator Provider Code Set

Indiana Health Coverage Programs Provider Bulletin (BT)

BT200526 – Notice of Program Change Due to the New Medicare Prescription

Drug Coverage PDPs must cover all, or substantially all, drugs in the

following six categories

BT200424 – Early and Periodic Screening, Diagnosis, and Treatment/

HealthWatch Services CPT codes HIV Aesting

BT200360 – DRG Relative Weight Table

BT200359 – Antiviral (Anti-Herpetic) Agents, W5A; HMG CoA Reductase

Inhibitors, M4E Valtrex Pravachol

BT200255 – Preferred Drug List–Pravastatin (PravacholÒ)

BT200006 – Package C Claim Submission and Coverage Information

BT199909 – Removal of Services from Prior Authorization

01/31/2007 HIV Care Coordination

Medical Policy Manual

195

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 HIV Care Coordination

Medical Policy Manual

196

Origination Date: 04/13/2006

Revisions and Reviews Reason Date

Indiana Medical

Assistance Program

Provider Manual

HIV/AIDS 1994

IC 16-41-6

Communicable Disease: Mandatory

Testing of Individuals with Communicable

or Dangerous Diseases

1993;1996;

1998

Review Scheduled 10/31/2006

APPLICABLE INDIANAAIM EDITS AND AUDITS

1020 – Rendering Provider Specialty Not Eligible to Render Procedure Code

6051 – Care Coordinator – Initial Assessment

6053 – HIV Case Management

6800 – Care Coordination Transportation for Home Visits (Initial Assessment)

6801 – Care Coordination – Transportation for Home Visits (Reassessment)

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HOME HEALTH SERVICES

DESCRIPTION

Home health services are available to Indiana Health Care Programs (IHCP) members

medically confined to home, when services are ordered by the member’s physician, and

performed in accordance with the written plan of care. IHCP members who, because of

illness or injury, are unable to leave home without assistance of another person or an

assistive device such as a wheelchair or walker, or for whom leaving the home is contrary

to medical advice are considered to be medically confined to home. Home health services

may be utilized for: care and treatment of acute or chronic conditions, rehabilitation,

education regarding care, coordination of community services, or to avoid prolonged or

repeated hospitalizations and/or higher and more costly levels of care.

SUMMARY OF CURRENT POLICY

IHCP reimbursement is available to home health agencies for skilled nursing care

services provided by a registered nurse (RN) or licensed practical nurse (LPN), home

health aide (HHA) services, physical, occupational, or speech therapy services,

respiratory therapy services, renal dialysis, and tocolytic infusion therapy subject to

limitations in 405 IAC 5-3, 5-16, and 5-22.

All home health services require prior authorization (PA) except those services provided

by a RN, LPN, or HHA ordered in writing by a physician prior to the member’s discharge

from a hospital and that do not exceed 120 hours within 30 days of discharge. Services

may not continue beyond 30 calendar days unless PA is received. Any combination of

therapy services ordered in writing by a physician prior to the member’s hospital

discharge does not require initial PA, but may not continue beyond 30 hours, sessions, or

visits in 30 calendar days unless PA is received.

Home health care is available to eligible IHCP members who are in need of intermittent

or part-time home health services. The type and extent of service required must be

documented in the plan of treatment and included with the PA request. Home health care

services must be rendered as indicated on the plan of treatment. The plan of treatment

must be signed by the attending physician and reviewed every 60 days. The PA request,

the plan of treatment, supporting documentation and hourly determination guidelines will

be when considered when evaluating the number of hours to approve for home health

care services. The hourly determination guidelines are used as an aid, but do not take the

place of clinical judgment when determining appropriate hours of service.

01/31/2007 Home Health Services

Medical Policy Manual

197

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Case management services for pregnancy and HIV/AIDS, and Diabetes Self Management

Training services can be provided in a home setting, but are not included under home

health care services. Each of these services has specific coverage criteria for

reimbursement. See individual policies for details.

DEFINITIONS

Encounter: An encounter occurs when a home health care provider enters a home,

provides services to one or more individuals within that home, and then departs.

Multiple member care situation: A home care situation in which more than one

member is receiving home health services in a single household. When this situation

occurs, care must be coordinated in the most efficient manner. Multiple care member

situations must be reported on each member’s individual PA request. When one member

of a home health agency provides care to multiple members during an encounter, only

one overhead may be billed.

Home Health Care Provider: Registered Nurse (RN), Licensed Practical Nurse (LPN),

Physical Therapist (PT), Occupational Therapist (OT), Speech Therapist (ST), Speech

Language Pathologist (SPL), Respiratory Therapist (RT), or a home health aid (HHA)

RELATED MEDICAL TOPICS

Aged and Disabled –Waiver Services

Autism – Waiver Services

Case Management - Pregnant Women

Case management - HIV/Aids Coordination

Diabetes Self-Management Training

Hospice

Intermediate Care Facilities for the Mentally Retarded

Medical Supplies and Equipment

Medically Fragile Children – Waiver Services

Nursing Services

Physical Rehabilitation Services

01/31/2007 Home Health Services

Medical Policy Manual

198

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RULES, CITATIONS, AND SOURCES

405 IAC 5-16 Home Health Agency and Clinic Services

405 IAC 5-16-1 Providers eligible for reimbursement

405 IAC 5-16-2 Home health agency services

405 IAC 5-16-3 Home health agency services; limitations

405 IAC 5-3-13 Prior Authorization--Services requiring prior authorization

405 IAC 5-19-6 Durable medical equipment subject to prior authorization

405 IAC 5-19-12 Home hemodialysis equipment

405 IAC 5-22 Nursing and Therapy Services

405 IAC 5-11 Case management Services for Pregnant Women

405 IAC 5-34 Hospice Services

405 IAC 5-36 Diabetes Self Management Training

405 IAC 5-35 Case Management Services for Infants and Toddlers With Disabilities

Indiana Code 16-41-6 Communicable Disease

42 CFR 441.15 Subpart A--General Provisions

405 IAC 5-19-6 Durable medical equipment subject to prior authorization

405 IAC 5-19-12 Home hemodialysis equipment

42 CFR 441.15 Subpart A--General Provisions

42 CFR 440.70 Subpart A--Definitions

Indiana Medicaid Update Bulletin 97-12-- Overhead Component

Indiana Medicaid Update Bulletin 97-14--Home Tocolytic Infusion Therapy Utilizing A

Home Uterine Monitoring Device

Indiana Medicaid Update Bulletin 97-05 --Clarification of Indiana Medicaid

Indiana Medicaid Update Bulletin 97-03--Billing Procedures for Home Infusion/Enteral

State Medicaid Plan 01/01/95--Home Health Services

Indiana medical Assistance Provider Manual 1994

Indiana Health Coverage Programs Manual 1999

Indiana Health Coverage Bulletin BT200353 – HIPPA-Mandated Elimination of Local

Codes and Local Code Modifiers

Indiana Health Coverage Programs Home Health Care Hourly Determination Guidelines

Indiana Health Coverage Banner BR200207

Indiana Health Coverage Bulletin BT200237 – Required Documentation for Prior

Authorization Requests for Home Health Services

Indiana Health Coverage Bulletin BT200349 – Change in Reimbursement Rates for

Home Health Providers

Indiana Health Coverage Banner BR200411

Indiana Health Coverage Provider Manual 2003

01/31/2007 Home Health Services

Medical Policy Manual

199

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

ORIGINATION, REVISION, AND REVIEWS

Origination Date: 12/31/00

Revisions and Reviews Reason Date

Indiana Medicaid Update

Bulletin 97-14

Tocolytic Home Infusion and Uterine

Monitoring Device

5/27/95

Indiana Medicaid Update

Bulletin 97-06

Clarification of Policies 1/1/97

Indiana Medicaid Update

Bulletin 97-03

Home Health Infusion 3/1/97

Indiana Medicaid Update

Bulletin 97-12, 3/31/97

Home Health Services 5/27/97

405 IAC 5-3-13

Prior Authorization-Services Requiring Prior

Authorization

8/24/97

405 IAC 5-16 Home Health Agency and Clinic Services- 8/24/97

405 IAC 5-19-6

Durable Medical Equipment Subject to Prior

Authorization

8/24/97

405 IAC 5-19-12 Home Hemodialysis Equipment 8/24/97

42 CFR 441.15 Subpart A-General Provisions 10/1/97

42 CFR 440.70 Subpart A-Definitions 10/1/97

405 IAC 5-16-2 Amended Home Health Agency and Clinic Services- 9/27/99

405 IAC 5-16-3 Amended Home Health Agency and Clinic Services- 9/27/99

405 IAC 5-19-3.1 Amended Home Health Agency and Clinic Services- 9/27/99

405 IAC 5-16-2 Amended Home Health Agency and Clinic Services- 10/1/99

405 IAC 5-16-3 Amended Home Health Agency and Clinic Services- 10/1/99

Revision

Home Health Care hourly Determination

Guidelines

4/30/04

BT200335

HIPAA-Mandated Elimination of Local Codes

and Love Code Modifiers, Updated

4/30/04

BT200117

PA Requests for Home Health, Quarterly

Update

7/30/04

BR200207 PA Request Criteria, Quarterly Update 7/30/04

BT200237

Required Documentation for Prior

Authorization Requests for Home Health

Services, Quarterly Update

7/30/04

IHCP Provider Manual

2003

Medically Confined to Home, Billing

Requirements, Quarterly Update

7/30/04

01/31/2007 Home Health Services

Medical Policy Manual

200

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

APPLICABLE INDIANAAIM EDITS AND AUDITS:

515

551

552

3016

6073

6260

6261

6752

6753

6916

6917

01/31/2007 Home Health Services

Medical Policy Manual

201

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

COVERAGE CRITERIA

HOME HEALTH CARE

IHCP reimbursement is available to members medically confined to home for

intermittent or part-time home health care services provided by home health care

providers. In order for home health services to be approved, the services must be

medically reasonable and necessary, and home care must be less expensive than

alternative modes of care.

Home health services may consist of the following.

♦ skilled nursing services provided by a registered nurse or licensed practical nurse;

♦ home health aide services;

♦ physical, occupational, and speech therapy services;

♦ respiratory therapy services;

♦ renal dialysis; and

♦ home tocolytic infusion therapy

Home health services require prior authorization (PA), except in the following

circumstances.

♦ Services provided by a registered nurse, licensed practical nurse, or home health aid

which have been ordered in writing by a physician prior to the member’s discharge

from a hospital that do not exceed one hundred twenty (120) hours within thirty (30)

days of discharge do not require PA. These services may not continue beyond thirty

(30) calendar days unless prior authorization is received.

♦ Any combination of therapy services which have been ordered in writing by a physician

prior to the member’s hospital discharge that does not exceed thirty (30) units in thirty

(30) calendar days does not require PA. These services may not continue beyond 30

days following discharge unless prior authorization is received.

♦ Home tocolytic infusion therapy does not require PA, effective April 4, 2002.

The PA request for home health services must contain information required for all prior

authorizations, as specified in 405 IAC 5-3-5, including but not limited to:

♦ the appropriate diagnosis and related information

♦ services or supplies requested with the appropriate codes

♦ name of suggested provider of services and supplies

01/31/2007 Home Health Services

Medical Policy Manual

202

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ description of previous services or supplies

♦ plan of treatment

♦ rehabilitation potential

In addition, the following information must be submitted with the PA request form for

home health services:

♦ An estimate of the costs for the services ordered by the physician and set out in the

written plan of treatment. The cost estimate must be provided with the plan of

treatment and signed by the attending physician. The estimate must reflect the cost of

each service requested, plus the overhead rate for the time period(s) requested, as

reflected on the plan of treatment.

♦ PA requests for home health services should provide documentation of all services

received by the IHCP member. For example, Medicare, CHOICE, IHCP waiver

programs, private insurance, and any other paid caregivers. The number of hours per

day and the number of days per week should be listed for each service.

♦ PA requests for home health services should indicate the number of non-paid

caregivers, (even if there are none) available to provide care for the member,

including consideration of whether the caregiver works outside the home or attends

school outside the home. A copy of the caregiver’s work schedule from the employer

or the class schedule from the school must be submitted with the PA request. The

provider is responsible for coordinating home care services with the caregiver’s work

or school schedule to meet the member’s needs, and should clearly document

caregiver information on the PA request form.

♦ PA requests for home health services should document whether the member works or

attends school outside the home, including what assistance is required.

♦ When there is a multiple member situation and more than one member is receiving

home health services in a single household, care must be coordinated in order to

utilize service in the most efficient manner. Only one overhead component can be

billed per encounter. Agencies are responsible for reporting this aspect of the case,

and should indicate this fact on the PA request submitted for each member of the

household.

A copy of the current plan of treatment, developed by the attending physician,

therapist(s), and agency personnel, and signed by the attending physician, must also be

included with the PA request for home health services. The plan of treatment should

include the date of onset of the medical problem(s) and progress notes regarding the

necessity, effectiveness, and goals of therapy services. The plan of treatment should

detail the types of services and equipment required, frequency of visits, prognosis,

rehabilitation potential, functional limitation, activities permitted, nutritional

requirements, medications and treatments, safety measures to protect against injury, and

any other relevant items.

01/31/2007 Home Health Services

Medical Policy Manual

203

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

NON-COVERED SERVICES

The following services are noncovered home health services, except as specified under

the applicable IHCP Waiver Service programs.

♦ Transportation to and from grocery stores, drug stores, banks, etc.

♦ Homemaker services, including shopping, laundry, cleaning, meal preparation, etc.

♦ Companion or sitter services, including escort services, activity planning, etc.

♦ Chores, including picking up prescriptions, household supplies and/or groceries, etc.

♦ Respite care

HOME HEALTH CARE HOURLY DETERMINATION GUIDELINES

The following are guidelines for determining the appropriate number of hours

reimbursable for general categories of home health care services. These are guidelines

only and do not override medical decisions based on individual case review.

Factors for consideration when determining the hours of service to be approved

include:

♦ Severity of illness and symptoms

♦ Stability of the condition and symptoms

♦ Change in medical condition that affects the type or units of service that can be

authorized

♦ Intensity of care required to meet needs

♦ Complexity of needs

♦ Amount of time required to complete treatment tasks

♦ Treatment plan, including identified goals

♦ History of previous response to care

♦ Whether the member works or attends school outside of the home, including what

assistance is required

♦ Caregivers available to provide care for the member, including the following

considerations:

01/31/2007 Home Health Services

Medical Policy Manual

204

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

 Number of caregivers available.

 Physical limitations of available caregiver(s) that limit that ability of the

caregiver(s) to provide care to the member.

 Number of hours requested, compared to availability of caregiver(s) available

time.

 If the caregiver has additional child care responsibilities.

 If the caregiver works outside the home.

♦ Other home care services currently being utilized including, but not limited to,

Medicare, Medicaid Waiver Programs, CHOICE, vocational rehabilitation, and

private insurance.

12-16 HOURS/DAY HOME HEALTH CARE SERVICES

Members requiring 24-hour monitoring may be authorized for up to 12 hours/day skilled

nursing or home health aide services to prevent deterioration in life sustaining systems.

