Coding Guideline for Synagis® (palivizumab)

Coding Guideline for Synagis® (palivizumab)

CPT© Code: 90378
Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each
Criteria for Coverage
Synagis® (palivizumab) will be allowed monthly during the RSV season, October 19th – April 21st
.
Prior Authorization
Prior Authorization must be obtained through Health Information Designs by completing the online
form found at; http://hidesigns.com/ndmedicaid/pa-forms.html - choose Synagis Registration Form
The ND MMIS Service Authorization Number located on the approval letter must be entered on the
claim at the time of submission. Failure to do so will result in claim denial.
Coding and Billing Instruction
CPT© 90378 must be billed electronically via an 837P transaction with the correlating NDC code for
the Synagis® administered.
Synagis® is available in both 50 mg and 100 mg vials. Multiple vial dosages should be reported with
the most accurate combination to reflect the actual amount of drug administered. Each unique NDC
must be reported on a separate line on the 837P with the correlating number of HCPCS units.
Effective for dates of service on or after 10/19/2018 standard National Correct Coding Initiative
(NCCI) Procedure to Procedure (PTP) editing will be applied to the administration code (CPT 96372)
and Evaluation and Management (E/M) Service combination when rendered on the same date of
service by the same provider.


References:
https://www.nd.gov/dhs/services/medicalserv/medicaid/docs/cpt/synagis-coding-guidelines.pdf

Coding Guidelines for Laboratory CPT codes

Coding Guidelines for Laboratory CPT codes
Urine Culture, Bacterial
1. Specific coding guidelines:
a. Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine
culture colony count is performed to determine the approximate number of bacteria
present per milliliter of urine. The number of units of service is determined by the
number of specimens.
b. Use CPT 87088 where a commercial kit uses manufacturer defined media for
isolation, presumptive identification, and quantitation of morphotypes present. The
number of units of service is determined by the number of specimens.
c. Use CPT 87088 where identification of morphotypes recovered by quantitative
culture or commercial kits and deemed to represent significant bacteriuria requires
the use of additional testing, for example, biochemical test procedures on colonies.
Identification based solely on visual observation of the primary media is usually not
adequate to justify use of this code. The number of units of service is determined
by the number of isolates.
d. Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be
significant is performed concurrently with identification. The number of units of
service is determined by the number of isolates. These codes are not exclusively
used for urine cultures but are appropriate for isolates from other sources as well.
e. Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088,
1 per isolate and 87184 or 87186 where appropriate.
f. Culture for other specific organism groups not ordinarily recovered by media used
for aerobic urine culture may require use of additional CPT codes (for example,
anaerobes from suprapubic samples).
g. Identification of isolates by non-routine, nonbiochemical methods may be coded
appropriately (for example, immunologic identification of streptococci, nucleic acid
techniques for identification of N. gonorrhoeae).
h. While infrequently used, sensitivity studies by methods other than CPT 87184 or
87186 are appropriate. CPT 87181, agar dilution method, each antibiotic or CPT
87188, macrotube dilution method, each antibiotic may be used. The number of
units of service is the number of antibiotics multiplied by the number of unique
isolates.


2. ICD-9-CM code 780.02, 780.9 or 799.3 should be used only in the situation of an
elderly patient, immunocompromised patient or patient with neurologic disorder who
presents without typical manifestations of a urinary tract infection but who presents with
one of the following signs or symptoms, not otherwise explained by another co-existing
condition: increasing debility; declining functional status; acute mental changes;
changes in awareness; or hypothermia.
3. In cases of post renal-transplant urine culture used to detect clinically significant occult
infection in patients on long term immunosuppressive therapy, use code V58.69.

190.13 – Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring)


1. Specific coding guidelines:
a. Temporary code G0100 has been superseded by code 87536 effective January 1,
1998.
b. CPT codes for quantification should not be used simultaneously with other nucleic
acid detection codes for HIV-1 (that is, 87534, 87535) or HIV-2 (that is, 87537,
87538).
2. Codes 647.60-647.64 should only be used for HIV infections complicating pregnancy.


