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 Previous versions of code tables are archived for purposes of historical reference.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 Inpatient Hospital Services provider reference module. Table 1 ICD-10 s for Newborn Light for Gestational Age Table 2 ICD-10 s for Newborn Small for Gestational Age Table 3 ICD-10 s for Newborn Extremely Low Birth Weight Table 4 ICD-10 s for Newborn Other Low Birth Weight Table 5 ICD-10 Deep Vein Thrombosis and Pulmonary Embolism s Excluded from Hospital-Acquired Condition (HAC) and Present on Admission (POA) Requirements for Pediatric or Obstetric Patients Table 6 s Payable as an Inpatient Service When Delivered in an Inpatient Setting for Stays of Less Than 24 Hours Table 1 ICD-10 s for Newborn Light for Gestational Age P05.00 Unspecified weight P05.01 Less than 500 grams P grams P grams P grams P grams P grams P grams P grams P grams and over October 1, 2016, update: Added (effective October 1, 2016): P05.09 Published: November 30,

2 Table 2 ICD-10 s for Newborn Small for Gestational Age P05.10 Unspecified weight P05.11 Less than 500 grams P grams P grams P grams P grams P grams P grams P grams P05.19 Other October 1, 2016, update: Added (effective October 1, 2016): P05.19 Table 3 ICD-10 s for Newborn Extremely Low Birth Weight P07.00 Unspecified weight P07.01 Less than 500 grams P grams P grams Table 4 ICD-10 s for Newborn Other Low Birth Weight P07.10 Unspecified weight P grams P grams P grams P grams P grams Published: November 30,

3 Table 5 ICD-10 Deep Vein Thrombosis and Pulmonary Embolism Diagnosis Codes Excluded from Hospital-Acquired Condition (HAC) and Present on Admission (POA) Requirements for Pediatric or Obstetric Patients I26.90 Septic pulmonary embolism without acute cor pulmonale I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I Acute embolism and thombos unsp deep vn unsp lower extremity I Acute embolism and thrombosis of unspecified femoral vein I Acute embolism and thrombosis of unspecified iliac vein I Acute embolism and thrombosis of unspecified popliteal vein I Acute embolism and thrombosis of unspecified tibial vein I Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity I82.4Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity I82.4Z9 Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity T80.0XXA Air embolism following infusion, transfusion and therapeutic injection, initial T81.718A Complication of other artery following a procedure, not elsewhere classified, initial T81.72XA Complication of vein following a procedure, not elsewhere classified, initial T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial Table 6 s Payable as an Inpatient Service When Delivered Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) Anesthesia for procedures on lower anterior abdominal wall; panniculectomy Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; radical prostatectomy (suprapubic, retropubic) Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomy Anesthesia for open or surgical arthroscopic procedures on knee joint; disarticulation at knee Published: November 30,

4 Table 6 s Payable as an Inpatient Service When Delivered Application of halo, including removal; cranial Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (list separately in addition to code for primary Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (list separately in addition to Open treatment of nasomaxillary complex fracture (Lefort II type); requiring multiple open approaches Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (list separately in addition to code for separate Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than decompression); each additional interspace (list separately in addition to Arthrodesis, posterior technique, atlas-axis (C1-C2) with bone graft and/or internal fixation Arthrodesis, posterior technique, cervical below C2 segment, local bone or bone allograft Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (list separately in addition to Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (list separately in addition to code for primary Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (list separately in addition to Anterior instrumentation; 2 to 3 vertebral segments (list separately in addition to Anterior instrumentation; 4 to 7 vertebral segments (list separately in addition to Removal of posterior nonsegmental instrumentation (eg, Harrington rod) Removal of posterior segmental instrumentation Removal of anterior instrumentation Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement [eg, total shoulder]) Closed treatment of femoral fracture, proximal end, head; with manipulation Arthrodesis, sacroiliac joint (including obtaining graft) Published: November 30,

5 Table 6 s Payable as an Inpatient Service When Delivered Arthroplasty, knee, total; prosthetic (eg, Walldius type) Arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty) Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed Catheter aspiration (separate ; tracheobronchial with fiberscope, bedside Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (list separately in addition to Exploration; popliteal artery Cervical lymphadenectomy (modified radical neck dissection) Nephrostomy, nephrotomy with drainage Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach) Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment Vertebral corpectomy (vertebral body resection), cervical, each additional segment November 7, 2017, update: Correction to include only codes for which the IHCP will bypass the 24-hour rule Published: November 30,