Examples of these conditions include, but are not limited to:

♦ Severe respiratory conditions resulting from pulmonary disorders such as,

bronchopulmonary dysplasia, severe respiratory complications of cystic fibrosis,

bronchitis, asthma; central nervous system disorders, cardiovascular disorders such

as cardiac anomalies; neuromuscular disorders such as muscular dystrophy, Guillain

Barré syndrome,

♦ Dependency on mechanical ventilator assistance

♦ Tracheostomy

Special situations may occur where home health hours may be approved for up to 16

hours per day of skilled care on an ongoing basis, although each individual situation must

be evaluated with a PA request. These special situations include but are not limited to:

♦ A single caregiver is available who also works full-time (or a significant number of

hours part time) outside the home. This also applies to situations where there may be

two adults present but one is unable to provide any, or a very limited amount, of care

due to physical disability or severe physical limitations. The disabled caregiver’s

physician must substantiate this in writing.

♦ Significant additional childcare responsibilities. Significant is defined as:

a) three or more children under the age of six, or four or more children under the

age of 10,

b) one or more children in the home with special medical care needs requiring

extensive medical and physical care above and beyond the needs of the

average well child. If Medicaid is not providing services to this child at home

also, the child’s physician must provide a statement of the child’s medical

01/31/2007 Home Health Services

Medical Policy Manual

205

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

needs. The same caregiver(s) must be caring for these children as well as the

member for whom the PA request has been submitted.

Special situations may occur where additional home health hours may be authorized on a

short term or temporary basis, that are evaluated individually, on a case-by-case basis.

Examples of these situations are as follows:

♦ Significant deterioration in the condition of the member, particularly if additional

hours will prevent an inpatient or extended inpatient hospital admission.

♦ Major illness or injury of the caregiver with expectation of recovery, including, but

not limited to:

a) illness or injury that requires an inpatient acute care stay;

b) chemotherapy or radiation treatments; or

c) a broken limb, which would impair the caregiver’s ability to lift the member.

♦ Temporary, but significant, change in the home situation, including, but not limited

to:

a) a caregiver’s call to military duty; or

b) temporary unavailability due to employment responsibilities.

(These must be substantiated in writing by the commanding officer, other

military representative, or by the employer.)

♦ Significant permanent change in the home situation, including, but not limited to,

death or divorce with loss of a caregiver. Additional units of service may be

authorized for a short period of time to assist in providing a transition.

8 HOURS /DAY HOME HEALTH CARE SERVICES

Members who require extensive care and daily monitoring of their medical/physical

condition, but do not possess the same degree of potential to deteriorate quickly into life

threatening situations as do members requiring 24-hour monitoring, may receive up to 8

hours of care daily. An additional hour or two may be allowed for transportation to and

from work in situations where the caregiver(s) work full time outside the home.

Examples of these situations/conditions may include, but are not limited to:

♦ Chronic, debilitating conditions such as severe forms of cerebral palsy, muscular

dystrophy, spina bifida, and other congenital anomalies, and quadriplegia.

♦ Conditions that require equipment or treatment needs with potential for serious

complications. For example, central lines, or Hickman catheters.

♦ Frequent treatments such as respiratory therapy required (in the form of updrafts,

CPT, etc.)

♦ Nutrition is provided by hyperalimentation or by gastrostomy tube feedings in

addition to one of the above.

♦ Skilled nursing assistance required to attend school.

♦ The member receives multiple medications that require monitoring for severe side

effects or responses.

01/31/2007 Home Health Services

Medical Policy Manual

206

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Special situations may occur in which additional home health hours may be authorized on

a short term or temporary basis. These will be evaluated individually, on a case-by-case

basis. Examples of these situations are:

♦ Significant deterioration in the condition of the member, particularly if additional

hours will prevent an inpatient or extended inpatient hospital admission.

♦ Major illness or injury of the caregiver with expectation of recovery, including, but

not limited to:

a) illness or injury that requires an inpatient acute care stay;

b) chemotherapy or radiation treatments; or

c) a broken limb, that impairs the caregiver’s ability to lift the member.

♦ Temporary, but significant, change in the home situation, including, but not limited

to:

a) a caregiver’s call to military duty; or

b) temporary unavailability due to employment responsibilities.

(These must be substantiated in writing by the commanding officer, other

military representative, or by the employer.)

♦ Significant permanent change in the home situation, including, but not limited to,

death or divorce with loss of a caregiver. Additional units of service may be

authorized for a short period of time to assist the member with a transition.

3 - 7 HOURS/DAY HOME HEALTH CARE SERVICES

Members without the severity of conditions noted above, who require primarily heavy

physical care, with some skilled nursing monitoring to avoid deterioration, may receive 3

to 7 hours of care per day. These members are generally chronic but stable and may have

conditions such as congenital anomalies, neuromuscular disorders, central nervous

system disorders, or other disorders that severely disrupt the capacity to care for self.

Adults requiring care/assistance must be homebound as certified by the attending primary

physician. However, consideration may be given to paraplegics, quadriplegics, or other

disabled members unable to provide self-care such as bathing or dressing, who are able to

drive mechanically altered vehicles in order to maintain meaningful employment and a

relationship with the community. Such adults may be considered for assistance from a

Home Health Aide for up to 3-4 hours per day. The agency may split the hours between

morning and evening to attend to the bedtime needs of the member. This service is

subject to medical necessity and documentation must demonstrate the need.

BILLING PROCEDURES

♦ The following is the computation of the total reimbursement rate:

♦ The overhead cost rate; plus

♦ The staffing cost rate multiplied by the number of hours spent performing

billable patient care activities.

01/31/2007 Home Health Services

Medical Policy Manual

207

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Each component of the total home health reimbursement rate is based on statewide

weighted median costs calculated for each component. The statewide weighted

median rate for each component is determined by calculating the per visit or per hour

cost of each component for each home health agency. These costs are ranked from the

highest to the lowest, calculating the cumulative number of Medicaid visits or hours,

and locating the point on the array in which half of the respective Medicaid visits or

hours were provided by agencies with a higher cost and half were provided by

agencies with a lower cost.

♦ The overhead cost rate per visit for each home health provider is based on total patient-

related costs, less the direct staffing and employee benefit costs, less the semi-

variable costs, divided by the total number of home health agency visits during the

Traditional Medicaid reporting period for that provider. The result of this calculation

is the overhead cost per visit for each home health provider that was included in the

statewide overhead array. The semi-variable cost was removed from the overhead

cost rate calculated, and included in the staffing cost rates.

♦ The staffing cost rate per hour for each discipline in the home health agency is based

on the total patient-related direct staffing and employee benefit costs, plus the semi-

variable cost divided by the total number of home health agency hours worked. The

result of this calculation is the staffing cost rate per hour per discipline for each home

health agency.

Occurrence Codes

Providers should use the UB-92 Occurrence Code, Occurrence Date, and Occurrence

Span for Locators 32–36, a–b, on the UB-92 to indicate the appropriate overhead fees.

The following six codes can be used 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 aides encounters of care.

♦ 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.

♦ 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 24-hour period may occur.

01/31/2007 Home Health Services

Medical Policy Manual

208

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ 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 24-hour period may occur.

♦ 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 24-hour period may occur.

All home health visits must be documented on any PA request submitted on behalf of

members. All home health claims utilizing occurrence codes 64, 65, and 66 which

indicate more than three visits a day are subject to post-payment review and will continue

to be monitored closely by the OMPP.

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-92 in the

Occurrence Code and Occurrence Date fields, Locators 32–35 a–b, on the UB-92. If the

dates of service billed are consecutive, and one encounter was provided per day, then

Occurrence Code 61 and the dates of service being billed are entered in the Occurrence

Span Code field, locator 36 a-b. Occurrence Codes 62 through 66 may not be used in the

Occurrence Span Code field.

Providers that submit more than one UB-92 claim form in a multiple member care

situation should submit only one of the forms 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.

Multiple Visit Billing

When multiple visits for the same prior authorized service are made to a member in one

day, providers should bill all visits on the same claim form. Billing these same-day

services on one claim form allows the system to bypass duplicate editing. If these

services are billed on separate claim forms, one or more of the services will be denied as

a duplicate service. It is not appropriate for home health agency (HHA) providers to

rotate personnel in the home merely to increase billing.

Partial Units of Service

Partial units of service must be rounded to the closest whole unit when calculating

reimbursement. A partial unit of service of 30 minutes or more should be rounded up to

the next highest unit. A partial unit of service of 29 minutes or less should be rounded

down to the next lowest unit. One unit of service equals 60 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.

01/31/2007 Home Health Services

Medical Policy Manual

209

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH SERVICES GENERAL GUIDELINES

CPT/HCPCS CODES

Local codes effective on or before 12/31/03

CROSSWALKED CODES

EFFECTIVE 1/1/04

Y0601 – Skilled nurse, per hour 99600 TD – Skilled nurse, RN

Y0501 – Home health aide, per hour 99600 – Home health aide

X3069 – Licensed practical nurse, per hour 99600 TE – Skilled nurse, LPN/LVN

Z5016 – Home tocolytic therapy

S9349 – Home infusion therapy, tocolytic

infusion therapy

W6503 – Physical therapy, individual, by the

unit; modalities not requiring use of capital

equipment

G0151 – Services of physical therapist is

home health setting, each 15 minutes

W7402 – Occupational therapy, by the unit,

individual

G0152 – Services of occupational

therapist in home health setting, each 15

minutes

W9083 – Speech therapy, home health

G1053 – Services of speech and language

pathologist in home health setting, each

15 minutes

TOCOLYTIC THERAPY

Local code effective on

or before 12/31/03

Crosswalked Code in

effect1/1/04 – 3/31/04

2004 HCPCS code change

effective 1/1/04

99601 – Home infusion, up to 2

hours Z5017 – Home tocolytic

therapy

99553 – Home infusion for

tocolytic therapy, per visit

99602 – Home infusion, each

additional hour

Indicators for Home Health Services

ONE of the following indicators from each category must be present for a member

to be eligible for home health services.

Category I: Member

♦ The member is at risk of respiratory failure, severe deterioration or hospitalization

without constant monitoring.

♦ The member requires total care 24 hour/day monitoring.

♦ The member desires to stay in the home, rather than a long term care facility.

♦ The medical condition of the member has deteriorated, creating the need for more

intense short-term care. (Physician’s statement required)

♦ The member does not have a primary caregiver or access to other care.

Category II: Caregiver

01/31/2007 Home Health Services

Medical Policy Manual

210

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Primary caregiver(s) is employed and absent from the home, or is unable to provide

the necessary care.

♦ Primary caregiver(s) has additional child care responsibilities disallowing the time

needed to care for the member. (3 or more under 6 years of age, or 4 or more under

the age of 10 years.)

♦ Primary caregiver(s) also has additional child(ren) with special needs to care for.

(One or more children with special health care needs requiring extensive medical and

physical care.)

♦ Major illness or injury of caregiver(s) with expectation of recovery. (Physician’s

statement required)

♦ Temporary but significant change in the availability of caregiver(s) for example,

military service. (Commanding officer, other military representative, or employer’s

statement required)

♦ Significant permanent change in status of caregiver(s), for example, death or divorce

with loss of one caregiver. (Physician’s statement required)

01/31/2007 Home Health Services

Medical Policy Manual

211

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH CARE FOR CENTRAL NERVOUS SYSTEM DISORDERS

CPT/HCPCS CODES

Local codes effective on or before 12/31/03

CROSSWALKED CODES

EFFECTIVE 1/1/04

Y0601 – Skilled nurse, per hour 99600 TD – Skilled nurse, RN

Y0501 – Home health aide, per hour 99600 – Home health aide

X3069 – Licensed practical nurse, per hour 99600 TE – Skilled nurse, LPN/LVN

Z5016 – Home tocolytic therapy

S9349 – Home infusion therapy, tocolytic

infusion therapy

W6503 – Physical therapy, individual, by the

unit; modalities not requiring use of capital

equipment

G0151 – Services of physical therapist is

home health setting, each 15 minutes

W7402 – Occupational therapy, by the unit,

individual

G0152 – Services of occupational

therapist in home health setting, each 15

minutes

W9083 – Speech therapy, home health

G1053 – Services of speech and language

pathologist in home health setting, each

15 minutes

Indicators for CNS Disorders

ONE of the following indicators must be present for a member to receive home

health care for CNS disorders.

♦ Altered level of consciousness

♦ Respiratory distress

♦ Potential for increased intracranial pressure

♦ Body temperature fluctuations (hypothalamus involvement)

♦ Posturing (decerebrate/decorticate)

♦ Seizure activity (current)

♦ Spasticity (severe)

♦ Pain

♦ Impaired motor/sensory function to include

 paresis

 paralysis

 vision impairment

 hearing impairment

 impaired gag reflex

 decreased tactile sensation

♦ Potential for self injury

♦ Need for constant supervision

01/31/2007 Home Health Services

Medical Policy Manual

212

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

ONE of the following services must also be necessary to receive either skilled or non-

skilled nursing care for CNS disorders.

SERVICES REQUIRING SKILLED

CARE

1. Vital signs

2. Ventilator operation/maintenance

3. Central line maintenance/dressings

4. Complex treatment modalities

(sterile dressings, soaks, packing,

etc.)

5. Parenteral/Enteral nutrition

6. Oxygen therapy

7. Respiratory treatments

8. Tracheostomy maintenance/change

9. Suctioning (frequency/secretion

type)

10. Stimulation (verbal/tactile)

11. Tube feedings/maintenance of tube

12. IV medication administration

13. Urinary catheter maintenance/change

14. Exercise (active/passive)

Services Requirin

Non-Skilled Care

1. Bathing/linen change/dressing

2. Catheter care

3. Skin care

4. Minor treatment modalities

5. Oral care

6. Stimulation

7. Continue plan of OT/PT

8. Assist with transfers/ambulation

9. Positioning

10. I & O records

11. Assist with oral feedings

12. Splint or brace application

13. Exercise (active or passive)

14. Ensure safety measures (seizure

precautions)

15. Vital signs

01/31/2007 Home Health Services

Medical Policy Manual

213

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH CARE FOR GASTROINTESTINAL DISORDERS

CPT/HCPCS CODES

Local codes effective on or before 12/31/03

CROSSWALKED CODES

EFFECTIVE 1/1/04

Y0601 – Skilled nurse, per hour 99600 TD – Skilled nurse, RN

Y0501 – Home health aide, per hour 99600 – Home health aide

X3069 – Licensed practical nurse, per hour 99600 TE – Skilled nurse, LPN/LVN

Z5016 – Home tocolytic therapy

S9349 – Home infusion therapy, tocolytic

infusion therapy

W6503 – Physical therapy, individual, by the

unit; modalities not requiring use of capital

equipment

G0151 – Services of physical therapist is

home health setting, each 15 minutes

W7402 – Occupational therapy, by the unit,

individual

G0152 – Services of occupational

therapist in home health setting, each 15

minutes

W9083 – Speech therapy, home health

G1053 – Services of speech and language

pathologist in home health setting, each

15 minutes

Indicators for Gastrointestinal Disorders

ONE of the following indicators must be present for a member to receive home

health care for gastrointestinal disorders.