190.14 - Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
1. Specific coding guidelines:
a. CPT 86701 or 86703 is performed initially. CPT 86702 is performed when 86701 is
negative and clinical suspicion of HIV-2 exists.
b. CPT 86689 is performed only on samples repeatedly positive by 86701, 86702, or
86703.
c. CPT 87534 or 87535 is used to detect HIV-1 RNA where indicated. CPT 87537 or
87538 is used to detect HIV-2 RNA where indicated.


190.16 – Partial Thromboplastin Time (PTT)
1. When patients are being converted from heparin therapy to warfarin therapy, use code
V58.61 to document the medical necessity of the PTT.
2. When coding for Disseminated Intravascular Coagulation (DIC), use 286.6 or code for
the signs and symptoms clinically indicating DIC.
3. If a specific condition is known and is the reason for a pre-operative test, submit the
clinical text description or ICD-9-CM code describing the condition with the
order/referral. If a specific condition or disease is not known, and the pre-operative test
is for pre-operative clearance only, assign code V72.84.
4. Assign codes 289.8 – other specified disease of blood and blood-forming organs only
when a specific disease exists and is indexed to 289.8, (for example, myelofibrosis).


Do not assign code 289.8 to report a patient on long term use of anticoagulant therapy
(for example, to report a PTT value or re-check need for medication adjustment.)
Assign code V58.61 to referrals for PTT checks or re-checks. (Reference AHA’s
Coding Clinic, March-April, pg 12 – 1987, 2nd quarter pg 8 – 1989)


190.17 – Prothrombin Time (PT)
1. If a specific condition is known and is the reason for a pre-operative test, submit the
text description or ICD-9-CM code describing the condition with the order/referral. If a
specific condition or disease is not known, and the pre-operative test is for preoperative clearance only, assign code V72.84.
2. Assign codes 289.8 – other specified disease of blood and blood-forming organs only
when a specific disease exists and is indexed to 289.8 (for example, myelofibrosis). Do
not assign code 289.8 to report a patient on long term use of anticoagulant therapy
(e.g. to report a PT value or re-check need for medication adjustment.) Assign code
V58.61 to referrals for PT checks or re-checks. (Reference AHA’s Coding Clinic,
March-April, pg 12 – 1987, 2nd quarter pg 8 – 1989)


190.19 – Collagen Crosslinks, Any Method
1. When the indication for the test is long-term administration of glucocorticosteroids, use
ICD-9-CM code V58.69.


190.20 – Blood Glucose Testing
1. A diagnostic statement of impaired glucose tolerance must be evaluated in the context
of the documentation in the medical record in order to assign the most accurate ICD-9-
CM code. An abnormally elevated fasting blood glucose level in the absence of the
diagnosis of diabetes is classified to Code 790.6 - other abnormal blood chemistry. If
the provider bases the diagnostic statement of impaired glucose tolerance” on an
abnormal glucose tolerance test, the condition is classified to 790.2 -- normal glucose
tolerance test. Both conditions are considered indications for ordering glycated
hemoglobin or glycated protein testing in the absence of the diagnosis of diabetes
mellitus.
2. When a patient is under treatment for a condition for which the tests in this policy are
applicable, the ICD-9-CM code that best describes the condition is most frequently
listed as the reason for the test.
3. When laboratory testing is done solely to monitor response to medication, the most
accurate ICD-9-CM code to describe the reason for the test would be V58.69 -- long
term use of medication.
4. Periodic follow-up for encounters for laboratory testing for a patient with a prior history
of a disease, who is no longer under treatment for the condition, would be coded with
an appropriate code from the V67 category -- follow-up examination.
5. According to ICD-9-CM coding conventions, codes that appear in italics in the
Alphabetic and/or Tabular columns of ICD-9-CM are considered manifestation codes
that require the underlying condition to be coded and sequenced ahead of the
manifestation. For example, the diagnostic statement, “thyrotoxic exophthalmos
(376.21),” which appears in italics in the tabular listing, requires that the thyroid
disorder (242.0-242.9) is coded and sequenced ahead of thyrotoxic exophthalmos.
Therefore, a diagnostic statement that is listed as a manifestation in ICD-9-CM must be
expanded to include the underlying disease in order to accurately code the condition.


