INDIANA HEALTH COVERAGE PROGRAMS

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1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables does not necessarily indicate current coverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedule for updates to coding, coverage, and benefit information. Previous versions of code tables are archived for purposes of historical reference. For information about using these code tables, see the Anesthesia Services provider reference module. Table 1 s That Require the AA Modifier When Billed for Anesthesia Services Table 2 Set for Certified Registered Nurse Anesthetists (CRNAs) Table 1 s That Require the AA Modifier When Billed for Anesthesia Services Note: Qualified anesthesia professionals performing the procedures in this table must bill with the AA modifier to denote anesthesia services and must bill these procedures in units. and Modifier AA Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age AA Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older AA Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age AA Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years and older AA Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; younger than 5 years of age AA Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older AA Insertion of tunneled centrally inserted central venous access device with subcutaneous pump AA Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter) AA Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; with subcutaneous port(s) Published: December 12,

2 Table 1 s That Require the AA Modifier When Billed for Anesthesia Services Note: Qualified anesthesia professionals performing the procedures in this table must bill with the AA modifier to denote anesthesia services and must bill these procedures in units. and Modifier AA Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; younger than 5 years of age AA Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years and older AA Insertion of peripherally inserted central venous catheter access device, with subcutaneous port; younger than 5 years of age AA Insertion of peripherally inserted central venous catheter access device, with subcutaneous port; age 5 years or older AA Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site AA Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site AA Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site AA Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access AA Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access AA Replacement, complete, of a tunneled centrally inserted central venous device, with subcutaneous port, through same venous access AA Replacement, complete, of a tunneled centrally inserted central venous device, with subcutaneous pump, through same venous access AA Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump through same venous access AA Replacement, complete, of a peripherally inserted central venous device with subcutaneous port, through same venous access AA Removal of tunneled central venous catheter, without subcutaneous port or pump AA Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion AA Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access AA Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen AA Repositioning of previously placed central venous catheter under fluoroscopic guidance AA Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous AA Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown Published: December 12,

3 Table 1 s That Require the AA Modifier When Billed for Anesthesia Services Note: Qualified anesthesia professionals performing the procedures in this table must bill with the AA modifier to denote anesthesia services and must bill these procedures in units. and Modifier AA Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes AA Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia procedure) AA Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session Table 2 Set for Certified Registered Nurse Anesthetists (CRNAs) Anesthesia codes Injection(s): single tendon origin/insertion Injection(s): single or multiple trigger point(s), 1 or 2 muscle(s) Injection(s); single or multiple trigger point(s), 3 or more muscle(s) Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed Intubation, endotracheal, emergency procedure Introduction of catheter, superior or inferior vena cava Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) Introduction of catheter, right heart or main pulmonary artery Selective catheter placement, left or right pulmonary artery Selective catheter placement, segmental or subsegmental pulmonary artery Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; scalp vein Published: December 12,

4 Table 2 Set for Certified Registered Nurse Anesthetists (CRNAs) Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; other vein Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) Collection of venous blood by venipuncture Venipuncture, cutdown; younger than age 1 year Venipuncture, cutdown; age 1 and over Catheterization of umbilical vein for diagnosis or therapy, newborn AA Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age AA Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older Arterial puncture, withdrawal of blood for diagnosis AA Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous AA Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown Catheterization of umbilical artery, newborn, for diagnosis or therapy Placement of needle for intraosseous infusion Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day Injection, epidural, of blood or clot patch Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic Published: December 12,

5 Table 2 Set for Certified Registered Nurse Anesthetists (CRNAs) Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; cervical or thoracic Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includes contrast for localization when performed, epidural or subarachnoid; lumbar or sacral (caudal) Injection, anesthetic agent; trigeminal nerve, any division or branch Injection, anesthetic agent; facial nerve Injection, anesthetic agent; greater occipital nerve Injection, anesthetic agent; vagus nerve Injection, anesthetic agent; phrenic nerve Injection, anesthetic agent; cervical plexus Injection, anesthetic agent; brachial plexus, single Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent, axillary nerve Injection, anesthetic agent; suprascapular nerve Injection, anesthetic agent; intercostal nerve, single Injection, anesthetic agent; intercostal nerves, multiple, regional block Injection, anesthetic agent, iloinguinal, iliohypogastric nerves Injection, anesthetic agent, pudendal nerve Injection, anesthetic agent; paracervical (uterine) nerve Injection, anesthetic agent, sciatic nerve; single Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent; femoral nerve, single Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) Injection, anesthetic agent, other peripheral nerve or branch Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level Published: December 12,

6 Table 2 Set for Certified Registered Nurse Anesthetists (CRNAs) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level Injection, anesthetic agent; sphenopalatine ganglion Injection, anesthetic agent; carotid sinus (separate procedure) Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Injection, anesthetic agent; superior hypogastric plexus Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial spasm) Destruction by neurolytic agent; intercostal nerve Destruction by neurolytic agent; pudendal nerve Destruction by neurolytic agent; other peripheral nerve or branch Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) Published: December 12,

7 Table 2 Set for Certified Registered Nurse Anesthetists (CRNAs) Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe only AA Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) Table Revision History July 1, 2017, update: Removed (effective January 1, 2016): Added AA modifier (correction): Published: December 12,