♦ Nutritional impairment

 malabsorption

 mechanical cause

♦ Stomatitis, pharyngitis, esophagitis

♦ Swallowing disorders

♦ Gastric reflux

♦ Vomiting

♦ Anorexia

♦ Pain

♦ Orthostatic B/P

♦ Significant rapid weight loss

♦ Morbid obesity >200% optimal weight

♦ Periorbital/perirectal lesions

♦ Unhealed wound(s)

 surgical

 fistula, abscess, fissures

♦ Bacterial/parasitic infections

♦ Diarrhea

01/31/2007 Home Health Services

Medical Policy Manual

214

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Constipation

♦ Subtotal/total gastrectomy

♦ Ostomies

♦ Anemia

♦ Weakness and fatigue

ONE of the following services must also be necessary to receive either skilled or non-

skilled nursing care for gastrointestinal disorders.

Services Requiring Skilled Care

1. Vital signs

2. IV medication administration

3. Parenteral/Enteral nutrition

4. Administration/maintenance

5. Central line maintenance

6. Oral medication administration

7. Gastric tube medication

administration

8. Placement of nasogastric tubes

9. Complex treatment/wound care,

sterile dressings/wound

packing/medicated soaks, etc.

10. Ostomy care/irrigation

11. Oxygen therapy

12. Bowel training

13. Weight

14. I & O

Services Requirin

Non-Skilled Care

1. Bathing/linens/dressing

2. Oral care

3. Skin care

4. Feedings (oral)

5. Force fluid

6. Assist with ambulation

7. Exercise active\passive

8. Reinforce teaching of OT/PT/ST

9. I & O

10. Weight

01/31/2007 Home Health Services

Medical Policy Manual

215

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH CARE FOR MUSCULOSKELETAL DISORDERS

CPT/HCPCS CODES

Local codes effective on or before 12/31/03

CROSSWALKED CODES

EFFECTIVE 1/1/04

Y0601 – Skilled nurse, per hour 99600 TD – Skilled nurse, RN

Y0501 – Home health aide, per hour 99600 – Home health aide

X3069 – Licensed practical nurse, per hour 99600 TE – Skilled nurse, LPN/LVN

Z5016 – Home tocolytic therapy

S9349 – Home infusion therapy, tocolytic

infusion therapy

W6503 – Physical therapy, individual, by the

unit; modalities not requiring use of capital

equipment

G0151 – Services of physical therapist is

home health setting, each 15 minutes

W7402 – Occupational therapy, by the unit,

individual

G0152 – Services of occupational

therapist in home health setting, each 15

minutes

W9083 – Speech therapy, home health

G1053 – Services of speech and language

pathologist in home health setting, each

15 minutes

Indicators for Musculoskeletal Disorders

ONE of the following indicators must be present for a member to receive home

health care for musculoskeletal disorders.

♦ Pain

♦ Loss of locomotor ability

♦ Decreased muscle strength

♦ Stiffness

♦ Joint pain, swelling, redness, tenderness

♦ Muscle wasting

♦ Paralysis

♦ Post amputation

♦ Multiple fractures

♦ Muscle spasms

♦ Potential for injury to self

01/31/2007 Home Health Services

Medical Policy Manual

216

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

ONE of the following services must also be necessary to receive either skilled or non-

skilled nursing care for musculoskeletal disorders.

SERVICES REQUIRING SKILLED

CARE

1. Assist with prostheses, braces,

splints

2. Treatments requiring sterile

procedures

SERVICES REQUIRING NON-

SKILLED CARE

1. Bathing/linen/dressing

2. Assistance with ADL’s

3. Assistance with

transfers/ambulation

4. Assist with prostheses, braces,

splints

5. Exercise active or passive

6. Position changes

7. Non-invasive treatments, comfort

measures

01/31/2007 Home Health Services

Medical Policy Manual

217

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH CARE FOR RESPIRATORY DISORDERS

CPT/HCPCS CODES

Local codes effective on or before 12/31/03

CROSSWALKED CODES

EFFECTIVE 1/1/04

Y0601 – Skilled nurse, per hour 99600 TD – Skilled nurse, RN

Y0501 – Home health aide, per hour 99600 – Home health aide

X3069 – Licensed practical nurse, per hour 99600 TE – Skilled nurse, LPN/LVN

Z5016 – Home tocolytic therapy

S9349 – Home infusion therapy, tocolytic

infusion therapy

W6503 – Physical therapy, individual, by the

unit; modalities not requiring use of capital

equipment

G0151 – Services of physical therapist is

home health setting, each 15 minutes

W7402 – Occupational therapy, by the unit,

individual

G0152 – Services of occupational

therapist in home health setting, each 15

minutes

W9083 – Speech therapy, home health

G1053 – Services of speech and language

pathologist in home health setting, each

15 minutes

Indicators

ONE of the following indicators must be present for a member to receive home

health care for respiratory disorders.

♦ Dyspnea

▪ quality of respiration (shallow, air hunger, etc.)

 rate of respiration's

 dyspnea at rest

 dyspnea with exertion

 cyanosis

 use of accessory muscles

 apnea/bradycardia

♦ Abnormal breath sounds

♦ Splinting respirations

♦ Strenuous coughing

♦ Excessive, tenacious secretions

♦ Ineffective airway clearance

♦ Abnormal ABG’s

♦ Decreased ability to be mobile due to dyspnea

♦ Irritability/depression

♦ Fatigue/weakness

♦ Anxiety

01/31/2007 Home Health Services

Medical Policy Manual

218

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

ONE of the following services must also be necessary to receive either skilled or non-

skilled nursing care for respiratory disorders.

SERVICES REQUIRING SKILLED

CARE

1. Oral medication administration

2. IV medication administration

3. Parenteral/Enteral nutrition

4. Vital signs

5. Ventilator operation/maintenance

6. Tracheostomy maintenance/change

7. Suctioning

8. Complex treatment modalities

(sterile dressing, wound care)

9. Respiratory treatments

SERVICES REQUIRING NON-

SKILLED CARE

1. Assist with bathing, dressing, ADL’s

(total care may be required)

2. Skin care

3. Oral care

4. Force fluids as instructed

5. Assist with ambulation

6. Exercise active/passive

7. Assist with meals (oral feeding)

8. Vital Signs

01/31/2007 Home Health Services

Medical Policy Manual

219

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME TOCOLYTIC INFUSION THERAPY

TOCOLYTIC THERAPY CODE Z5016

Local code effective on or before 12/31/03

Crosswalked code effective 1/1/04

Z5016 – Home tocolytic therapy

S9349 - Home infusion therapy, tocolytic

infusion therapy

TOCOLYTIC THERAPY CODE Z5017

Local code effective on

or before 12/31/03

Crosswalked code

effective 1/1/04 – 3/31/04

2004 code change effective

1/1/04

99601 – Home infusion, up to 2

hours Z5017 – Home tocolytic

therapy

99553 – Home infusion for

tocolytic therapy, per visit

99602 - Home infusion, each

additional hour

Indicators

ALL of the following indicators must be present for a member to receive home

health care for home tocolytic infusion therapy.

♦ The member must be at least 24 to 34 weeks gestation;

♦ The member must be in current preterm labor (preterm labor being defined as greater

than or equal to six contractions per hour);

♦ The member must have a cervical dilation of greater than or equal to 1 cm, or an

effacement of greater than or equal to 75%;

♦ The member must have experienced secondary failure to wean from infused

tocolytics, or have failed oral therapy and requires continued infusion therapy; and

♦ The member must have direct home telephone access to providers.

Agency guidelines for home tocolytic infusion therapy

Home Health care agencies must meet the following minimum guidelines to be

reimbursed for home tocolytic infusion therapy.

♦ Provide home health care to the pregnant member on a 24 hour/day, 7 day/week

basis;

♦ Provide the member with a tocolytic infusion pump and a uterine monitoring device

(including set up and delivery); provide member education regarding the use of the

equipment and be available for trouble shooting for the equipment on a 24 hour/day,

7 day/week basis;

♦ Provide pharmacological consultation regarding the use of tocolytics and

individualized member dosing on a 24 hour/day, 7 day/week basis;

♦ Provide member education regarding uterine contractions and other subtle symptoms

of preterm labor.

01/31/2007 Home Health Services

Medical Policy Manual

220

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

♦ Contact the member’s physician at least weekly for updates on member

condition/compliance.

01/31/2007 Home Health Services

Medical Policy Manual

221

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH CARE FOR URINARY/RENAL DISORDERS

CPT/HCPCS CODES

Local codes effective on or before 12/31/03

CROSSWALKED CODES

EFFECTIVE 1/1/04

Y0601 – Skilled nurse, per hour 99600 TD – Skilled nurse, RN

Y0501 – Home health aide, per hour 99600 – Home health aide

X3069 – Licensed practical nurse, per hour 99600 TE – Skilled nurse, LPN/LVN

Z5016 – Home tocolytic therapy

S9349 – Home infusion therapy, tocolytic

infusion therapy

W6503 – Physical therapy, individual, by the

unit; modalities not requiring use of capital

equipment

G0151 – Services of physical therapist is

home health setting, each 15 minutes

W7402 – Occupational therapy, by the unit,

individual

G0152 – Services of occupational

therapist in home health setting, each 15

minutes

W9083 – Speech therapy, home health

G1053 – Services of speech and language

pathologist in home health setting, each

15 minutes

Indicators for Urinary/Renal Disorders

ONE of the following indicators must be present for a member to receive home

health care for urinary/renal disorders.

♦ Anemia

♦ Dyspnea

♦ Increased BUN/creatinine

♦ Decreased mental acuity

♦ Increased B/P

♦ Abnormal electrolytes

♦ Oliguria

♦ Weakness/fatigue

♦ Decreased mobility

♦ Neuropathies

♦ New diagnosis of renal failure

♦ Vascular access

♦ Newly initiated hemodialysis

♦ Recent admission for renal failure

♦ Recent admission for urinary tract surgery

♦ Peritoneal dialysis

♦ Pain

♦ Edema

♦ Potential for self injury

01/31/2007 Home Health Services

Medical Policy Manual

222

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

ONE of the following services must also be necessary to receive either skilled or non-

skilled nursing care for urinary/renal disorders.

SERVICES REQUIRING SKILLED

CARE

1. Complex treatment modalities

 sterile dressings

 special catheter care (ureteral

catheters, irrigation, etc.)

2. Urinary, suprapubic catheter care

3. I & O

4. Weight

5. Vital signs

SERVICES REQUIRING NON-

SKILLED CARE

1. Assist bathing/linens/dressing

2. Skin care

3. Oral care

4. Assist with exercise and ambulation

5. Reinforce nutritional teaching

6. Weight

7. I & O

8. Vital signs

9. Safety measures

01/31/2007 Home Health Services

Medical Policy Manual

223

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

HOME HEALTH SERVICES

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the Home Health Services Fact Sheet. The information in this addendum will

be incorporated into the fact sheet at the next review.

Provider Notification: NL200509 Publication Date: 09/2005

Subject: Physician Signature Stamps

Date Added to Manual: 10/31/2005

Text of Publication

Effective January 24, 2004, CMS Transmittal 59 allows for the acceptance of a

physician’s rubber stamp signature for clinical record documentation, provided it is

permitted by Federal, state, and local law, and authorized by the home health agency’s or

hospice agency’s policy. This newsletter article addresses the impact this new policy will

have on the Medicaid prior authorization process for home health and hospice services by

referring providers to the appropriate regulations for Medicaid.

Chapter 6 of the IHCP Provider Manual and state regulations at 405 IAC 5-5-5 specify

that the provider must approve the Indiana Prior Review and Authorization Request form

by personal signature, or providers and their designees may use a signature stamp.

Providers that are agencies, corporations, or business entities may authorize one or more

representatives to sign requests for prior authorization (PA). Providers should note that

this section of the IHCP Provider Manual and state regulation address permissible

signature requirements for the Indiana Prior Review and Authorization Request form, and

must be differentiated from the signature requirements for physician orders and care

plans. Under the above-mentioned regulation, it is permissible for the agency to use a

signature stamp for the Indiana Prior Review and Authorization Request form.

The following state regulations apply to Medicaid prior authorization request for home

health services and can be viewed on the internet at www.accessindiana.com

• 405 IAC 5-16-3.1 Home health agency services; limitations: does not address

physician signature stamps for physician orders or written care plans.

• 405 IAC 5-22-2 Nursing services; prior authorization requirements does not address

physician signature stamps for prior authorization of nursing services.

In conclusion, physician signature stamps may be used on the Indiana Prior Review and

Authorization Request form when requesting Medicaid prior authorization for home

health services; however, any physician order or plan of treatment that is attached to the

Indiana Prior Review and Authorization Request form must include an original signature

by the physician.

01/31/2007 Home Health Services

Medical Policy Manual

224

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

State regulations for the Medicaid hospice benefit do not specifically provide for

physician signature stamps. The following regulations do apply to Medicaid prior

authorization request for hospice services with regard to the hospice physician

certification and the hospice plan of care. They can be viewed on the internet at

www.accessindiana.com .

• 405 IAC 5-34-5 Physician certification

• 405 IAC 5-34-7 Plan of care

In order to ensure that the medical director or physician member of the hospice reviewed

the plan of care, an original signature is required.

In conclusion, physician signature stamps may be used on the Indiana Prior Review and

Authorization Request form when requesting Medicaid prior authorization for hospice

services; however, any Medicaid Hospice Physician Certification form or Medicaid

Hospice Plan of Care that is attached to the Indiana Prior Review and Authorization

Request form must include an original signature by the physician.

Furthermore, the IHCP notes that electronic signatures are not acceptable on plans of care

submitted to the HCE Prior Authorization Unit.

Home health and hospice providers should contact the Acute Care Division of the Indiana

State Department of Health at (317) 233-7474 with regard to ISDH home health and

hospice survey rules.

Information To Be Read In Conjunction with Provider Bulletin BT200117 Prior

Authorization Request for Home Health

This information should be read in conjunction with information already published in

BT200117 (April 27, 2001 release date). BT200117 may be viewed on the Indiana

Medicaid Web site at www.indianamedicaid.com .

Providers are informed that there have been no changes to Medicaid state regulations at

405 IAC 5-16-3(d)(2)(G), which requires a home health agency to state the amount of

time required to complete the treatment task on the plan of care. However, the IHCP has

made a change to the directions in BT200117, which specified that the Indiana Prior

Review and Authorization Request form and the signed plan of care must reflect the

specific frequency and duration of care.

This newsletter notes the following change:

• The Indiana Prior Review and Authorization Request form may now reflect the

maximum amount of time it may require for the home health agency to care for the

patient; however, the provider should only bill the IHCP the actual service units

provided on each visit.

ISDH regulations regarding patient care and the medical plan of care that were referenced

in BT200117 have changed. The new home health regulations may be viewed by

01/31/2007 Home Health Services

Medical Policy Manual

225

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Home Health Services

Medical Policy Manual

226

accessing the IAC on the Web site at www.accessindiana.com . The new regulations may

be viewed as follows:

• Encounter defined may be viewed at 410 IAC 17-9-12.

• Frequency of visits defined may be viewed at 410 IAC 17-9-13.

EDS Page 4 of 20 P.O. Box 7263 Indianapolis, IN 46207-7263 For more information

visit www.indianamedicaid.com Indiana Health Coverage Programs Provider Monthly

Newsletter NL200509 September 2005

• Information regarding patient care and the medical plan of care may be viewed at 410

IAC 17-13-1.

It is the responsibility of home health providers to ensure that their plans of care are

compliant with Medicaid regulations and ISDH survey regulations.

