INDIANA HEALTH COVERAGE PROGRAMS

Transcription

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 Previous versions of code tables are archived for purposes of historical reference.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 Hospice Services provider reference module. Table 1 ICD-10 s for Amyotrophic Lateral Sclerosis (ALS) Table 2 ICD-10 s for Alzheimer s Disease and Related Disorders Table 3 ICD-10 s for Heart Disease Table 4 ICD-10 s for Pulmonary Disease Table 5 ICD-10 for Human Immunodeficiency Virus (HIV) Table 6 ICD-10 Noncovered HIV s Table 7 ICD-10 s for Liver Disease Table 8 ICD-10 Renal s Table 9 ICD-10 s for Stroke and Coma Table 10 ICD-10 s for Failure to Thrive Syndrome Table 11 Revenue Codes for Hospice Billing Table 1 ICD-10 s for Amyotrophic Lateral Sclerosis (ALS) Reviewed/Updated: October 1, 2017 G12.21 Amyotrophic lateral sclerosis G12.23 Primary lateral sclerosis G12.24 Familial motor neuron disease G12.25 Progressive spinal muscle atrophy Table Revision History October 1, 2017, update: Added (effective October 1, 2017): G12.23, G12.24, G12.25 Published: October 26,

2 Table 2 ICD-10 s for Alzheimer s Disease and Related Disorders F10.27 Alcohol dependence with alcohol-induced persisting dementia F10.97 Alcohol use, unspecified with alcohol-induced persisting dementia G30.0 Alzheimer s disease with early onset G30.1 Alzheimer s disease with late onset G30.8 Other Alzheimer s disease G30.9 Alzheimer s disease, unspecified G31.01 Pick s disease G31.1 Senile degeneration of brain, not elsewhere classified Table 3 ICD-10 s for Heart Disease Reviewed/Updated: October 1, 2017 I20.0 Unstable angina I20.8 Other forms of angina pectoris I25.2 Old myocardial infarction I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic and diastolic (congestive) heart failure I50.41 Acute combined systolic and diastolic (congestive) heart failure I50.42 Chronic combined systolic and diastolic heart failure I50.43 Acute on chronic combined systolic and diastolic heart failure I Right heart failure, unspecified I Acute right heart failure I Chronic right heart failure I Acute on chronic right heart failure I Right heart failure due to left heart failure I50.82 Biventricular heart failure I50.83 High output heart failure Published: October 26,

3 Table 3 ICD-10 s for Heart Disease I50.84 End stage heart failure I50.89 Other heart failure I50.9 Heart failure, unspecified Reviewed/Updated: October 1, 2017 Table Revision History October 1, 2017, update: Added (effective October 1, 2017): I I50.814, I50.82 I50.84, I50.89 Table 4 ICD-10 s for Pulmonary Disease Reviewed/Updated: October 1, 2017 I27.0 Primary pulmonary hypertension I27.20 Pulmonary hypertension, unspecified I27.21 Secondary pulmonary arterial hypertension I27.22 Pulmonary hypertension due to left heart disease I27.23 Pulmonary hypertension due to lung diseases and hypoxia I27.24 Chronic thromboembolic pulmonary hypertension I27.29 Other secondary pulmonary hypertension I27.81 Cor pulmonale (chronic) I27.83 Eisenmenger s syndrome I27.89 Other specified pulmonary heart diseases I27.9 Pulmonary heart disease, unspecified J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified R09.02 Hypoxemia R09.2 Respiratory arrest Table Revision History October 1, 2017, update: Added (effective October 1, 2017): I27.21, I27.22, I27.23, I27.24, I27.29, I27.83 Table 5 ICD-10 for Human Immunodeficiency Virus (HIV) B20 Human immunodeficiency virus (HIV) disease Published: October 26,

