INDIANA HEALTH COVERAGE PROGRAMS
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1 INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Medical Review Team s 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 Previous versions of code tables are archived for purposes of historical reference.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 this code table, see the Claim Submission and Processing provider reference module. Medical Review Team s and SE Collection of venous blood by venipuncture Description SE Radiologic examination, skull; less than 4 views SE Radiologic examination skull; minimum of 4 views SE X-ray of chest, 1 view SE X-ray of chest, 2 views SE X-ray of chest, 3 views SE X-ray of chest, minimum of 4 views SE Radiologic examination, ribs, unilateral; 2 views SE Radiologic examination, spine, cervical; 3 views SE Radiologic examination, spine, cervical; 4 or 5 views SE Radiologic examination, spine, cervical; complete, 6 or more views SE Radiologic examination, spine; thoracic; 2 views SE Radiologic examination, spine; thoracic; 3 views SE Radiologic examination, spine; thoracic; minimum of 4 views SE Radiologic examination, spine; thoracolumbar; 2 views SE Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); one view SE Radiologic examination, spine, lumbosacral; 2 or 3 views SE Radiologic examination, spine, lumbosacral; minimum of 4 views Published: March 8,
2 Medical Review Team s Medical Review Team s and Description SE Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views SE Radiologic examination, pelvis; 1 or 2 views SE Radiologic examination, sacroiliac joints; less than 3 views SE Radiologic examination, sacroiliac joints; 3 or more views SE Radiologic examination, sacrum and coccyx; minimum of 2 views SE Radiologic examination, shoulder; 1 view SE Radiologic examination, shoulder; complete, minimum of 2 views SE Radiologic examination, humerus; minimum of 2 views SE Radiologic examination, elbow; 2 views SE Radiologic examination, elbow, complete; minimum of 3 views SE Radiologic examination, forearm; 2 views SE Radiologic examination, wrist; 2 views SE Radiologic examination, wrist; complete, minimum of 3 views SE Radiologic examination, hand; 2 views SE Radiologic examination, hand; minimum of 3 views SE Radiologic examination, hip unilateral, with pelvis when performed; 1 view SE Radiologic examination, hip unilateral, with pelvis when performed; 2-3 views SE Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views SE Radiologic examination, hips, bilateral, with pelvis when performed; 2 views SE Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views SE Radiologic examination, femur; minimum 2 views SE Radiologic examination, knee; 1 or 2 views SE Radiologic examination, knee; 3 views SE Radiologic examination, knee; complete, 4 or more views SE Radiologic examination, knee; both knees, standing, anteroposterior SE Radiologic examination, tibia and fibula; 2 views SE Radiologic examination, ankle; 2 views SE Radiologic examination, ankle; complete, minimum of 3 views SE Radiologic examination, foot; 2 views SE Radiologic examination, foot; complete, minimum of 3 views SE X-ray of abdomen, 1 view SE X-ray of abdomen, 2 views SE X-ray of abdomen, minimum of 3 views Published: March 8,
3 Medical Review Team s Medical Review Team s and Description SE Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views; single view chest SE Ultrasound, abdominal, real time with image documentation; complete SE Basic metabolic panel SE Comprehensive metabolic panel SE Lipid panel SE Hepatic function panel SE Dipropylacetic acid (valproic acid) SE Amylase SE Cholesterol, serum or whole blood, total SE Creatinine; blood SE Creatinine; clearance SE Gases, blood, any combination of ph, pco2, po2, CO2, HCO3 (including calculated O2 saturation) SE Glucose; quantitative, blood (except reagent strip) SE Hemoglobin; glycosylated (A1C) SE Lipase SE Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) SE Thyroxine, total SE Thyroid stimulating hormone (TSH) SE Transferase; aspartate amino (AST) (SGOT) SE Transferase; alanine amino (ALT) (SGPT) SE Triglycerides SE Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) SE Uric acid; blood SE Blood count; hemoglobin (Hgb) SE Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC, and platelet count) and automated differential WBC count SE Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) SE Sedimentation rate, erythrocyte; non-automated SE Sedimentation rate, erythrocyte; automated SE T cells; absolute CD4 count SE Rheumatoid factor; qualitative SE Hepatitis Be antibody (HBeAb) SE Hepatitis A antibody (HAAb); total SE Hepatitis C antibody Published: March 8,
4 Medical Review Team s Medical Review Team s and SE Psychiatric diagnostic evaluation Description SE Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient SE Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient SE Assessment for prescription eye wear using a range of lens powers SE Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2) SE Screening test; pure tone, air only SE Pure tone audiometry (threshold); air only SE Pure tone audiometry (threshold); air and bone SE Comprehensive audiometry threshold evaluation and speech recognition (92553 and combined) SE Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report SE Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only SE Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s) with or without maximal voluntary ventilation SE Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration SE Electroencephalogram (EEG); including recording awake and drowsy SE Electroencephalogram (EEG); including recording awake and asleep SE Needle electromyography; 1 extremity with or without related paraspinal areas SE Needle electromyography; 2extremities with or without related paraspinal areas SE Needle electromyography; 3 extremities with or without related paraspinal areas SE Needle electromyography; 4 extremities with or without related paraspinal areas SE Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS) per hour of the psychologist s or physician s time, both face-to-face time administering tests to the patient and time interpreting test results and preparing the report SE Special reports as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form Published: March 8,
5 Medical Review Team s Medical Review Team s and Description SE Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family needs. Usually, the presenting problem(s) are moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family SE Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity; counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family needs. Usually the presenting problem(s) are moderate to high severity. Typically, 45 minutes are spent face to face with the patient and/or family SE Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patients and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family SE Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity; counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face to face with the patient and/or family SE Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians. Other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face o-face with the patient and/or family SE Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. Published: March 8,
6 Medical Review Team s Medical Review Team s and Description SE Basic life and/or disability examination that includes: Measurement of height, weight, and blood pressure; Completion of a medical history following a life insurance pro forma; Collection of blood sample and/or urinalysis complying with chain of custody protocols; and Completion of necessary documentation/certificates. A0425 SE Ground mileage, per statute mile S9981 SE Medical records copying fee, administrative T2003 SE Nonemergency transportation; encounter/trip T2007 SE Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour increments Table Revision History March 6, 2018, update: Added (effective January 1, 2018): , 74018, 74019, January 1, 2018, update: Removed (effective January 1, 2018): 71010, 71020, 74000, Updated description (effective January 1, 2018): June 2, 2017, update: Added (effective June 2, 2017): 72081, 73501, 73502, 73503, 73521, 73522, 73552, 73560, 76700, 82803, 85027, 99203, 99204, 99205, 99213, 99214, Removed (effective June 2, 2017): 70210, 70220, 90736, 99199, 99244, 99245, C8932, D7295, H0035, Q4129, T1023 July 1, 2016, update: Removed (effective January 1, 2016): 72069, 73500, 73510, 73520, 73550, Removed (effective January 1, 2015): Published: March 8,
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