Home health providers may direct any questions regarding the ISDH home health survey

process to the ISDH Acute Care Unit at (317) 233-7472. Home health providers may

direct any questions regarding Medicaid home health prior authorization to the HCE Prior

Authorization Unit at (317) 347-4511 or 1-800-457-4518.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HOSPICE

DESCRIPTION:

The Indiana Health Coverage Programs (IHCP) hospice benefit program mirrors the

covered services and reimbursement methodology of the Medicare hospice program.

IHCP hospice providers are required to comply with the federal hospice regulations located

in the Code of Federal Regulations (CFR), 42 CFR Part 418 et al implementing the

Balanced Budget Act of 1997. These regulations require hospice providers to list all hospice

covered services in frequency and scope on the hospice plan of care necessary to treat the

terminal illness and related conditions. Additionally, IHCP hospice providers must be

Medicare-certified and licensed as hospice providers by the Indiana State Department of

Health as a condition of provider enrollment.

Hospice providers are health care providers who own or operate hospice

programs/facilities that use interdisciplinary teams directed by licensed physicians.

These programs provide planned and continuous care for hospice program members and

their families. Hospice programs are designed to alleviate the physical, emotional, social,

and spiritual discomforts of a member who is experiencing the last phase of a terminal

illness or disease.

This document is intended to serve as a general summary of the IHCP policies regarding

this service. More specific information may be found in the IHCP provider manual,

program notices, the Indiana Administrative Code (IAC), or other sources as appropriate.

See the “Rules, Citations, and Sources” section of this document for further information.

COVERAGE CRITERIA

The IHCP consults hospice criteria published by the fiscal intermediary for Indiana

Medicare hospice providers, Palmetto Government Benefits Administrators, LLC.

Palmetto has established these guidelines as a matter of protocol for medical criteria.

Providers are to use current professional guidelines, including the Local Medical Review

Policy (LMRP), to determine when members meet medical necessity for hospice

services. Hospice providers are reminded that the IHCP recognizes the LMRP is a

guideline to determine when members are appropriate for hospice and palliative services.

The LMRP is not meant to replace the overall clinical evaluation by the hospice provider,

01/31/2007 Hospice

Medical Policy Manual

227

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

IHCP, or its contractor when evaluating the unique clinical condition of each hospice

member.

Any IHCP member, who is terminally ill and meets medical necessity criteria, may

receive services from an IHCP hospice provider. Additional to service compliance with

42 CFR Part 418 et. al and the Balanced Budget Act of 1997, providers are required to

document in the member’s hospice medical record support for a terminal diagnosis versus

a chronic condition.

PRIOR AUTHORIZATION

Hospice care is dependent upon a physician’s certification endorsing a member's

prognosis of life-expectancy to be six months or less, if the terminal condition runs its

normal course. Hospice services must be reasonable and meet medical necessity for the

palliation and management of the terminal illness. Coverage for hospice care is strongly

dependent upon documentation of the member's condition and the overall decline in the

member's health status as recorded in the physician certification and the hospice plan of

care. Additionally, documentation must include any co-morbidities. Documentation is

utilized in the prior authorization (PA) and review processes to determine medical

necessity. Each case is evaluated on its own merit. The IHCP, Medicare, and its

contractors are not prevented from requesting medical documentation regarding hospice

members at any time during the member’s enrollment the hospice program. This practice

is consistent with the IHCP provider agreement.

All IHCP hospice providers are required to be Medicare-certified and licensed as a

hospice by the Indiana State Department of Health before enrolling as an IHCP hospice

provider. Each hospice agency must ensure that the medical documentation submitted to

Health Care Excel (HCE) meets Medicare conditions of participation. The IHCP requires

hospice providers to request PA for members at the beginning of each hospice benefit

period. PA requests for hospice services may be modified by the HCE PA department.

When entering the third hospice benefit period of 60 continuous days, hospice providers

must submit specific medical documentation that supports the need of continued hospice

care. If the HCE PA department determines that the information is insufficient to process

the request, the PA hospice reviewer will return it for the required documentation. The

following information must be documented and sent to the PA department for initial and

continued hospice care.

• Member has a terminal prognosis, as well as, a physician certification that

meets the Medicare guidelines for participation.

• Clinical evidence must support a terminal diagnosis at the time of the initial

certification and each subsequent certification.

• Documentation must describe why a member’s condition is terminal, not

chronic (Medical history may provide clarification for documentation that

reflects a chronic condition).

01/31/2007 Hospice

Medical Policy Manual

228

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• For each hospice benefit period, the interdisciplinary team must assess the

member's condition and service appropriateness. Documentation must

distinguish between exacerbation and stabilization, as well as, exacerbation and

deterioration.

• Documentation must include the most specific and appropriate terminal

diagnosis from the International Classification of Diseases 9

Edition, Clinical

Modification (ICD-9-CM).

• Documentation must specify any necessary medications, treatments, and

services that are considered aggressive treatments.

• Document must detail the member's decline.

• Document must describe how the systems of the body are in a terminal

condition.

Hospice Forms

IHCP hospice providers must complete and submit the appropriate forms for each

member. Required forms are dependent upon the member’s status and requested actions.

Refer to the IHCP Hospice Provider Manual and the Indiana Family and Social Services

Administration web site for detailed information regarding these forms. Below is a brief

description of the hospice forms available to providers.

• Medicaid Hospice Election

Members complete this form to elect the hospice benefit. Additionally, it is

used to select a particular hospice provider. Election of the hospice benefit

requires the member to waive: (a) other forms of health care treatment of the

terminal illness for which hospice care was elected or for treatment of a

condition related to the terminal illness; (b) services provided by another

provider that are equivalent to the care provided by the elected hospice

provider; and (c) hospice services other than those provided by the elected

hospice provider or its contractors.

• Medicaid Physician Certification

Providers complete this form in conjunction with the Hospice Election Form

and the Hospice Plan of Care when requesting the first hospice benefit period.

Assuming the information is sufficient and accurate, an initial benefit period of

90 days is approved. If benefit periods beyond the first 90 days are necessary,

then recertification on the IHCP Physician Certification form and an updated

Hospice Plan of Care is required for hospice authorization of the next benefit

period.

• Medicaid Hospice Plan of Care

Providers complete this form must be completed by an interdisciplinary team

member and who must confer with at least one other member of the

interdisciplinary team. One of the conferees must be a licensed physician or

nurse. All team members must review the plan of care. All of the services

stipulated within the plan of care must be reasonable and necessary for

palliation or management of the terminal illness and related condition. The

01/31/2007 Hospice

Medical Policy Manual

229

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

plan of care must be signed by the hospice medical director and include two

other signatures from any of the disciplines listed on the IHCP Hospice Plan of

Care.

• Hospice Authorization Notice for Dually-Eligible Medicare/Medicaid Nursing

Facility Residents

Providers complete this form for dully-eligible Medicare/Medicaid members.

These members must elect, revoke, and change providers under both the

Medicare and the IHCP programs at the same time. The hospice provider is

required to notify both programs of any changes in the dually-eligible

Medicare/IHCP member’s hospice care status. The IHCP requires that the

hospice provider submit all the required certification forms

• Hospice Provider Change Request Between Indiana Hospice Providers

Providers complete this form when a member, or representative of the

member, is not satisfied with the hospice provider. A member may change

hospice providers once during any benefit period. This change does not

constitute a revocation of services.

• Change in Status of Medicaid Hospice Patient

Providers complete this form when there is an eligibility status change.

• Medicaid Hospice Discharge

Providers complete this form when a hospice provider discharges a member

from future services. Refer to the section, Discharge by a Provider, to

determine appropriate discharge criteria.

• Medicaid Hospice Revocation

Providers complete this form when a member, or representative of the

member, is not satisfied with hospice care and revokes hospice services. This

form includes a signed statement that the individual revokes the election of

IHCP hospice services for the remaining days in the election period. A

member can elect to receive hospice care intermittently, rather than

consecutively, over the three benefit periods and can therefore elect and revoke

hospice coverage an unlimited number of times.

Covered Services

Hospice core services are covered services in the Medicare and IHCP hospice per diem

that must be provided directly to the member by hospice employees. Hospice core

services include nursing services, medical social work services, and counseling services

(including bereavement, dietary, spiritual, and other services). Hospice noncore services

are services in the Medicare or IHCP hospice per diem not identified as hospice core

services. The following list includes hospice services included in the Medicare and

Medicaid hospice per diem:

• Nursing care provided by or under the supervision of a registered nurse

01/31/2007 Hospice

Medical Policy Manual

230

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Medical social work services provided by a social worker with at least a

bachelor’s degree working under the supervision of a physician

• Physician services provided by the medical director or a physician part of

the interdisciplinary team participating in services as follows.

• General supervising services, participating in the plan of care, conducting

periodic reviews, establishing governing policies, and providing direct-care

to members

• Counseling services provided to the member, member’s family, and other

people caring for the member

• Short-term inpatient care provided on a hospice inpatient unit, participating

hospital, and nursing home setting

• Medical equipment and supplies, including palliative drugs, related to the

palliation and management of the member’s terminal illness

• Home health services furnished by qualified aides

• Homemaker services that assist in providing a safe and healthy environment

• Physical therapy, occupational therapy, and speech-language pathology

services provided for the purpose of symptom control

• Inpatient respite care

• Room and board (dually-eligible hospice members) residing in long-term

care facilities

• Room and board for IHCP-only hospice members who reside in long-term

care facilities

• Any other item or service specified in the member’s plan of care, if the item

or service is a covered service under the Medicare program

Treatment of Nonterminal Conditions

The IHCP covers medical care for conditions unrelated to the terminal illness. The IHCP

expects the hospice provider to actively interface and coordinate these services with other

IHCP providers. Medical care for nonterminal conditions may be met by one of the

following methods.

• Outpatient physician services

• Inpatient and outpatient hospital admissions

• Emergency admissions to a nursing facility from a private home

If the IHCP hospice member requires an inpatient or outpatient hospital admission for

conditions unrelated to the terminal illness, the hospital must bill the IHCP directly for

these services. The hospice provider coordinates the inpatient or outpatient hospital

services. Hospice provider responsibility for the treatment of nonterminal conditions is

case specific. The following guidelines provide clarification for hospice providers

regarding this issue.

• If the hospice member currently does not receive treatment for a nonterminal

condition, the hospice provider is required to locate appropriate IHCP

services for the treatment of a nonterminal condition.

01/31/2007 Hospice

Medical Policy Manual

231

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• To ensure that the hospice member is not billed for these services, the

hospice provider must ensure that the hospital is enrolled as an IHCP hospice

provider.

• The hospice provider must communicate and coordinate with the hospital’s

medical personnel does not compromise the member’s hospice care.

• If the IHCP hospice member is admitted to the hospital from a private home,

the hospice provider must submit to the HCE PA department a Change in

Status of Medicaid Hospice Patient form. This form reflects the hospice

member’s change of care. The same form must be completed once the

hospice member is discharged from the hospital to either another institutional

care setting or to a private home.

The IHCP provider billing for the treatment of the nonterminal illness must obtain PA for

these services. The following services do NOT require PA for the treatment of

nonterminal conditions.

• Pharmacy services not related to the member’s terminal condition

• Dental services

• Vision care services

Discharge by Hospice Provider

Once a hospice provider chooses to admit a member, the provider may not automatically

or routinely discharge the member at its discretion, even if the care is costly or

inconvenient. The election of the hospice benefit is the member’s choice, rather than the

hospice’s choice; therefore, the hospice may not revoke the member’s election.

Additionally, hospice providers may not request or demand hospice revocation. Reasons

a hospice provider may discharge a member from care include the following situations.

• Member dies

• Member’s prognosis is determined to be greater than six months

• Member moves out of the hospice service area

• Member’s safety or hospice staff safety is compromised

When a member moves out of the service area, the hospice provider notifies the fiscal

intermediary of the discharge so that hospice services and billings are terminated as of the

discharge date. In this situation, the member loses the remaining days in the benefit

period; however, there is no increase cost to the member.

For circumstances when a member’s safety is compromised, the hospice must make

every effort to resolve these problems satisfactorily before discharge is considered an

option. All efforts by the hospice to resolve the problem must be documented in detail in

the member’s record. The hospice must notify the fiscal intermediary and the State

Survey Agency (SA) of the circumstances surrounding the impending discharge.

Hospice providers must submit specific forms to facilitate the discharge. For

reimbursement, hospice program guidelines must be followed.

01/31/2007 Hospice

Medical Policy Manual

232

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Hospice providers may fax the Medicaid Hospice Discharge form to the

HCE PA department, as long as all the hospice benefit periods preceding the

hospice discharge date have been previously authorized.

• For members residing in nursing facilities, hospice providers are encouraged

to provide a copy of the discharge form to the appropriate staff in the

nursing facility to ensure the form is included in the hospice member’s

nursing facility clinical record. These coordination procedures ensure staff is

aware of the exact date that the hospice provider discharged the member.

Additionally, hospice providers must provide a copy of this form to the

nursing facility billing department.

• Hospice providers must bill the IHCP for the hospice per diem for nursing

facility room and board for the hospice discharge date.

• Nursing facilities may resume billing the IHCP directly for nursing facility

care for the date of service following the hospice discharge date once the

hospice provider has provided a copy of the PA form reflecting an updated

hospice discharge claim.

• Hospice providers are reminded that it is a violation of medical records

standard to predate the hospice discharge. The documented discharge date

cannot precede the actual discharge.

Noncompliance

As part of the admissions process, hospice providers should explain to members covered

hospice services, actions that may constitute noncompliance with the hospice care

philosophy, and charges members may be responsible for paying. When a hospice

provider believes a member has reflected significant noncompliance with the hospice

plan of care, documentation standards outlined below must be followed.

• Must have clear written admissions policies

• Must have informed the member of the hospice benefit responsibilities

• Must have thorough documentation of the noncompliance issues

Once the hospice provider follows these guidelines, the SA must be contacted. The SA

contacts the Centers for Medicare and Medicaid Services (CMS) for further discharge

consideration.

Dually-Eligible and Medicaid-Only Hospice Members in Nursing Facilities

The IHCP hospice benefits must comply with the Omnibus Budget Reconciliation Act of

1989 (OBRA 1989). OBRA 1989 requires dually-eligible Medicare/IHCP members to

elect, revoke, or change providers under both the Medicare and the IHCP programs

simultaneously. Hospice providers are required to notify both programs of any changes

in the member’s hospice care status. Additionally, hospice providers are required to

coordinate regularly with nursing facility providers. To ensure that the IHCP member's

enrollment in the IHCP hospice benefit is clear to both hospice and nursing facility staffs,

the hospice provider must furnish the nursing facility staff and the nursing facility’s

billing department with the member’s Medicaid hospice forms.

01/31/2007 Hospice

Medical Policy Manual

233

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Waiver Members

Once hospice service criteria are met, IHCP waiver members are eligible for hospice

services. Waiver members are not required to disenroll from the waiver program;

however, they must be under direct-care of an IHCP hospice provider for those services

that both programs have in common. Member may receive waiver services unrelated and

non-duplicative of the hospice services. Hospice providers must coordinate with

nonhospice providers to ensure overall care is met and the hospice plan of care is not

compromised. The number of hours related to the member’s nonterminal condition is

determined on a case specific basis. Additional waiver services should not be provided

due to the hospice election.

MANAGED CARE ORGANIZATIONS

Members enrolled in an IHCP Managed Care Organization (MCO) must disenroll.