190.21 – Glycated Hemoglobin/Glycated Protein
1. A diagnostic statement of impaired glucose tolerance must be evaluated in the context
of the documentation in the medical record in order to assign the most accurate ICD-9-
CM code. An abnormally elevated fasting blood glucose level in the absence of the
diagnosis of diabetes is classified to Code 790.6 - other abnormal blood chemistry. If
the provider bases the diagnostic statement of impaired glucose tolerance” on an
abnormal glucose tolerance test, the condition is classified to 790.2 -- normal glucose
tolerance test. Both conditions are considered indications for ordering glycated
hemoglobin or glycated protein testing in the absence of the diagnosis of diabetes
mellitus.


190.22 – Thyroid Testing
1. When a patient is under treatment for a condition for which the tests in this policy are
applicable, the ICD-9-CM code that best describes the condition is most frequently
listed as the reason for the test.
2. When laboratory testing is done solely to monitor response to medication, the most
accurate ICD-9-CM code to describe the reason for the test would be V58.69 - long
term use of medication.
3. Periodic follow-up for encounters for laboratory testing for a patient with a prior history
of a disease, who is no longer under treatment for the condition, would be coded with
an appropriate code from the V67 category -- follow-up examination.
4. According to ICD-9-CM coding conventions, codes that appear in italics in the
Alphabetic and/or Tabular columns of ICD-9-CM are considered manifestation codes
that require the underlying condition to be coded and sequenced ahead of the
manifestation. For example, the diagnostic statement “thyrotoxic exophthalmos
(376.21),” which appears in italics in the tabular listing, requires that the thyroid
disorder (242.0-242.9) is coded and sequenced ahead of thyrotoxic exophthalmos.
Therefore, a diagnostic statement that is listed as a manifestation in ICD-9-CM must be
expanded to include the underlying disease in order to accurately code the condition.
5. Use code 728.9 to report muscle weakness as the indication for the test. Other
diagnoses included in 728.9 do not support medical necessity.
6. Use code 194.8 (Malignant neoplasm of other endocrine glands and related structures,
other) to report multiple endocrine neoplasia syndromes (MEN-1 and MEN-2). Other
diagnoses included in 194.8 do not support medical necessity.


190.26 – Carcinoembryonic Antigen
1. To show elevated CEA, use ICD-9-CM 790.99 (Other nonspecific findings on
examination of blood) only if a more specific diagnosis has not been made. If a more
specific diagnosis has been made, use the code for that diagnosis.


190.31 – Prostate Specific Antigen
1. To show elevated PSA, use ICD-9-CM code 790.93 (Elevated prostate specific
antigen). If a more specific diagnosis code has been made, use the code for that
diagnosis.


References:
http://healthnetworklabs.com/pdf/5Additional%20Coding%20Guidelines.pdf

Manipulation Procedure/CPT codes Under Anesthesia

Manipulation Procedure/CPT codes Under Anesthesia

Overview
This Coverage Policy addresses manipulation under anesthesia (MUA).


Coverage Policy
A single treatment of manipulation under anesthesia* (MUA) is considered as medically necessary for
ANY of the following indications:
• adhesive capsulitis (i.e., frozen shoulder) when there is failure of conservative medical management,
including medications with or without articular injections, home exercise programs and physical
therapy (Common Procedural Terminology [CPT] code 23700)
• post-traumatic or postoperative arthrofibrosis of the knee (e.g., total knee replacement, anterior
cruciate ligament repair) (CPT code 27570) when there is failure of conservative medical
management, including exercise and physical therapy
• reduction of a displaced fracture (e.g., vertebral, long bones) (e.g., CPT code 22505, 25675)
• reduction of acute/traumatic dislocation (e.g., vertebral, perched cervical facet) (e.g., CPT code
22505)
• chronic contracture of upper or lower extremity joint (e.g., fixed contracture from a neuromuscular
condition) when there is failure of conservative medical management including range of motion
exercise programs and physical therapy