4 Table 6 ICD-10 Noncovered HIV s R75 Z21 Inconclusive laboratory evidence of human immunodeficiency virus Asymptomatic human immunodeficiency virus infection status Table 7 ICD-10 s for Liver Disease K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K70.40 Alcoholic hepatic failure without coma K70.41 Alcoholic hepatic failure with coma K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.3 Toxic liver disease with chronic persistent hepatitis K71.4 Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 Toxic liver disease with hepatitis, not elsewhere classified K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K73.0 Chronic persistent hepatitis, not elsewhere classified K73.1 Chronic lobular hepatitis, not elsewhere classified K73.2 Chronic active hepatitis, not elsewhere classified K73.8 Other chronic hepatitis, not elsewhere classified K73.9 Chronic hepatitis, unspecified K74.0 Hepatic fibrosis K74.3 Primary biliary cirrhosis K74.4 Secondary biliary cirrhosis K74.5 Biliary cirrhosis, unspecified K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.9 Inflammatory liver disease, unspecified K76.7 Hepatorenal syndrome Published: October 26,

5 Table 8 ICD-10 Renal s I12.0 Hyp chr kidney disease w stage 5 chr kidney disease or ESRD N17.0 Acute kidney failure with tubular necrosis N17.1 Acute kidney failure with acute cortical necrosis N17.2 Other acute kidney failure N17.8 Other acute kidney failure N17.9 Acute kidney failure, unspecified N18.6 End stage renal disease N19 Unspecified kidney failure Table 9 ICD-10 s for Stroke and Coma I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation I60.01 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation I60.02 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation I60.10 Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral I60.11 Nontraumatic subarachnoid hemorrhage from right middle cerebral I60.12 Nontraumatic subarachnoid hemorrhage from left middle cerebral I60.2 Nontraumatic subarachnoid hemorrhage from anterior communicating I60.30 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating I60.31 Nontraumatic subarachnoid hemorrhage from right posterior communicating I60.32 Nontraumatic subarachnoid hemorrhage from left posterior communicating I60.4 Nontraumatic subarachnoid hemorrhage from basilar I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral I60.6 Nontraumatic subarachnoid hemorrhage from other intracranial I60.7 Nontraumatic subarachnoid hemorrhage from unspecified intracranial I60.8 Other nontraumatic subarachnoid hemorrhage I60.9 Nontraumatic subarachnoid hemorrhage, unspecified I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical I61.2 Nontraumatic intracerebral hemorrhage in hemisphere, unspecified I61.3 Nontraumatic intracerebral hemorrhage in brain stem I61.4 Nontraumatic intracerebral hemorrhage in cerebellum Published: October 26,

6 Table 9 ICD-10 s for Stroke and Coma I61.5 Nontraumatic intracerebral hemorrhage, intraventricular I61.6 Nontraumatic intracerebral hemorrhage, multiple localized I61.8 Other nontraumatic intracerebral hemorrhage I61.9 Nontraumatic intracerebral hemorrhage, unspecified I62.00 Nontraumatic subdural hemorrhage, unspecified I62.01 Nontraumatic acute subdural hemorrhage I62.02 Nontraumatic subacute subdural hemorrhage I62.03 Nontraumatic chronic subdural hemorrhage I62.9 Nontraumatic intracranial hemorrhage, unspecified I Cerebral infarction due to thrombosis of right vertebral I Cerebral infarction due to thrombosis of left vertebral I Cerebral infarction due to thrombosis of bilateral vertebral I Cerebral infarction due to thrombosis unspecified vertebral I Cerebral infarction due to thrombosis of bilateral carotid I Cerebral infarction due to embolism of right vertebral I Cerebral infarction due to embolism of left vertebral I Cerebral infarction due to embolism of bilateral vertebral I Cerebral infarction due to embolism of unspecified vertebral I Cerebral infarction due to embolism of right carotid I Cerebral infarction due to embolism of left carotid I Cerebral infarction due to embolism of bilateral carotid I Cerebral infarction due to embolism of unspecified carotid I63.20 Cerebral infarction due to unspecified occlusion or stenosis of unspecified precerebral I Cerebral infarction due to unspecified occlusion or stenosis of right vertebral I Cerebral infarction due to unspecified occlusion or stenosis of left vertebral I Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral I Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar art I Cerebral infarction due to unspecified occlusion or stenosis of right carotid I Cerebral infarction due to unspecified occlusion or stenosis of left carotid I Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid I Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid I Cerebral infarction due to thrombosis of right middle cerebral I Cerebral infarction due to thrombosis of left middle cerebral Published: October 26,