Disenrollment is necessary for hospice authorization to be completed. Members become

eligible for hospice services the day following disenrollment from the MCO.

To facilitate the hospice authorization process, the hospice provider may fax the

Medicaid Hospice Election form to the HCE PA department initiating MCO

disenrollment. The corresponding Medicaid Hospice Physician Certification form and

Medicaid Hospice Plan of Care form must be sent to the HCE PA department within ten

business days. If the hospice provider fails to verify IHCP eligibility or fails to fax the

Medicaid Hospice Election form to the HCE PA department, the hospice provider will

not receive payment for these dates of service the member is MCO member.

REIMBURSEMENT INFORMATION

Hospice providers must provide care based on the medical acuity of the member at one of four

distinct hospice levels of care: routine home care, continuous home care, general inpatient

hospice care, and inpatient hospice respite. Hospice inpatient care must be provided in an

inpatient unit or contracted inpatient facility that meets the parameters at 42 CFR Part 418.100

et al. The following information describes the four levels of service and the two levels of

care available to members. Table 1 outlines the hospice reimbursement methodology.

• Routine home care delivered in a private home

• Continuous home care delivered in a private home

• Routine home care delivered in a nursing facility

• Continuous home care delivered in a nursing facility

• Inpatient respite care (available to private home hospice members only)

• General inpatient hospice care

01/31/2007 Hospice

Medical Policy Manual

234

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Table 1 Hospice Reimbursement Methodology

Revenue

Code

Revenue Code Descriptions and Explanations

180

Nursing Facility Bed Hold Non-Paid Revenue Code***

The hospice provider should bill the IHCP using this revenue code for leave

days when the nursing facility occupancy is less than 90%. This code

generates an IHCP denial; however, providers may charge members for the

nonreimbursed bed hold days.

183

Nursing facility bed hold for hospice therapeutic leave days***

Therapeutic leave days are reimbursed at 50% of the 95% of the nursing

facility room and board per diem rate. Eighteen therapeutic leave days are

reimbursable per member per calendar year. Hospice providers should not

bill the IHCP using this revenue code when the nursing facility occupancy

rate is below 90%.

185

Nursing facility bed hold for hospitalization for services unrelated to the

terminal illness***

Bed holds for hospitalization for services unrelated to the terminal illness are

reimbursed at 50% of the 95% of the nursing facility room and board per

diem rate. Fifteen days per hospitalization is reimbursable. Hospice

providers should not bill the IHCP using this revenue code when the nursing

facility occupancy rate is below 90%.

651

Routine home care in a private home

The hospice provider is paid 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. This rate is paid without regard to the volume or

intensity of routine home care services.

652

Continuous home care in a private home *

Continuous home care per diem rate is calculated into an hourly rate. The

hourly rate is reimbursed to the hospice provider to 24 hours a day. Home

health aides may supplement the nursing care in the total continuous care

hours. All hours must be counted. Documentation must clearly indicate the

nature of the medical crisis, need for skilled intervention, and illustrate hourly

and daily what level of staffing and the services provided.

653

Routine home care in a nursing facility

The hospice provider is paid at the routine home care rate for each day the

member is in a nursing facility, under the care of the hospice provider, and

not receiving continuous home care. The rate is paid without regard to the

volume or intensity of routine home care services. The hospice provider is

paid an additional room and board per diem at 95% of the lowest nursing

facility rate for contracted nursing facility cost.

01/31/2007 Hospice

Medical Policy Manual

235

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Revenue

Revenue Code Descriptions and Explanations

Code

654

Continuous home care in a nursing facility

The continuous home care rate is calculated into an hourly rate. The hourly

rate is reimbursed up to 24 hours a day. Home health aides may supplement

the nursing care in the total continuous care hours. All hours must be

counted. Documentation must clearly indicate the nature of the medical

crisis, need for skilled intervention, and illustrate hourly and daily what level

of staffing and the services provided. The hospice provider is paid an

additional room and board per diem at 95% of the lowest nursing facility rate

for contracted nursing facility cost.

655

Inpatient respite care**

Respite care is an occasional, short-term inpatient care provided to hospice

members to relieve caregivers. Respite care is available to members residing

in private homes. The hospice provider is paid at the inpatient respite care

rate for each day the member resides in an approved inpatient facility and

receives respite care. Payment for respite care is for a maximum of five

consecutive days per stay. Payment for the sixth day and subsequent days is

at the routine home care rate.

656

General inpatient hospice care

The hospice provider is paid at the general inpatient hospice rate for each day

the member resides in an approved inpatient hospice facility and receives

general inpatient hospice care. Inpatient hospice care is for pain control and

acute/chronic symptom management not manageable in other settings.

657

Hospice direct-care physician services

Physician services, hospice provider employee or authorized hospice

provider, are separately reimbursable on a fee-for-service basis. Services are

billed by the hospice provider utilizing the hospice provider number. This

code may be billed on the same day other hospice revenue codes are billed.

659

Room and Board for Dually-eligible Medicare/Medicaid nursing facility

members only (Room and board portion of the hospice per diem rate)

The hospice provider must bill Medicare for the hospice services and

Medicaid for room and board. The hospice provider is paid 95% of the

lowest nursing facility per diem to cover the room and board cost incurred by

the contracted nursing facility. Revenue code 659 may not billed with the

hospice related revenue codes 651, 652, 653, 654, 655, or 656. These codes

are designated for IHCP-only hospice services.

*Continuous home care is provided only during a period of crisis requiring continuous care for acute medical

symptoms, palliation and management treatments. A nurse, registered or licensed practical nurse, must

provide over half the total care. This care need not be continuous and uninterrupted.

**Inpatient facility is defined as a hospital, long-term care facility, or the facility of a hospice provider that

provides care 24 hours a day.

***Please have hospice revenue codes 180, 183, and 185 follow hospice revenue code 659 in the table.

01/31/2007 Hospice

Medical Policy Manual

236

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Reimbursement for Room and Board on Date of Death or Date of Physical

Discharge

The OMPP does not pay the nursing facility per diem or room and board services for the

day a member is discharged from the nursing facility. When a hospice member dies in a

nursing facility, the date of death follows the same reimbursement procedures as the date

of physical discharge from the nursing facility. If a hospice member is admitted and dies

in the nursing facility on the same day, the nursing facility is not paid the room and board

per diem for that day; however, hospice providers may bill the IHCP for the hospice per

diem for either a physical or death discharge. Providers bill revenue code 653 or 654

with occurrence code 51.

Hospice Member Liability Residing in a Nursing Facility

An IHCP member (dually-eligible Medicare/IHCP or IHCP-only) residing in a nursing

facility is responsible for the member's portion of the payment before the IHCP pays the

remaining balance of nursing facility care (i.e., room and board services). Member

liability includes, but is not limited to, personal savings account, Medicare pension funds,

or Social Security funds. Member liability is deducted the first date of service the

member resides and eligible for the IHCP nursing facility LOC.

Hospice providers can obtain a member’s patient liability for a particular month by

contacting EDS Customer Assistance or using one of the eligibility verification system

(EVS). When a provider obtains the patient liability amount, the RA is used to determine

how EDS calculates the paid amount. The following formula is used if the RA does not

match the rates the provider submitted on the claim.

1. Nursing facility case mix rate on file x 95% (.95) = allowed amount on the RA

for room and board

2. (Number of dates of service x allowed amount on RA) minus member liability

= room and board amount

Prior Authorized Physician Services

Additional reimbursement is available for an independent physician's direct-care services

in accordance with the IHCP reimbursement physician service methodology. Hospice

providers may not bill these services under the hospice provider number. Services must

be the physician's professional services. Costs for services related to the terminal

condition, such as laboratory or X-rays, may not be included in this billing. These

services are included in the per diem rates.

Emergency Service Charges

Emergency service charges related to the terminal illness for hospice members are the

responsibly of the hospice provider. These responsibilities include all hospice and

transportation charges associated with emergency. Emergency service charges unrelated

to the terminal illness are separately reimbursable by the IHCP by the appropriate

provider.

01/31/2007 Hospice

Medical Policy Manual

237

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

NURSING FACILITY QUALITY ASSESSMENT

The IHCP began retro rate adjustments to nursing home rates for the nursing facility

quality assessment fee July 2005. The change in nursing facility rates, due to the quality

assessment fee results in retro rate adjustments for room and board to hospice providers

retroactive to July 1, 2003. Hospice and nursing facility providers are reminded that all

coordination and payment arrangements should be reflected in the hospice contract with

the nursing facility. Hospice claims reflecting room and board payments for the dates of

service July 1, 2003 to present are included in the retro rate adjustment. OBRA 1989 and

405 IAC 1-16-4 require the IHCP to reimburse hospice providers nursing facility room

and board payments; Hospice providers reimburse nursing facilities according to their

contract. The IHCP pays the hospice 95% of the nursing home rate on file to the hospice.

INDIANA HEALTH COVERAGE PROGRAMS HOSPICE PROVIDER

MANUAL 4.0

The IHCP Hospice Provider Manual provides a comprehensive, single-source document

outlining policies and procedures associated with the IHCP hospice program. The

manual does not address general aspects of IHCP policy such as IHCP member

eligibility, third party liability, medical policy, PA, utilization review, or inspection of

care. The manual is divided into nine main sections.

• Section 1: Introduction

This section outlines key policies and procedures

• Section 2: Provider Enrollment

This section outlines the conditions for provider participation and enrollment

procedures. Special attention is given to provider certification requirements,

locational service issues, and institutional policies.

• Section 3: Member Eligibility

This section outlines the target group by population category, hospice benefit

periods, and member certification requirements.

• Section 4: Election and Revocation

This section explains election and revocation hospice services, discharging hospice

members, and changing hospice providers.

• Section 5: Hospice Authorization Process

This section defines the procedures and policies that determine the framework of a

member's hospice services. Emphasis is placed on the informational requirements

associated with the hospice benefit periods and the prior authorization process for

services unrelated to the terminal condition.

01/31/2007 Hospice

Medical Policy Manual

238

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Section 6: Reimbursement

This section describes reimbursement for hospice services detailing billing revenue

codes and level-of-care categories.

• Section 7: IHCP Recoupment

This section describes methods of IHCP recoupment and overpayment.

• Section 8: Most Common Error Codes

This section describes common reimbursement denials, explanation of benefit

codes, and methods to correct errors.

• Section 9: Hospice Contracts with Nursing Facilities

This section explains hospice provider and nursing facilities contracts.

RELATED MEDICAL TOPICS

Emergency Services

Home Health Services

Hospital Inpatient Services

Hospital Outpatient Services

Long-Term Care Services

Managed Care Organization Services

Mental Health Services

Nursing Facilities Services

Out-of-State Servies

Pharmacy Services

Therapy Services

Waiver Services

RULES, CITATIONS, AND SOURCES

Code of Federal Regulations (CFR)

42 CFR 1001.952 – Safe Harbor Regulation

42 CFR 418 – Conditions of Participation for Hospice Care

01/31/2007 Hospice

Medical Policy Manual

239

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Indiana Administrative Code (IAC)

405 IAC 1-16 – Reimbursement for Hospice Services

405 IAC 5-2-10.2 – “Hospice Program” defined

405 IAC 5-5-1 – Out-of-State Services; general

405 IAC 5-34 – Hospice Services

Indiana Code (IC)

IC 4-21.5-3-33 – Adjudicative Proceedings, Records

IC 16-25-3 – Licensure of Hospices

Indiana Health Coverage Programs Provider Manual

1999

Revised 2005, Version 5.0

Indiana Health Coverage Programs Hospice Provider Manual

Revised March 2004, Version 4.0

Indiana Health Coverage Programs Banner Page (BR)

BR200536 – Retro Rate Adjustments under Hospice

BR200513 – Information about Hospice Retro Rate Room and Board Adjustment

Procedures

BR200503 – Change Order to Expedite the Adjustment of Hospice Claims for

Room and Board

BR200502 – Hospice and Nursing Facility Change Order

BR200501 – Hospice and Nursing Facilities Claims Changes

BR200452 – Hospice and Nursing Facilities Update

BR200446 – Hospice for Managed Care Member Update

BR200442 – Hospice Update

BR200413 – Hospice Counties 1-9 EOB code 4014

BR200412 – Hospice Update as in BT200372

BR200411 – Hospice Changes to Authorization Process

BR200410 – Hospice Providers Enrolled in MCO and Hospice Authorization

Update

BR200331 – Hospice Verification Responses

BR200315 – Hospice Update

BR200216 – Hospice Rule Change

BR200043 – Hospice Agency Review Process

BR200025 – Hospice Benefits Clarification

BR199919 – Hospice Claims Mass Adjustments

BR12-29-1998 – Hospice Forms

BR12-15-1998 – Hospice “Private Pay”

BR11-10-1998 – Medicaid Hospice Forms

Indiana Health Coverage Programs Provider Bulletin (BT)

BT200372 – Changes in Hospice Authorization Process

BT200367 – Hospice Rates Effective October 1, 2003 and Hospice Benefits

Updates

BT200365 – Pharmacy Hard Edits and Hospice Review Process

BT200331 – Changes to the Hospice Benefit Rules

BT200259 – Detailed Explanation of Rule Changes and the Impact of the

Changes on Hospice Providers for IHCP Hospice Authorization

01/31/2007 Hospice

Medical Policy Manual

240

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

BT200234 – System Changes Affecting Hospice Revenue Codes 655 and 656

BT200147 – Hospice Rates Effective October 1, 2001

BT200146 – Nursing Facility Bed Hold Days

BT200116 – Nursing Facility Retro Rate Adjustments for Hospice Members

Receiving Hospice Care Prior to July 1, 1999

BT200112 – Revised Indiana Health Coverage Programs Hospice Rates Effective

April 1, 2001

BT200107 – Notification of Systems Issues Regarding Incorrect Payments to

Hospice Providers for Room and Board Payments on Member's

Date of Death

BT200102 – New Hospice Rate Effective October 1, 2000

BT200041 – Incorrect Payment to Hospice Providers for Room and Board

Payments for Member’s Date of Death

BT200030 – Revised Hospice Provider Manual

BT200011 – New Hospice Policy for Nursing Facility Residents

BT200002 – Use of Forms 450B and OMPP 450B SA/DE

BT199940 – New Rates

BT199939 – Billing Procedures, Edit1024

BT199925 – Policies and Procedures for Treatment for Non-Terminal Conditions

BT199924 –Treatment for Non-Terminal Conditions for Hospice Recipients

Admitted to a Nursing Facility After a Hospital Stay.