MUA provided for these indications consists of a SINGLE treatment session. Repeat treatment
sessions involving a previously treated bone or joint are subject to medical necessity review.
Furthermore, serial treatment sessions (i.e., treatments of the same bone/joint provided
subsequently over a period of time) are not in accordance with generally accepted standards of
medical practice and are therefore not medically necessary.
MUA for any other indication, including the treatment of acute or chronic pain conditions, involving one
or more of the following joints, is considered experimental, investigational or unproven:
• ankle (CPT code 27860)
• cervical, thoracic or lumbar spine (e.g., CPT code 22505)
• elbow (CPT code 24300)
• finger (e.g., CPT code 26340, 26675)
• hip (CPT code 27275)
• pelvis, sacroiliac (CPT code 27198)
• temporomandibular (CPT code 21073)
• thumb (CPT code 26340)
• toe (CPT code 28635, 28665)
• wrist (CPT code 25259

General Background
Manipulation under anesthesia (MUA) is aimed at reducing pain and improving range of motion and is a
treatment modality that consists of manipulation and stretching procedures performed while an individual
receives anesthesia (e.g., conscious sedation, general anesthesia). A chiropractor, osteopathic physician or
medical physician may perform this type of manipulation with an anesthesiologist in attendance.
MUA is considered a safe and effective form of treatment for some joint conditions, such as arthrofibrosis of the
knee and adhesive capsulitis. It is also utilized for treatment of fractures (e.g., vertebral, long bones) and
dislocations. Although there is limited evidence in the peer-reviewed medical literature supporting safety and
efficacy for the treatment of pain conditions, MUA has been recommended as a treatment modality for acute and
chronic pain conditions, particularly of the spinal region, when standard chiropractic care and other conservative
measures have proved unsuccessful.
An individual’s protective reflex mechanism is absent under anesthesia and proponents contend it is less difficult
to separate and move the joint when the reflex is absent. During MUA, the chiropractor or physician performs a
combination of short manipulations, passive stretches and maneuvers to break up fibrous and scar tissue around
the spine and surrounding joint areas. This manipulation typically includes a high velocity thrust (i.e., a technique
that adjusts the joints rapidly), which may be followed by a popping or snapping sound.
In a less frequently used technique, manipulation under anesthesia (MUA) may be accompanied by
fluoroscopically-guided intra-articular injections with corticosteroid agents to reduce inflammation. This procedure
is referred to as manipulation under joint anesthesia/analgesia (MUJA). Manipulation under epidural anesthesia
(MUEA) employs an epidural, segmental anesthetic, often with simultaneous epidural steroid injections, followed
by spinal manipulation therapy. Some therapies may combine manipulation with cortisone injections into
paraspinal tissues and proliferant injections. Other forms of manipulation under anesthesia include spinal
manipulation under anesthesia (SMUA) performed with or without manipulation of other joints and total body joint
manipulation.
MUA is considered safe and effective and is a well-established method of treatment for conditions such as
adhesive capsulitis of the shoulder, arthrofibrosis of the knee, and some fractures, dislocations and contractures.
When performed for these specific conditions, MUA generally requires a single session of treatment, most often
performed unilaterally, involving a single joint. Data supporting the need for, and clinical efficacy of multiple,
repeat MUA treatment sessions for these specific conditions, is lacking in the peer-reviewed published medical
literature.

Adhesive Capsulitis/Frozen Shoulder
Adhesive capsulitis, also referred to as frozen shoulder, is used to describe a painful restriction (both passive
and active) of shoulder motion in an individual whose radiographs are typically normal. It may also be referred to
as pericapsulitis and occurs in approximately 2-5% of the general population. Some authors contend the
condition results from synovial inflammation with subsequent reactive capsular fibrosis. Early stages are treated
with steroid injections and home therapy. For refractory cases, more aggressive treatment involves manipulation
of the shoulder joint under anesthesia or an arthroscopic capsular release (Griffen, 2003). Manipulating the joint
under anesthesia breaks up the adhesions surrounding the joint and stretches the fibrotic tissue thereby
increasing joint motion and reducing pain. Evidence in the peer-reviewed published scientific literature, including
textbook sources, supports MUA may be considered for refractory cases of adhesive capsulitis of the shoulder
MUA is generally recommended for individuals who do not respond to or who
demonstrate little improvement after conservative treatment.