7 Table 9 ICD-10 s for Stroke and Coma I Cerebral infarction due to thrombosis of bilateral middle cerebral I Cerebral infarction due to thrombosis of unspecified middle cerebral I Cerebral infarction due to thrombosis of right anterior cerebral I Cerebral infarction due to thrombosis of left anterior cerebral I Cerebral infarction due to thrombosis of bilateral anterior I Cerebral infarction due to thrombosis of unspecified anterior cerebral I Cerebral infarction due to thrombosis of right posterior cerebral I Cerebral infarction due to thrombosis of left posterior cerebral I Cerebral infarction to thrombosis of bilateral posterior I Cerebral infarction due to thrombosis of unspecified posterior cerebral I Cerebral infarction due to thrombosis of right cerebellar I Cerebral infarction due to thrombosis of left cerebellar I Cerebral infarction to thrombosis of bilateral cerebellar I Cerebral infarction due to thrombosis of unspecified cerebellar I63.40 Cerebral infarction due to embolism of unsp cerebral I Cerebral infarction due to embolism of right middle cerebral I Cerebral infarction due to embolism of left middle cerebral I Cerebral infarction due to embolism of bilateral middle cerebral I Cerebral infarction due to embolism of unspecified middle cerebral I Cerebral infarction due to embolism of right anterior cerebral I Cerebral infarction due to embolism of left anterior cerebral I Cerebral infarction due to embolism of bilateral anterior cerebral I Cerebral infarction due to embolism of unspecified anterior cerebral I Cerebral infarction due to embolism of right posterior cerebral I Cerebral infarction due to embolism of left posterior cerebral I Cerebral infarction due to embolism of bilateral posterior cerebral I Cerebral infarction due to embolism of unspecified posterior cerebral I Cerebral infarction due to embolism of right cerebellar I Cerebral infarction due to embolism of left cerebellar I Cerebral infarction due to embolism of bilateral cerebellar I Cerebral infarction due to embolism of unspecified cerebellar I63.49 Cerebral infarction due to embolism of other cerebral I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral I Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral I Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral Published: October 26,

8 Table 9 ICD-10 s for Stroke and Coma I Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle I Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral I Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral I Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral I Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior I Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral I Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral I Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral I Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior I Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral I Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar I Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar I Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar I Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar I63.59 Cerebral infarction due to unspecified occlusion or stenosis of cerebral I67.89 Other cerebrovascular disease R40.20 Unspecified coma Table Revision History October 1, 2016, update: Added (effective October 1, 2016): I60.2, I63.013, I63.033, I , I63.133, I63.213, I63.233, I63.313, I63.323, I63.333, I63.343, I63.413, I63.423, I63.433, I63.443, I63.513, I63.523, I63.533, I Removed (effective October 1, 2016): , , Published: October 26,

9 Table 10 ICD-10 s for Failure to Thrive Syndrome R62.51 Failure to thrive (child) R62.7 Failure to thrive (adult) R69 Illness, unspecified Table 11 Revenue Codes for Hospice Billing Revenue Code IHCP Explanation 551 RN service intensity add-on payment 561 Social Worker service intensity add-on payment 651 Routine home care delivered in a private home 652 Continuous home care delivered in a private home The service intensity add-on (SIA) payment is made for services provided by a registered nurse (RN) during the last seven days of a member s life. The payment amount is calculated using the continuous home care hourly rate adjusted by the regional wage index. The SIA payment is limited to 16 units or 4 hours per day. The service intensity add-on (SIA) payment is made for services provided by a social worker during the last seven days of a member s life. The payment amount is calculated using the continuous home care hourly rate adjusted by the regional wage index. The SIA payment is limited to 16 units or 4 hours per day. 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 on any given day. Continuous home care is provided only during a period of crisis. A period of crisis occurs when a patient requires continuous care, which is primarily nursing care, to achieve palliation and management of acute medical symptoms. A minimum of eight hours of care must be provided during a 24-hour day that begins and ends at midnight. An RN or a licensed practical nurse (LPN) must provide care for over half the total period of time. This care need not be continuous and uninterrupted. If less skilled care is needed on a continuous basis to enable the member to remain at home, this is covered as routine home care. The continuous home care per diem rate is divided by 24 hours to calculate an hourly rate. For every hour or part of an hour of continuous care furnished, the hourly rate is reimbursed to the hospice provider for up to 24 hours a day. Published: October 26,