BT199919 – New Effective Date OMPP Recoupment Based on Noncompliance

with 405 IAC 1-16-4

BT199905 – Exceptional Services Managed Care (Medicaid Hospice)

Information

BT199904 – Election of Hospice Services by Home and Community-Based

Waiver Recipients Information

BT199846 – New Hospice Rates

BT199840 – Updated Form 450B Information

BT199838 – Hospice Authorization and Claim Payment Issues

BT199836 – Contracted Hospice Services in Nursing Facility

BT199830 – Reimbursement and Survey Issues (Hospice Benefits)

BT199817 – Procedures to Request Hospice Forms

BT199802 – Medicaid Hospice Billing Procedures

Indiana Health Coverage Programs Provider Newsletter (NL)

NL200411 – Hospice Services

Omnibus Budget Reconciliation Act of 1989 (OBRA 1989)

Social Security Act, Section 1902(a)(57)

Origination Date: 12/31/2000

Revision

and Review

Reason Date

Revision E97-25 New Hospice Benefit 07/01/97

Revision E98-15 New HCPC Procedure Codes 01/01/98

01/31/2007 Hospice

Medical Policy Manual

241

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Revision

Reason Date

and Review

Revision E98-02 Medicaid Hospice Billing Procedures 01/09/98

Revision

E98-30 Reimbursement and Survey Issues Related to the

Hospice Benefit

09/18/98

Revision E98-17 Procedures to Request Hospice Forms 09/18/98

Revision E98-46 New Hospice Rates 10/01/98

Revision E98-37 Recoupment Based on 405 IAC 1-16-4 11/06/98

Revision E98-36 Contracted Hospice Services in Nursing Facilities 11/06/98

Revision

E98-38 Issues Regarding Hospice Authorizations and

Hospice Claims Payment

11/06/98

Revision

E99-04 Election of Hospice Services by Home and

Community-Based Services Waiver Recipients

01/26/99

Revision

E99-05 Parameters and Procedures for Reimbursement for

Exceptional Circumstances for Managed Care Recipients

Who Elect Hospice

01/26/99

Revision

Medicaid Hospice Benefit Provider Manual Policy and

Procedures

02/01/99

Revision

E99-19 New Effective Date for OMPP Recoupment

Based on Non-Compliance

06/14/99

Revision E99-24 Treatment for Non-Terminal Hospice Conditions 07/30/99

Revision

E99-25 Policies and Procedures for Treatment for Non-

Terminal Conditions

07/30/99

Revision E99-40 New Rates 11/17/99

Revision E99-39 Billing Procedure and Edit 1024 12/01/99

Revision E00-11 New Policy 02/25/00

Revision E00-30 New Hospice Provider Manual 07/01/00

Review Scheduled 07/31/06

APPLICABLE INDIANAAIM EDITS AND AUDITS

387 – Service Is Not Payable

403 – Hospital “From” Date Invalid

404 – Hospital “Thru” Date Invalid

439 – Hospice Services Being Billed (Manual Payout)

499 – Claims Correction Form Not Returned Within Days

513 – Recipient’s Number Does Not Match the Recipient’s Name

01/31/2007 Hospice

Medical Policy Manual

242

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hospice

Medical Policy Manual

243

547 – Hospital Leave Billed Without Accommodation

564 – Revenue Code Is Not Allowed for this Recipient’s Eligibility

641 – Patient Reported as Deceased

646 – Coordination With Hospice Provider

665 – Patient Enrolled Under Managed Care

1001 – Billing Provider Not Eligible to Bill on this Program

1002 – Rendering Provider Not Eligible to Render Service on this Program

1003 – Billing Provider Not Eligible to Bill on this Program for the Date of Service

1004

–

Rendering Provider Not Eligible to Render Service on this Program for the Date of

Service

1015 – Provider Not Authorized to Render this Service for this Program Without PA

1024 – Billing Provider Not Listed As Member’s LTC Provider

1025 – Billing Provider Not Eligible to Bill on this Program for the Dates of Service

1032 – Billing Provider Not Eligible to Bill this Claim

1035 – Hospice Provider Billing for Hospice Services

1036 – Rendering Provider Not Eligible

1037 – Private Duty Nurse

1039 – Services Rendered By Out of Network Provider

1042 – Certification Code Missing

2003 – Recipient Ineligible on Date of Service

2018 – Recipient Ineligible on Date(s) of Services

2023 – Recipient Ineligible on Dates of Service Due to Enrollment in a Managed Care

Organization

2024 – Patient Ineligible for Hospice Level-of-Care

2025 – Hospice Recipient Billed Without Hospice Services

2026 – Hospice Recipient Ineligible for Nursing Home

2027 – Hospice Service Not Billed Correctly

2034 – Medical and Non-Medical Supplies and Routine DME Items are Covered in the Per

Diem Rate

4014 – No Pricing Segment on File

4214 – Hospice/Waiver Duplicative Services

4233 – Date of death/discharge not covered

5001 – Duplicate of Another Claim

6748 – Hospice Respite Limited to Five Days

9064 – Hospice Pricing (Rate on File)

9069 – Room and Board Not Paid on Date of Death/Discharge

9070 – Payment is Based on the Lessor of the Billed

9090 – State Enforced Rate Reduction

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HOSPITAL INPATIENT

DESCRIPTION:

“Inpatient” defined is a patient required to be admitted to the hospital to treat a condition

requiring close monitoring or skilled professional management.

SUMMARY OF CURRENT POLICY:

Inpatient hospital services can be covered when they are medically reasonable and

necessary and can be performed only in an inpatient hospital setting. Most inpatient

admissions are reimbursed by Diagnosis Related Groupings (DRG) methodology.

Catastrophic cases are given special consideration and are reimbursed based on outliers

of the case.

Admissions reimbursed by level of care are psychiatric admissions, physical

rehabilitation admissions, and burn admissions.

Medicaid does require prior authorization for all out-of-state admissions, in-state

psychiatric admissions, substance abuse admissions, physical rehabilitation admissions,

and burn admissions. Prior Authorization must be obtained for all admissions requiring

prior authorization wi.thin forty-eight (48) hours, excluding Saturday, Sunday, and legal

holidays. Concurrent review is necessary beyond the approved days. (Prior

Authorization requirements may be found in 405 IAC 5-3.)

MEDICAL TOPICS CROSS-REFERENCES:

Family Planning

Hospital Inpatient – Readmissions/General/Same Provider

Mental Health/Behavioral Health – Inpatient Services

Mental Health/Behavioral Health – Outpatient Services

Nursing Facilities

01/31/2007 Hospital Inpatient

Medical Policy Manual

244

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hospital Inpatient

Medical Policy Manual

245

RULES, CITATIONS, AND SOURCES:

405 IAC 5-17 Hospital Services

Initial Policy Issue

Effective

Date

Implementation

Date

Retroactive

Date

470 IAC 5-8-9

Transferred

Hospital services 7/1/91

405 IAC 1-6-9

Repealed 8/24/97

Hospital Services

1/1/92

Revisions:

405 IAC 5-17-1

405 IAC 5-17-2

Hospital Services

8/24/97

405 IAC 5-17-3

Emergency

Inpatient

Admission

8/24/97

APPLICABLE INDIANAAIM EDITS AND AUDITS:

2020

2021

3007

3014

4081

4085

4087

4092

4099

4103

4106

4116

4202

6046

6508

6509

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Coverage Criteria

INPATIENT ACUTE CARE HOSPITAL ADMISSIONS

405 IAC 5-17 provides the rules governing hospital services.

Inpatient hospitalizations for medical conditions other than mental health, burns or

rehabilitation following a traumatic injury, are reimbursed utilizing the DRG

methodology and do not require prior authorization. (See 405 IAC 1-10.5 for DRG

reimbursement methodology)

Inpatient hospitalizations for the immediate treatment of burns DO require prior

authorization. However, considering these admissions are usually emergent in nature, the

facility has 48 hours from the time of admission, excluding weekends and holidays, in

which to request authorization. Additional days are based on medical necessity and the

percentage of the body involved.

NOTE: Effective January 10, 2001, the Office of Medicaid Policy and Planning

(OMPP) determined that the prior authorization requirement for inpatient burn

admissions was no longer required. It was determined that the prior authorization

requirement is hard coded in the IndianaAIM system and would require a Customer

Service Request (CSR) to have the hard coding removed. The CSR will not be able to be

completed until after HIPPA implementation in October 2003. In the interim, the HCE

Prior Authorization department has created a work around process that allows for

information to be received from the provider and entered in the IndianaAIM system. The

provider can be instructed that there are no further clinical updates required and request

that the provider call the department with a discharge date so that the number of days can

be added to the prior authorization approval.

Surgical procedures typically performed on an outpatient basis, when performed as an

inpatient, must be prior authorized (405 IAC 5-17-2). These may be the result of

technical or medical difficulties during the outpatient procedure; presence of physical or

mental conditions making prolonged pre or postoperative observation by skilled medical

personnel necessary, a simultaneous procedure requiring hospitalization or the likelihood

of an additional procedure requiring hospitalization.

Substance abuse admissions are also reimbursed utilizing the DRG methodology, but do

require prior authorization, as outlined under “Mental Health”.

All out-of-state services require prior authorization. (See 405 IAC 5-5-2 and Claims

Resolution Manual ESC 3010) [Exception—405 IAC 5-5-2(3)(4)]

01/31/2007 Hospital Inpatient

Medical Policy Manual

246

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Hospitalization Adult burns

(Age 10 and over)

Overview

General Information:

Prior authorization is required for all Medicaid covered burn inpatient stays that are

reimbursed under the level of care methodology described in 405 IAC 1-10-5. Days that

are not prior authorized under the level of care methodology as required by this rule will

not be covered by Medicaid.

405 IAC 5-17-3 Emergency inpatient admissions for diagnoses reimbursed under the

level of care payment methodology must be reported to the office within forty-eight (48)

hours of admission, not including Saturdays, Sundays, or legal holidays, in order to

receive Medicaid reimbursement. At that time, the same standards for prior authorization

will be applied as would have been applied if the authorization had been requested before

the admission.

First degree: Superficial

. Damage is limited to the epidermis. Erythema appears.

Between 10 and 20 % total body surface area-minor burn.

Second degree: Deep partial thickness burns of the eyes, ears, face, hands, feet or

perineum; or burns complicated by fractures or respiratory

damage; electrical burns; and all burns in poor-risk patients.

Involvement of less than 15% total body surface area-minor burn.

Involvement of 15% - 25% total body surface area-moderate burn.

Involvement of more than 25% total body surface area-major

burn.

Third degree: Full thickness burns covering less than 3% of the body, excluding

the eyes, ears, face, hands, feet or perineum = minor burn.

Full thickness burns of the eyes, ears, face, hands, feet or perineum

covering > 3% and < 10% total body surface area = moderate burn.

Full thickness burns of more than 10% of the total body surface-

major burn.

01/31/2007 Hospital Inpatient

Medical Policy Manual

247

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Revenue Code Narrative Description

207 Admissions for burns. One (1) unit = one (1) day.

405 IAC 5-17-2 (a)

Indicators

The admission may be approved without referral for physician review if ONE of the

following is present: (recent onset)

1. Loss or damage of skin ≥ 15% of TBS (total body surface) area.

2. High voltage burn with devitalized skin, fat, or muscle.

3. 2nd or 3rd degree burns of one of the following: Face, hands, perineal region,

encircling neck or extremities, anterior or posterior neck or limbs.

4. T ≥ 104.0° F

5. T ≥ 102.0° F and ONE of the following:

• WBC ≥ 18,000/cu.mm

• WBC ≥ 15,000/cu.mm with ≥ 7% bands

1. T ≥ 100.5° F and ONE of the following:

• Absolute neutrophil count ≤ 500/cu.mm

• WBC ≤ 1,500/cu.mm

2. Admission for an invasive procedure which necessitates an inpatient setting AND is

scheduled for the same day as admission.

AND ONE of the following treatments is being provided: (at least daily)

1. Post surgery or procedure care ≤ 3 days and at least TWO of the following:

• IV fluids ≥ 100 mL/h

• IV, IM, or ED analgesics

01/31/2007 Hospital Inpatient

Medical Policy Manual

248

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• IV or IM antiemetics

• Graft or wound care

1. Burn therapy with at least THREE of the following:

• IV electrolyte (K, Ca, Mg, P)

• IV fluids ≥ 100 mL/h

• IV plasma expanders

• O2 ≥ 28% (4L) or Hyperbaric

• TPN

OR at least THREE of the following treatments are being provided:

1. Blood or blood products

2. Complex burn, graft, or wound care

3. IV fluids ≥ 100 mL/h

4. Restorative PT or OT at least 2x/24h

5. TPN

6. IV or IM corticosteroids at least 3x/24h

7. IV or IM diuretics at least 2x/24h

8. IV or IM analgesics at least 4x/24h

9. IV or IM antiemetics at least 4x/24h

10. IV or IM anti-infectives at least 3x/24h

References

Information obtained from the Medicare MDC Criteria Manual.

01/31/2007 Hospital Inpatient

Medical Policy Manual

249

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Hospitalization Pediatric Burns

(Age 10 and under)

Overview

Prior authorization is required for all Medicaid covered burn inpatient stays that are

reimbursed under the level of care methodology described in 405 IAC 1-10-5. Days that

are not prior authorized under the level of care methodology as required by this rule will

not be covered by Medicaid.

405 IAC 5-17-3 Emergency inpatient admissions for diagnoses reimbursed under the

level of care payment methodology must be reported to the office within forty-eight (48)

hours of admission, not including Saturdays, Sundays, or legal holidays, in order to

receive Medicaid reimbursement. At that time, the same standards for prior authorization

will be applied as would have been applied if the authorization had been requested before

the admission.

The following descriptions are for age clarification purposes only.

Newborn-birth to 28 days

Infant=28 days to 18 months

Preschool=18 months to 6 years

Preadolescent=6 years to 12 years

Adolescent=12 to 18 years

Degree(s) of burns: (< 10 years old)

First degree: Superficial. Damage is limited to the epidermis. Erythema appears.

Between 10 and 20 % total body surface area-minor burn.

Second degree: Deep partial thickness

burns of the eyes, ears, face, hands, feet or

perineum; or burns complicated by fractures or respiratory

damage; electrical burns; and all burns in poor-risk patients.

9 Involvement of less than 10% total body surface area-minor

burn.

9 Involvement of 10% - 20% total body surface area-moderate

burn.

01/31/2007 Hospital Inpatient

Medical Policy Manual

250

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

9 Involvement of more than 20% total body surface area-major

burn.

Third degree: Full thickness

burns covering 2% of the body, excluding the eyes,

ears, face, hands, feet or perineum = major burn.

Full thickness burns of the eyes, ears, face, hands, feet or perineum

covering > 1% and < 10% total body surface area = major burn.

Revenue Code

Narrative Description

207 Admissions for burns. One (1) unit = one (1) day.

405 IAC 5-17-2 (a)

Indicators

The admission may be approved without referral for physician review if at least ONE of

the following is present: (recent onset)

1. Electrical burns with devitalized skin, fat, or muscle

2. 1st degree burns covering 40% of TBS

3. 2nd degree burns covering 15% of TBS

4. 2nd degree burns covering face, genitalia, hands, or feet

5. 3rd degree burns covering 5% or more of TBS

AND at least ONE of the following treatments is being provided at least daily:

1. Post surgery or procedure care ≤ 2 days

2. IV electrolytes

3. Burn therapy with at least TWO of the following:

• IV fluids ≥ 30 mL/kg/24h

• IV plasma expanders

01/31/2007 Hospital Inpatient

Medical Policy Manual

251

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• O2 ≥ 28% (4L)

OR at least THREE of the following treatments are being provided:

1. Blood or blood products

2. Complex burn, graft, or wound care

3. Physical therapy

4. IV fluids ≥ 30 mL/kg/24h

5. IV plasma expanders

6. TPN or Enteral feeding

7. IV or IM corticosteroids at least 3x/24h

8. IV diuretics at least 2x/24h

9. IV or IM analgesics at least 4x/24h

10. IV or IM antiemetics at least 4x/24h

11. IV or IM anti-infectives at least 3x/24h

References

Information obtained from the Medicare MDC Criteria Manual.