Postoperative/Post-traumatic Arthrofibrosis of the Knee
Arthrofibrosis of the knee is a condition that may occur following trauma, surgery or joint replacement and results
from inflammation and proliferation of scar tissue. Physiologically, traumatic injury to the knee leads to the
formation of internal scar tissue with shrinking and tightening of the joints knee capsule. Tendons outside the
joint may also shrink and tighten, leading to a further decrease of joint mobility. Treatment of arthrofibrosis of the
knee begins with physical therapy to improve motion, for refractory cases manipulation of the joint under
anesthesia may be performed. However in some cases manipulation of the joint inadvertently results in femoral
or tibial fracture, depending on the severity of adhesion formation and weak joints. As a result, some surgeons
perform an arthroscopic internal resection of scar tissue prior to manipulating the joint in order to reduce the
manipulation force and prevent fractures. MUA is indicated, with or without arthroscopy for arthrofibrosis of the
knee, when there is < 90° range of motion following surgery or trauma despite physical therapy (Magit, et al.
2007). Published evidence in the medical literature supports MUA as a well-established safe and effective
treatment for arthrofibrosis of the knee

Postoperative/Post-traumatic Arthrofibrosis of the Elbow
Arthrofibrosis of the elbow often occurs following injury (e.g., operative, fracture). The elbow becomes stiff as a
result of soft-tissue contracture of the ligaments, muscles and/or tendons. Early management generally involves
bracing and splints (Araghi, et al, 2010). Manipulation under anesthesia may be recommended when there is
failure to progress improve and progress following the use of bracing. Operative release may be considered a
treatment option depending on the cause of the contracture, the presence of pain or other symptoms, and
decrease in functional level.
Published evidence in the peer reviewed scientific literature supporting the safety and effectiveness of using
manipulation under anesthesia of the elbow is limited to retrospective case series, involve small sample
populations and lack control groups (Rotman, et al, 2019; Spitler, et al., 2018; Araghi, et al, 2012, Duke, et al.,
1991, Davilia, Johnston-Jones, 2006; Tan, et al., 2006; Chao, et al, 2002; Gaur, et al, 2003). Few studies lend
support to clinical effectiveness for the treatment of joint stiffness/fibrosis when other conservative measures,
such as bracing and splinting, have failed to improve range of motion. In addition, evidence-based clinical
practice guidelines supporting MUA for arthrofobrosis of the elbow are not available. There is insufficient
evidence in the peer-reviewed published literature and lack of consensus among professional societies to
support the effectiveness of MUA as treatment for arthrofibrosis of the elbow

Fracture and/or Dislocation
MUA is also considered a well-established and successful treatment for some types of fractures (e.g., vertebral,
long bones) and acute/traumatic dislocations (e.g., perched cervical facet). It is typically performed with surgical
Page 4 of 13
Medical Coverage Policy: 0276
repair and other medically necessary procedures such as arthroscopy. When performed in this context, MUA is
considered incidental to the base procedure.


Chronic Contracture of Upper or Lower Extremity Joint
A joint contracture is a limitation in the passive range of motion of a joint. Joint contractures prevent normal
movement of the associated body part and can result from a variety of causes such as spasticity or prolonged
immobilization. Intra-articular adhesions and peri-articular adhesions, as well as capsular, ligament and muscle
shortening and tightness may develop. As a result, activities of daily living and other skills may be adversely
affected due to the decreased mobility. In many cases, contractures can be successfully treated nonoperatively
with aggressive physical therapy or splinting with restoration of functional range of motion. When conservative
treatment fails more aggressive treatment may necessary and includes anesthetic block, maximal stretching, and
in some cases, serial casting (Garden, 2002). For joint contracture deformities, extra-articular and intra-articular
soft tissue releases are considered standard treatment (Paley, 2003). Surgical treatments include tenotomy,
tendon lengthening and joint capsule release. Manipulation under anesthesia, involving maximal passive
stretching may be considered standard treatment and is often performed in combination with serial casting
and/or surgical release when less aggressive treatments have failed.