10 Table 11 Revenue Codes for Hospice Billing Revenue Code IHCP Explanation 653 Routine home care delivered in a nursing facility 654 Continuous home care delivered 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 (NF) 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 service on any given day. In addition, the IHCP pays the hospice provider 95% of the lowest NF case-mix rate to cover room-and-board costs incurred by the contracted NF. The additional room and board per diem is 95% of the NF case mix rate. As in the private home setting, the continuous home care rate is divided by 24 hours in order to calculate an hourly rate. For every hour or part of an hour of continuous care furnished, the hourly rate is reimbursed to the hospice provider up to 24 hours a day. All of the limitations listed for the private home setting also apply to the NF setting. In addition, the IHCP pays the hospice provider 95% of the lowest NF case-mix rate to cover room-and-board costs incurred by the contracted NF. The additional room and board per diem is 95% of the NF case mix rate. 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 is in an approved inpatient hospice facility, and is receiving general inpatient hospice care for pain control or acute or chronic symptom management that cannot be managed in other settings. This code is not to be used for inpatient respite care. Published: October 26,

11 Table 11 Revenue Codes for Hospice Billing Revenue Code IHCP Explanation 657 Hospice direct care physician services 659 Medicare/Medicaid dually eligible nursing facility members only Physician services provided by a physician who is an employee of the hospice provider or by arrangement of the hospice provider are reimbursed outside the per diem rate, on a feefor-service basis. These services are billed by the hospice provider, under the hospice provider number. Revenue code 657 can be billed on the same day as other hospice revenue codes. For dually eligible Medicare and Medicaid hospice members residing in an NF, the hospice provider must bill Medicare for the hospice services and then bill IHCP for the room and board portion of the hospice per diem rate. This revenue code is used for Medicare and Medicaid dually eligible members residing in an NF. This code represents the room and board portion of the hospice per diem rate. The IHCP pays the hospice provider 95% of the lowest NF case-mix rate to cover room-and-board costs incurred by the contracted NF. The room and board portion of the hospice per diem rate is 95% of the single NF case mix rate. Revenue code 659 must not be billed with the hospice related revenue codes 651, 652, 653, 654, 655, and 656 designated for IHCP-only hospice members because this results in the hospice claim denying or suspending appropriately. This section provides guidelines for hospice providers regarding billing on a UB-04 claim form for nursing facility bed-hold days for dually eligible (Medicare and Medicaid) or Medicaid-only IHCP hospice members residing in a nursing facility. 180 Nursing facility bed-hold nonpaid revenue code 183 Nursing facility bed hold for hospice therapeutic leave days When the NF occupancy is less than 90%, the hospice agency should use revenue code 180 to bill the IHCP for leave days. Revenue code 180 is a revenue code used to generate an IHCP denial and can be used to charge a resident or legal guardian for nonreimbursed bed-hold days. The hospice provider receives 50% of the 95% of the NF per diem rate to cover the NF room and board associated with therapeutic leave of absence days. A total of 18 therapeutic leave of absence days are allowed per patient per calendar year. This revenue code may also be used to pay for bed-hold days when a member is hospitalized for the terminal illness. The room and board portion of the hospice per diem rate is 95% of the NF case mix rate. Hospice providers should not bill the IHCP using this revenue code when the NF occupancy rate is below 90% pursuant to 405 IAC (e). Published: October 26,

12 Table 11 Revenue Codes for Hospice Billing Revenue Code IHCP Explanation 185 Nursing facility bed-hold policy for hospitalization for services unrelated to the terminal illness of the hospice member Table Revision History April 1, 2016, update: Added (effective January 1, 2016): 551, 561 The hospice provider receives 50% of the 95% of the lowest NF per diem rate to cover NF room and board associated with each hospitalization up to 15 days per occurrence. The room and board portion of the hospice per diem rate is 95% of the NF case mix rate. Hospice providers should not bill the IHCP using this revenue code when the NF occupancy rate is below 90% pursuant to 405 IAC (e). Published: October 26,