01/31/2007 Hospital Inpatient

Medical Policy Manual

252

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

INPATIENT DENTAL ADMISSIONS

Revenue Code Narrative Description

120 Inpatient days (Appropriate procedure code for

dental procedure must also be authorized.)

405 IAC 5-14-18

Indicators

ONE of the following:

1. Mental incapacitation such that the recipient’s ability to cooperate with procedures is

impaired, including mental retardation, organic brain disease and behavioral problems

associated with uncooperative, but otherwise healthy, children.

2. Severe physical disorders affecting the tongue, or jaw movements.

3. Seizure disorders.

4. Significant psychiatric disorders resulting in impairment of the recipient’s ability to

cooperate with procedures.

5. Previously demonstrated idiosyncratic or severe reactions to IV sedation medication.

6. The need for oral surgery, listed in 405 IAC 5-19-17 or in extreme cases of facial

trauma, pathology, or deformity.

7. Periodontal surgery only in cases of drug-induced periodontal hyperplasia.

8. Elective oral surgery when recipient is unable to cooperate with or tolerate the

procedure.

01/31/2007 Hospital Inpatient

Medical Policy Manual

253

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hospital Inpatient

Medical Policy Manual

254

HOSPITAL INPATIENT

FACT SHEET

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the Hospital Inpatient Fact Sheet. The information in this addendum will be

incorporated into the fact sheet at the next review.

Provider Notification: BR200509 Publication Date: 03/01/2005

Subject: Hospital Stays <24 hours

Date Added to Manual: 04/29/2005

Text of Publication

As a result of changes to 405 IAC 1-10.5-3 (y), effective for admissions on or after

November 1, 2004, providers are required to bill an inpatient stay of less than 24 hours as

an outpatient service. Claims that group to diagnosis-related grouping (DRG) 637 -

Neonate, died w/in one day of birth, born here and DRG 638 - Neonate, died w/in one

day of birth, not born here are exempt from this policy because they are specific to one-

day stays. The Office of Medicaid Policy and Planning (OMPP) has received inquiries

about potential medical record compliance issues with this rule. Specifically, providers

have questioned whether billing for outpatient services when a patient has been admitted

as an inpatient will be viewed by the OMPP as non-compliance with program policies

concerning internal records and billing requirements. The OMPP will not take action

against a provider for adhering to the agency’s billing requirements for inpatient stays of

less than 24 hours, because this is in compliance with the Indiana regulation and billing

requirements. In addition, providers have questioned whether their medical records,

which originally indicated an inpatient stay of less than 24 hours, should be amended to

show that outpatient services were performed. Providers do not need to amend their

medical record keeping to comply with the changes that became effective on November

1, 2004.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HOSPITAL INPATIENT--READMISSIONS GENERAL/

SAME PROVIDER

DESCRIPTION:

Readmission is the term used when patients are admitted to the hospital, acute care or

other, with the same diagnosis.

SUMMARY OF CURRENT POLICY:

Readmissions are subject to medical review [currently performed by the Surveillance,

Utilization and Review Department of Health Care Excel] to determine if previous

discharge was premature. Reviews are conducted based on statistical data sets for

readmissions. If the discharge was premature and payment made, the readmission or

discharge may be subject to recoupment [currently performed by the Surveillance,

Utilization and Review Department of Health Care Excel]. Readmissions will be treated

as separate stays for payment purposes.

MEDICAL TOPICS CROSS-REFERENCES:

Hospital Inpatient

Nursing Facilities

Mental Health/Behavioral Health – Inpatient Services

Mental Health/Behavioral Health – Outpatient Services

RULES, CITATIONS, AND SOURCES:

405 IAC 1-10.5-3 Reimbursement for Inpatient Hospital Services

Indiana Health Coverage Programs Provider Manual 1999

01/31/2007 Hospital Inpatient – Readmissions/General/Same Provider

Medical Policy Manual

255

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hospital Inpatient – Readmissions/General/Same Provider

Medical Policy Manual

256

Initial Policy Issue Effective

Date

Implementation

Date

Retroactive

Date

470 IAC 5-9-15,

5-9-38 Transferred

Hospital

Services

7/1/91

405 IAC 1-7-15,

1-7-36

Repealed

8/24/97

Hospital

Services

1/1/92

Revisions:

405 IAC 1-10.5-3 Prospective

Reimbursement

Methodology

12/27/96

405 IAC 5-17 Hospital

Services

8/24/97

APPLICABLE INDIANAAIM EDITS AND AUDITS:

6508

6509

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HOSPITAL OUTPATIENT

DESCRIPTION

Outpatient hospital services refer to disease prevention and diagnosis and/or therapeutic

and rehabilitative services including, but not limited to, surgery, therapy, laboratory,

radiology, chemotherapy, renal dialysis, clinic, treatment room, and emergency

department care. Services must be provided by or under the direction of a physician.

This document is intended to serve as a general summary of the Indiana Health Coverage

Programs’ (IHCP) policies regarding these services. More specific information may be

found in the IHCP Provider Manual, program notices, the Indiana Administrative Code

(IAC) or other sources as appropriate. See the “Rules, Citations, and Sources” section of

this document for further information.

COVERAGE CRITERIA

The IHCP will reimburse for outpatient services provided to a member who is not

registered as an inpatient in an acute care, psychiatric, or rehabilitation hospital.

Outpatient hospital services are covered when such services are provided or prescribed by

a physician. Documentation must support medical necessity for the diagnosis and

treatment of the condition. There are four categories of service within the defined

outpatient hospital prospective payment system.

• Outpatient surgery services

• Treatment room visit services

• Standalone services

• Add-on services

Observation Room Services

Outpatient services that occur within three days preceding an inpatient admission to the

same facility for the same or related diagnosis will be considered part of the

corresponding inpatient admission.

Outpatient services within three days preceding a less than 24-hour inpatient stay should

continue to be billed as an outpatient service. Because the inpatient service was less than

24 hours, it should be billed as an outpatient service.

01/31/2007 Hospital Outpatient

257

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Emergency Room Services

Payments for non-emergent care that do not include surgery and that are provided in an

emergency department, treatment room, observation room, or clinic will be based on the

statewide fee schedule amount that went into effect during state fiscal year 2003.

Noncovered Services

Reimbursement shall not be made for any hospital services not covered under the IHCP.

In addition, if a service requires prior authorization (PA), which was either not obtained

or denied, reimbursement for any associated services may be denied. Separately

reimbursable DME devices may not be covered if they are not prior authorized.

PRIOR AUTHORIZATION

Surgical procedures that are usually provided on an outpatient basis, but are performed as

an inpatient service must be prior authorized (i.e., medical difficulties during the

outpatient procedure, prolonged pre- or post-operative observation, and simultaneous

procedure requiring hospitalization).

The following services require PA.

• Stress electrocardiograms except for medical conditions

• All out-of-state services

• Separately reimbursable implantable DME items

MANAGED CARE

For members enrolled in Risk-Based Managed Care (RBMC), providers must contact the

member’s managed care organization (MCO) for more specific guidelines. Refer to the IHCP

Provider Manual, Chapter 1, for detailed information about the fee-for-service (FFS), Primary

Care Case Management (PCCM), and RBMC delivery systems.

IHCP members enrolled in Medicaid Select receive the same benefit coverage, and are subject

to the same limitations as Traditional Medicaid FFS. Refer to the Medicaid Select Provider

Manual for Primary Care Providers and Office Staff for further information.

BILLING REQUIREMENTS

Outpatient Surgeries

Outpatient surgeries provided in either a hospital or an ambulatory surgical center (ASC)

are reimbursed an all-inclusive flat fee that includes all related procedures.

01/31/2007 Hospital Outpatient

258

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Reimbursement is available for outpatient surgeries provided in a number of settings

including an operating room, treatment room, emergency department, or clinic.

Reimbursement is based on the assignment of the Current Procedural Terminology®

(CPT) code to one of the ASC groups. Reimbursement rates have been established for

each ASC group that is reflective of the average cost for procedures within the group.

The IHCP will reimburse a maximum of two units of service regardless of the number of

incisions. The procedure with the highest ASC rate is reimbursed at 100 percent of that

rate. The procedure with the second highest ASC rate or bilateral procedure is

reimbursed at 50 percent of the respective ASC rate. All other procedures are denied. To

denote multiple surgeries, the appropriate revenue code and CPT code must be listed as

two separate detail line items on the claim form.

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 Healthcare Common Procedure

Coding System (HCPCS) code. These revenue codes are paid at the appropriate ASC

rate. If no surgical procedure is performed, the revenue code must be submitted without

a CPT or HCPCS code. These services are then priced at the treatment room rate.

Component billing of any related services is not appropriate and will be denied. Add-on

or standalone services are not allowed with any surgical revenue codes.

Any details billed on the claim form, not among the approved surgical revenue codes,

will be denied as services included in the ASC procedure reimbursement rate. To denote

multiple surgeries, the appropriate revenue code must be listed as two separate detail line

items on the Uniform Billing (UB-92) claim form with the applicable HCPCS surgical

procedure code.

• The primary surgical procedure is reimbursed at 100 percent of the IHCP

allowable rate.

• The second procedure is reimbursed at 50 percent of the IHCP allowable rate.

• Bilateral procedures are reimbursed at 150 percent of the IHCP allowable rate.

• Because only two procedure codes are allowed, other procedure codes will be

denied.

All outpatient services provided on the day of the surgery must be included on a single

claim. Charges for any other services provided on the day of the surgery must be

included with the charge for the surgery, as described above. Add-on or standalone

services are not separately reimbursable and will be denied.

Durable Medical Equipment

The cost of certain implantable durable medical equipment is separately reimbursable.

Some of these items require prior authorization and/or a manufacturer’s cost invoice

showing the purchase price. Claims for these items should be submitted on the CMS-

01/31/2007 Hospital Outpatient

259

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

1500 billing form or 837P electronic transaction. The IHCP permits only these items to

have separate reimbursement.

• Cardiac Pacemakers Single-chamber

• Cardiac Pacemakers Dual-chamber

• Implantable Loop Recorders

• Phrenic Nerve Stimulators

• New Technology Intraocular Lenses

• Vagal Nerve Stimulators

• Implantable Infusion Pumps-Non-programmable

• Implantable Infusion Pumps-Programmable

Outpatient Corneal Tissue Transplant Procedures

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. Claims for this item should be submitted on

the CMS-1500 claim form or through the 837P electronic transaction. A copy of the

invoice from the eye bank or organ procurement organization showing the actual cost of

acquiring the tissue must be attached to the claim form. Providers must follow current

policy for submitting paper attachments with the 837P electronic transaction. For

additional information about corneal tissue transplant services, please refer to the

Surgery–Transplants Medical Policy Fact Sheet.

Treatment Room Services

For purposes of the IHCP’s outpatient prospective payment system, treatment rooms

include emergency department, clinics, cast room, labor and delivery room, recovery

room, and observation room.

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.

Otherwise, facilities should 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-92 claim form using the appropriate revenue code.

Standalone services may be billed in conjunction with treatment room services.

Standalone services include therapies, dialysis, radiology, and laboratory services.

Certain add-on services are allowed if billed in conjunction with a treatment room. All

other add-on services are denied if billed in conjunction with a treatment room service.

Emergency Room Services

Reimbursable emergency room services are for the treatment of ill and injured members

requiring immediate, unscheduled medical or surgical services. These claims may be

suspended for review to determine whether medical necessity, for an emergency medical

01/31/2007 Hospital Outpatient

260

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

condition, is met. Reimbursement is denied if services are not medically necessary. A

comprehensive list of all diagnosis codes considered emergency for outpatient

reimbursement is located in Chapter 8 of the IHCP Provider Manual. Please refer to the

Medical Policy Emergency Medicine-Emergency Services Fact Sheet for specific

coverage and billing information.

Observation Room Services

Reimbursable observation room services are furnished on the hospital’s premises,

including the use of a bed and periodic monitoring by a hospital’s nursing staff. These

services are reasonable and necessary to evaluate a patient’s condition or to determine the

need for an inpatient admission. Services are covered only when ordered by a physician

or other individual authorized by state licensure law and hospital bylaws to admit patients

or order outpatient tests.

Standalone Services

Standalone services include therapies, diagnostic testing, dialysis, laboratory, and

radiology procedures performed in an outpatient setting. Standalone services may be

billed separately, or in conjunction with treatment room visits. Standalone services are

not separately reimbursable with outpatient surgeries or on the same day as an outpatient

surgery.

Standalone services are reimbursed at an established flat statewide rate. Laboratory and

radiology services are reimbursed at the lower of the submitted charge or the fee schedule

amount. A maximum of one unit of service, per revenue code, for each date of service is

allowed, except for lab and radiology. Services must be billed on the UB-92 claim form.

Table 8.15 of Chapter 8 in the IHCP Provider Manual provides a list of revenue codes for

standalone services.

Add-on Services

Add-on services are separately reimbursable in conjunction with a standalone procedure.

Certain revenue codes for add-on services are 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 visit.

Add-on services are not separately reimbursable if billed with a surgery or provided on

the same day as an outpatient surgery. Refer to table 8.14 of Chapter 8 in the IHCP

Provider Manual for specific information regarding billing add-on services.

Add-on services are complementary outpatient services provided either in a treatment

room or with a standalone service. Add-on services are reimbursed at a flat rate.

01/31/2007 Hospital Outpatient

261

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

RELATED MEDICAL TOPICS

Anesthesia Services

Consultations – Second Opinion Services

Diagnostic Services

Emergency and Evaluation Management Services

Emergency Room Services

Federally Qualified Health Centers/Rural Health Centers

Home Health Services

Inpatient Hospital Services

Laboratory Services

Managed Care Organization Services

Mental/Behavioral Health Services

Nursing Services

Observation Services

Pharmacy Services

Radiology Services

Surgery Services

Treatment Room Services

RULES, CITATIONS, AND SOURCES

Code of Federal Regulation (CFR)

42 CFR 440.20–Outpatient hospital services

Indiana Administrative Code (IAC)

405 IAC 5-1-5–Global Fee Billing

405 IAC 5-5-2–Prior authorization requirements for out-of-state services

405 IAC 5-3-13–Services requiring prior authorization

405 IAC 5-17-2–Hospital Services

405 IAC 5-28-1–Medical and Surgical Services; Reimbursement limitations

405 IAC 5-28-2–Medical and Surgical Services; Medical diagnostic procedures

405 IAC 5-29-1–Services Not Covered by Medicaid; Noncovered services

Indiana Health Coverage Programs Provider Manual

1994

1999

2005, Version 5.1

Indiana Health Coverage Programs Provider Bulletin (BT)

BT200420-Changes in DRG/LOC Inpatient and Outpatient Reimbursement

BT200114-Implantable Loop Recorders

BT200108-Phrenic Nerve Stimulators

BT200106-New Technology Intraocular Lenses

BT200032-Vagal Nerve Stimulators

Indiana Health Coverage Programs Provider Banner (BR)

BR200314-Vagal Nerve Stimulators

01/31/2007 Hospital Outpatient

262

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hospital Outpatient

Medical Policy Manual

263

Origination Date: 08/24/1997

Revisions and

Reviews

Reason Effective Date

Revision

405 IAC 5-17-2 Hospital Services-Prior

Authorization, outpatient versus Inpatient

Procedures/Surgery

08/24/1997

Revision

405 IAC 5-3-13 Prior Authorization;

Procedures Requiring Prior Authorization

08/24/1997

Revision

405 IAC 5-16-6 Free-standing clinics and

surgical centers; limitations

08/24/1997

Review Scheduled 01/31/2007

APPLICABLE INDIANAAIM EDITS AND AUDITS

3010-Out of state provider requires prior authorization

3011-Out of state provider requires prior authorization

4000-More than two surgical units on the claim

4081-Invalid Service-Per Diem

4089-Missing or invalid HCPCS code for surgery revenue code

4095-Nonsurgical services are not reimbursed individually if performed in conjunction

with an outpatient surgery

4099-DRG not on file

4116-Diagnosis is not valid for DRG pricing

4108-No ASC on file

6514-No more than one emergency room visit per day

6515-Inpatient admit date within three days after DOS of paid outpatient claim

6516-Outpatient service rendered within three days prior to admit date of paid inpatient

claim

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: HYPERBARIC OXYGEN THERAPY

DESCRIPTION

Hyperbaric Oxygen Therapy (HBO) is a modality in which the entire body is exposed to

oxygen under increased atmospheric pressure, increasing vascular flow and improved

oxygenation of body tissue. Originally developed for the treatment of decompression

sickness, hyperbaric oxygen is adjunctive treatment for the management of select non-

healing wounds, treatment of carbon monoxide poisoning, and other conditions as noted

on pages 2 and 3, in the section entitled, “Coverage Criteria.”