Pain Management
Although not well-supported in the peer-reviewed published scientific literature, manipulation under anesthesia
has been proposed as a treatment for spine-related pain conditions, including but not limited to, acute or chronic
cervical pain, cervicobrachial, cervicocranial, lumbar, pelvis, or lower extremity syndromes with somatic
dysfunctions that have not responded to conservative management. Manipulation under anesthesia for pain
management often involves the spine and/or other major body joints in addition to the spine. Individuals typically
undergo a 4 to 8 week trial of conservative manipulation management (e.g., chiropractic care) prior to more
aggressive approaches, such as MUA. Authors contend failure of a trial of conservative therapy is thought to be
the primary basis for more aggressive MUA approaches (Kohlbeck, et al., 2002).
When utilized for pain management, MUA treatment typically consists of consecutive daily treatment sessions,
(generally one to five sessions, with three being the average), followed by additional outpatient chiropractic
sessions and may or may not be accompanied by steroid injections. During the procedure, manipulation of
various joints, including the spine, may be performed as part of the overall therapy plan. Cremata and associates
(2005) identified three distinct stages to MUA: sedation of the patient, specific chiropractic adjustments, and
passive stretching and traction procedures of the spine, sacroiliac and pelvis. The literature suggests maneuvers
are predetermined for each individual patient but often involves all regions of the spine (i.e., cervical, thoracic,
lumbar) as well as distal extremities and that the need for serial manipulations is determined by the degree of
biomechanical function following the initial procedure. However, there is insufficient evidence in the peerreviewed published scientific literature to support safety and efficacy of MUA for the management of acute or
chronic pain conditions, when performed as single or multiple treatment sessions.


Spine: Theoretically, spinal manipulation as a method of treatment for subluxation stretches the joint capsules
and resets the spinal cord and nerve position, allowing the nervous system to function optimally. Evidence in the
published, peer-reviewed scientific literature has failed to demonstrate the safety and efficacy of MUA when used
for the treatment of pain associated with the spine (SMUA) and some sources indicate the treatment may be
hazardous and is obsolete (Kohatsu, 2007; Lindsey, et al., 2003). In addition, anesthesia itself carries a small but
clinically significant risk. Overall, the evidence evaluating SMUA consists mainly of case reports, case series, few
controlled clinical trials and literature reviews (Peterson, et al., 2014; Taber, et al., 2013; Cremata, et al., 2005;
Kohlbeck, et al., 2005; Palmieri and Smoyak, 2002; Kohlbeck and Haldeman, 2002; West, et al., 1999). Some of
the study results support improvement in pain and function following SMUA when compared to traditional
manipulation (Kohlbeck, et al., 2005; Palmieri and Smoyak, 2002); however these studies are limited by lack of
randomization, small sample populations and measurement of short-term outcomes. Follow-up assessments
were generally conducted from three months to one year post-MUA treatment, some of which consisted of selfreported outcomes and questionnaires. Patient selection criteria are poorly defined and treatment protocols vary
making comparisons difficult. Much of the evidence evaluating SMUA is low quality and reliable conclusions
cannot be drawn regarding efficacy and improvement of health outcomes. Further well-designed clinical trials are
needed to support the safety and effectiveness of the procedure for the management of acute or chronic pain
conditions related to the spine.
Medical Coverage Policy: 0276


Other Joints: Evidence in the medical literature evaluating the use of MUA for management of pain conditions
involving one or more (i.e., multiple joints, whole body MUA) of other major joints such as the hip, ankle, toe,
elbow, and wrist, is lacking. Due to insufficient evidence conclusions cannot be made regarding the clinical utility
or safety and efficacy of MUA involving other single or multiple joints for pain management.
Other Conditions
There is insufficient evidence in the peer-reviewed published scientific literature to support safety and efficacy of
manipulation under anesthesia of any joint such as the hip, ankle, toe, elbow, and wrist for the treatment of any
other condition.
Professional Societies/Organizations
Published guidelines on the diagnosis and treatment of neck, upper back and low back pain prepared by the
Work Loss Data Institute (WLDI) both address MUA; MUA is listed in both documents as a procedure that was
evaluated and that is not recommended (Work Loss Data Institute, 2013a, 2013b).
According to the American College of Occupational and Environmental Medicine (ACOEM) practice guidelines
regarding physical methods of treatment for low back disorders (Hegmann, 2007; update: Hegmann, et al.,
2008), due to insufficient evidence manipulation under anesthesia (MUA) and medication-assisted spinal
manipulation (MASM) for acute, subacute or chronic low back pain is not recommended.
Centers for Medicare & Medicaid Services (CMS)
• National Coverage Determinations (NCDs): A CMS NCD Manipulation (150.1) is less broad in scope.
Please reference the CMS NCD table of contents link in the reference section.
• Local Coverage Determinations (LCDs): A CMS LCD Manipulation Under Anesthesia (MUA) (L33594) is
less broad in scope. Please reference the CMS LCD table of contents link in the reference section.
Use outside the US
No relevant information.


Coding/Billing Information
Note: 1) This list of codes may not be all-inclusive.
 2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible
 for reimbursement.
Coverage is limited to a SINGLE treatment session of an isolated joint condition.


SHOULDER
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus
(dislocation excluded)


SPINE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
22505 Manipulation of spine requiring anesthesia, any region

PELVIS
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27198 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation
of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s)
and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or
bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia,
moderate sedation, spinal/epidural)


ARM
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
24300 Manipulation, elbow, under anesthesia
24605 Treatment of closed elbow dislocation; requiring anesthesia
25675 Closed treatment of distal radioulnar dislocation with manipulation


WRIST
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
25259 Manipulation, wrist, under anesthesia
25690 Closed treatment of lunate dislocation, with manipulation
26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each
joint; requiring anesthesia


HAND /FINGERS
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
26340 Manipulation, finger joint, under anesthesia, each joint
26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring
anesthesia
26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring
anesthesia
26989† Unlisted procedure, hands or fingers
28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia
†Note: Covered when medically necessary when used to report MUA of a finger or thumb
requiring anesthesia.
Medical Coverage Policy: 0276


HIP
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27252 Closed treatment of hip dislocation, traumatic; requiring anesthesia
27275 Manipulation, hip joint, requiring general anesthesia


LEG
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27831 Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia


KNEE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27552 Closed treatment of knee dislocation; requiring anesthesia
27562 Closed treatment of patellar dislocation; requiring anesthesia
27570 Manipulation of knee joint under general anesthesia (includes application of traction or other
fixation devices)


ANKLE
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
27860 Manipulation of ankle under general anesthesia (includes application of traction or other
fixation apparatus)
28545 Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia


FOOT/TOES
Considered Medically Necessary when criteria in the applicable policy statements listed above are met:
CPT®* Codes Description
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
28899 Unlisted procedure, foot or toes
Experimental, investigational or unproven when used to report manipulation under anesthesia of a
single joint or multiple body joints for any other condition, including the management of acute or chronic
pain conditions:
Medical Coverage Policy: 0276


CPT®* Codes Description
21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia
service (ie, general or monitored anesthesia care)
22505 Manipulation of spine requiring anesthesia, any region
23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia
23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus
(dislocation excluded)
24300 Manipulation, elbow, under anesthesia
25259 Manipulation, wrist, under anesthesia
25675 Closed treatment of distal radioulnar dislocation with manipulation
25690 Closed treatment of lunate dislocation, with manipulation
26340 Manipulation, finger joint, under anesthesia, each joint
26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation
26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each
joint, requiring anesthesia
26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring
anesthesia
26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring
anesthesia
26989 Unlisted procedure, hands or fingers
27198 Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation
of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s)
and/or dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or
bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia,
moderate sedation, spinal/epidural)
27275 Manipulation, hip joint, requiring general anesthesia
27570 Manipulation of knee joint under general anesthesia (includes application of traction or other
fixation devices)
27860 Manipulation of ankle under general anesthesia (includes application of traction or other
fixation apparatus)
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia
28899 Unlisted procedure, foot or toes
*Current Procedural Terminology (CPT®) ©2017 American Medical Association: Chicago, IL




References:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0276_coveragepositioncriteria_spinal_manipulation_under_anesthesia.pdf

Procedures Designated as "Separate Procedure"

Procedures Designated as "Separate Procedure"

Scope
This policy applies to all Commercial, Medicare Advantage, and Medicaid/EOCCO claims.