RELATED MEDICAL TOPICS

Physician Services

RULES, CITATIONS, AND SOURCES

405 IAC 5-28-11

Origination Date: 1/31/05

Reviews and

Revision

Reason Date

APPLICABLE INDIANAAIM EDITS AND AUDITS

4104 – HBO Therapy Restricted by Diagnosis Code

6096 – CPT Code Billed is Not Payable According to PPS Reimbursement Methodology

6652 – Multiple Surgeries Must Be Billed on Same Claim

6751 – Hyperbaric Oxygen Therapy Greater than Two Months

6754 – Hyperbaric Oxygen Therapy

01/31/2007 Hyperbaric Oxygen Therapy

264

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

PRIOR AUTHORIZATION

Prior authorization is not required for HBO

COVERAGE CRITERIA

Reimbursement for HCPCS code C1300, Hyperbaric oxygen under pressure, full body

chamber, per 30 minute interval and CPT code 99183, Physician attendance and

supervision of hyperbaric oxygen therapy, per session is available for the following

conditions.

Table 1. – Diagnosis Codes for HBO Therapy

Diagnosis ICD 9 Codes Limitations

Acute carbon

monoxide intoxication

986

Decompression illness 993.2, 993.3

Gas embolism 958.0, 999.1

Gas gangrene 040.0

Acute traumatic

peripheral ischemia

902.53, 903.1, 903.01, 903.4,

904.0, 904.41, 996.9

Adjunctive treatment to be used

in combination with accepted

standards and therapeutic

measures.

Crush injuries and

suturing of severed

limbs

902.53, 925.1, 925.2, 926.0,

926. 1, 926.11, 926.12,

926.19, 926.8, 926.9, 927.0,

927.00, 927.01, 927.02,

927.03, 927.09, 927.10,

927.11, 927.20, 927.21,

927.3, 927.8, 927.9, 928.0,

928.00, 928.01, 928.1,

928.10, 928.11, 928.2,

928.20, 928.21, 928.3, 928.8,

928.9, 929.0, 929.9,

903.1, 903.01, 903.4, 904.0,

904.41

Adjunctive treatment to be used

in combination with accepted

standards and therapeutic

measures.

(Meleney Ulcers)

Progressive

necrotizing infections

686.0, 686.09, 728.86

Other types of cutaneous ulcers

are not covered.

Acute peripheral

arterial insufficiency

444.21, 444.22, 444.81

Compromised skin

grafts

996.52 Preparation and preservation.

Chronic Refractory

Osteomyelitis

730.10-730.19

Use when unresponsive to

conventional medical and

01/31/2007 Hyperbaric Oxygen Therapy

265

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hyperbaric Oxygen Therapy

266

Diagnosis ICD 9 Codes Limitations

surgical management.

Osteoradionecrosis 526.89

Adjunct to conventional

treatment.

Soft tissue

radionecrosis

990

Adjunct to conventional

treatment.

Cyanide poisoning 987.7, 989.0

Actinomycosis 039.0-039.4, 039.8, 039.9

Use when unresponsive to

conventional medical and

surgical management.

Acute Cerebral Edema 348.5

Reimbursement is not available for HBO for the following conditions or services.

♦ Topical application of oxygen

♦ Cutaneous, decubitus, and stasis ulcers

♦ Chronic peripheral vascular insufficiency

♦ Anaerobic septicima and infection other than clostridial

♦ Thermal skin burns

♦ Senility

♦ Myocardial Infarction

♦ Cardiogenic shock

♦ Sickle cell crisis

♦ Acute thermal and chemical pulmonary damage including smoke

inhalation with pulmonary insufficiency

♦ Acute or chronic cerebral vascular insufficiency

♦ Hepatitis necrosis

♦ Aerobic septicemia

♦ Nonvascular causes of chronic brain syndrome, including Picks,

Alzheimers, and Korsakoff's disease

♦ Tetanus

♦ Systemic aerobic infection

♦ Organ Transplantation

♦ Organ storage

♦ Pulmonary emphysema

♦ Exceptional blood loss anemia

♦ Multiple sclerosis

♦ Arthritic diseases

Treatment may include multiple HBO sessions that may be administered over a duration

ranging from less than one week to two months, the average being two to four weeks.

Claims submitted for treatment sessions lasting more than a two-month period will be

suspended to Location 22 for submission of documentation to support medical necessity

of continued therapy.

Medical Policy Manual

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

01/31/2007 Hyperbaric Oxygen Therapy

Medical Policy Manual

267

405 IAC 5-11(c) cites “Hyperbaric therapy shall be clinically practical and shall not be a

replacement for other standard successful therapeutic measures”

BILLING REQUIREMENTS

Providers may use HCPCS code 99183 or C1300, with revenue code 413 for

reimbursement of hyperbaric oxygen therapy services as a hospital outpatient service. An

appropriate diagnosis code (see Table 1. Diagnosis codes for HBO Therapy) must be

included on claims.

Note: The evaluation and management services and/or procedures (such as wound

debridement) provided in a hyperbaric oxygen treatment should be reported separately from

CPT code 99183.

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

MEDICAL POLICY FACT SHEET

TITLE: IMMUNIZATIONS AND VACCINES

DESCRIPTION

Immunization is the process by which a person becomes protected against a disease. This

term is often used interchangeably with vaccination or inoculation. It is defined as the

injection of a killed or weakened infectious organism in order to prevent disease.

COVERAGE CRITERIA

Vaccinations and immunizations are covered through the Vaccines for Children (VFC)

program and the Indiana Health Coverage Programs (IHCP). The VFC program provides

a variety of free vaccines to children 18 years of age and younger. The IHCP also

reimburses for vaccines not covered by the VFC program or for administration of the

vaccines to IHCP members 19 years of age and over.

Vaccines Not Available Through the Vaccines for Children Program or

Administered to Members 19 Years of Age and Older

Vaccines not available through the VFC program or vaccines administered to members

19 years of age and older are reimbursed the lesser of the provider’s usual and customary

charge, or the IHCP allowed amount for the vaccine supply. A $2.90 administration fee

is included in the reimbursement of the vaccine supply code. Influenza vaccine

instructions are revised frequently, therefore providers are to monitor program

publications for special instructions.

Vaccines for Children Program

The VFC program is a federally funded program intended to help raise childhood

immunization levels in the United States by supplying health care providers with free

vaccines to administer to children 18 years of age and younger. Recipients must meet

one or more of the following criteria.

• Be enrolled in the IHCP

• Have no health insurance

• Be identified by parent or guardian as American Indian or Alaskan native

01/31/2007 Immunizations and Vaccines

Medical Policy Manual

268

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

• Be underinsured. For example, children with health insurance that does not cover

immunizations (administered in federally qualified health care centers or rural health

clinics only)

The VFC Program makes vaccines available at no cost to providers for members 18 years

of age and younger (including those 18 years of age and younger enrolled in Hoosier

Healthwise Package C). Providers are reimbursed either the lower of their submitted

charge or $8 for the administration of each vaccine. Providers are not required to

physically separate vaccine stock for children in the VFC program from the vaccine stock

for Hoosier Healthwise Package C children. No additional storage rules apply.

Currently, the VFC program offers free vaccines against the following diseases.

• Diphtheria

• Hemophilus influenza type B

• Hepatitis B

• Measles

• Mumps

• Rubella

• Pertussis

• Poliomyelitis

• Pneumococcal disease

• Tetanus

• Varicella

All vaccine ordering, distribution, and accountability processes are administered through

the Indiana State Department of Health’s (ISDH) Indiana Immunization Program. The

federal VFC program includes private and public practitioners across Indiana. Providers

should contact the ISDH to enroll in the VFC program. Under an arrangement, the ISDH

performs the VFC program administration functions, including provider enrollment,

education, and vaccine ordering and distribution. To participate in the VFC program

providers must complete the following.

1. Call the ISDH office and request VFC provider enrollment forms

2. Complete and mail the provider enrollment forms

3. Receive appropriate training and technical assistance

4. Order vaccines periodically, as needed, and maintain appropriate vaccine

supply records

Providers who choose not to participate in the VFC program must provide appropriate

vaccine referrals for the member, follow-up with the member, and document the

immunization history of the member. Hoosier Healthwise Primary Medical Providers

(PMP) who choose not to participate in the VFC program must have a procedure in place,

such as a Memorandum of Collaboration (MOC), to ensure that children are adequately

and appropriately immunized. For more information about the MOC and collaborative

agreements, contact the Hoosier Healthwise Primary Care Case Management Helpline.

01/31/2007 Immunizations and Vaccines

Medical Policy Manual

269

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

BILLING GUIDELINES

Billing Guidelines for Vaccines Not Available Through the Vaccines for Children

Program or Administered to Members 19 Years of Age and Older

Vaccines not available through the VFC program or administered to members 19 years of

age and older have an all-inclusive fee attached to the vaccine code. The IHCP calculates

the maximum allowable reimbursement based on the current average wholesale price for

the procedure code, plus $2.90 for vaccine administration to cover the costs of supplies

and staff time associated with giving the injection. The $2.90 is included in the

reimbursement for the vaccine product, and is not to be billed as a separate charge on the

claim form. The provider is reimbursed the lesser of their usual and customary charge or

the IHCP allowed amount.

Billing Guidelines in the Vaccines for Children Program

Vaccines through the VFC program are supplied to providers at no cost, and providers

are reimbursed only for the administration of the vaccine. Providers are to report the

appropriate vaccine product code, and will be reimbursed the lesser of their usual and

customary charge for administration or an $8 administration fee. In addition, providers

are to report a principal diagnosis of V20.2, Routine infant or child health check. The

IHCP permits only one administration fee per VFC vaccine injection administered. For

combined vaccines, the correct code for the combined vaccine with only one vaccine

administration fee should be billed. However, if no combination vaccine is available and

the provider must administer more than one injection, each injection is to be listed with

the appropriate CPT code and a vaccine administration fee is allowed for each. When a

specific vaccine has been removed from VFC pricing, providers are to submit claims with

charges reflective of whether the vaccine was from VFC or private stock ($8 for VFC

stock or the provider’s usual and customary charge for private stock). If the only service

performed is vaccine administration, providers must not submit a bill for an office visit.

Providers can bill an office visit in conjunction with vaccine administration only when

other services are performed during the same visit.

PRIOR AUTHORIZATION

Prior authorization is required for Synagis and Respigam for the treatment of respiratory

synctial virus. Refer to the Synagis and Respigam fact sheet for additional information.

MANAGED CARE

Coverage and billing guidelines for PrimeStep/PCCM is the same as Traditional

Medicaid fee for service. For Risk Based Managed Care, vaccines are administered to

01/31/2007 Immunizations and Vaccines

Medical Policy Manual

270

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

VFC-eligible children and billed directly to the appropriate MCO with the principal

diagnosis of V20.2, Routine infant or child health check. Managed care providers who

are not the PMP or do not have an authorization from the PMP may charge the member

for the service. The member must sign a waiver acknowledging they would not

otherwise be required to pay for the vaccination from an in-network provider. Contact

the appropriate MCO for details about reimbursement under the RBMC delivery system.

Since vaccines are provided by different funding sources, the ISDH must report the

number of doses administered to VFC members and Hoosier Healthwise Package C

members separately. Providers must indicate vaccines administered to Hoosier

Healthwise Package C members on the Patient Eligibility Screening Record and the

Vaccine Accountability Tally Sheet. Providers are to submit the forms to the ISDH by the

10th day of the following month in which the vaccines were administered. This change

standardizes the reporting time frame for all providers.

RELATED MEDICAL TOPICS

EPSDT – HealthWatch

RULES, CITATIONS, AND SOURCES:

405 IAC 5-15-3 EPSDT

Indiana Health Coverage Programs Provider Bulletins

E98-11 – Vaccines For Children Program Rate Increase

E98-21 – Vaccines For Children Program Administration Fee

BT200007 – Vaccine for Children Update

BT200151 – Revised Policy for Billing of Office-Administered Injectible Drugs

and Infusions

Indiana Health Coverage Programs Provider Banners

BR200045 – Prevnar Available Through Vaccines For Children Program

BR200144 – Influenza Vaccines

BR200233 – Administration Fee in the Vaccines For Children Program

BR200442 – Administration Fee

Indiana Health Coverage Programs Provider Newsletter

NL200404 – Vaccines for Children and Injectibles

Indiana Health Coverage Programs Provider Manual 2004

Origination Date: July 1, 1991

Revisions and Reviews Reason Date

Revision EPSDT Services 1/1/92

Revision EPSDT Periodic Screening 8/24/97

Revision Vaccines For Children (VFC) Program 1/1/98

Review Immunizations and Screenings

February

2002

01/31/2007 Immunizations and Vaccines

Medical Policy Manual

271

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

Revisions and Reviews Reason Date

Revision Vaccines for Children April 2002

Review

Expansion of Vaccinations Not Reimbursed

for the Vaccines for Children Program

April 30,

2005

APPLICABLE INDIANAAIM EDITS AND AUDITS:

6018-Global Fee- Immunizations

6031-Global Immunization Not Payable When Component Paid

6096-The CPT/HCPCS code is not payable according to the PPS payment methodology

01/31/2007 Immunizations and Vaccines

Medical Policy Manual

272

IHCP Policy and Review Services Library Item #: MP10004 Document Control #: H20070007

IMMUNIZATIONS AND VACCINES FACT SHEET

ADDENDUM A

Note: This addendum contains provider notifications that have been published since the

review of the Immunizations and Vaccines Fact Sheet. The information in this

addendum will be incorporated into the fact sheet at the next review.

Provider Notification: BT200511 Publication Date: 06/01/2005

Subject: Submission of Miscellaneous Drug Injection Codes

Date Added to Manual: 07/29/2005

Text of Publication

The provider should indicate the National Drug Code (NDC) code for the drug dispensed

in the claim notes segment.