Reimbursement Guidelines
If a CPT code descriptor includes the term “separate procedure”, the CPT code may not be reported
separately with a related procedure. Moda Health follows CMS/NCCI Policy Manual guidelines to
determine whether or not the “separate procedure” code is related to the other procedure codes
billed.


Codes designated as “separate procedure” CPT codes are eligible for separate reimbursement when
they are the only procedure code reported for that joint, body part, or organ system during that
surgical session.


Many CCI procedure-to-procedure (PTP) edits deny “separate procedure” CPT codes as included in
related comprehensive codes. Some of these edits are eligible for a modifier bypass (modifier
indicator of “1”), and others are not (modifier indicator of “0”). Other code combinations do not
appear in the CCI PTP edits; the claims processing bundling edits are based upon the separate
procedure guidelines found in the CCI Policy Manual (CMS2 ) guidelines.


A CPT code with a descriptor including the term “separate procedure” may be reported with a
bypass modifier in combination with a more comprehensive related procedure code when the
modifier indicator is a “1” and the following criteria is met:

Modifier XE may be appended when the “separate procedure” service is performed first,
the patient leaves the operating room, is recovered, and hours later on the same date of
service needs to return to the operating room for a more comprehensive procedure on the
same organ system or a related body part.

Modifier XS may be appended when the “separate procedure” service is performed on one
side of the body (e.g. left knee) and the more comprehensive, related procedure code is
performed on the contralateral (opposite side) of the body (e.g. right knee).


Modifier XS may be appended to a separate procedure code when performed during the
same operative session as a more comprehensive related code, but the “separate
procedure” service is performed on one lesion and the more comprehensive, related
procedure code is performed on a different lesion which is not touching the first lesion
(non-contiguous). The two lesions may be located in the same organ (e.g. breast, liver, etc.)
or different organs (depending upon the code descriptions involved), or on the skin but not
touching or located in a different area.


Not Eligible for Bypass-Modifier Usage or Separate Reimbursement


A code designated as “separate procedure” may not be reported with a modifier for separate
reimbursement in combination with a more comprehensive, related procedure when:
 Both codes are performed on the same joint or body part during the same operative
session.
o The use of a separate surgical approach (laparoscopic versus open approach) or a
separate incision is not a sufficient reason to use a modifier to obtain separate
reimbursement.
o The CMS/CCI guidelines indicate that the use of a separate incision or separate
surgical approach alone is not sufficient when the more comprehensive procedure
is performed on an anatomically related area.
 Both codes are performed during the same operative session, but by different providers.
o Separate procedure bundling and guidelines apply to assistant surgeon, cosurgeon, and/or other situations involving multiple surgeons during the same
surgical session.
o It is not appropriate to use modifier XP or 59 to bypass separate procedure
bundling during the same operative session.
 The CCI procedure-to-procedure (PTP) edit is not eligible for a modifier bypass (modifier indicator of “0”).


For Example:
58805 “Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal
approach.”
This separate procedure may not be reported in combination with other procedure codes for
fallopian tubes, ovaries, or other female organs on the same date of service during the same
surgical session. Procedure codes for female organs are considered anatomically related.


Codes and Definitions


Modifier Definitions
Modifier Modifier Definition

Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A
Separate Encounter
Modifier XS Separate Structure, A Service That Is Distinct Because It Was Performed On A
Separate Organ/Structure
Modifier XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A
Different Practitioner
Modifier XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because
It Does Not Overlap Usual Components Of The Main Service




Modifier 59 Distinct Procedural Service: Under certain circumstances, it may be necessary
to indicate that a procedure or service was distinct or independent from other
non-E/M services performed on the same day. Modifier 59 is used to identify
procedures/services, other than E/M services, that are not normally reported
together, but are appropriate under the circumstances. Documentation must
support a different session, different procedure or surgery, different site or
organ system, separate incision/excision, separate lesion, or separate injury (or
area of injury in extensive injuries) not ordinarily encountered or performed on
the same day by the same individual. However, when another already
established modifier is appropriate it should be used rather than modifier 59.
Only if no more descriptive modifier is available, and the use of modifier 59 best
explains the circumstances, should modifier 59 be used.


Note: Modifier 59 should not be appended to an E/M service. To report a
separate and distinct E/M service with a non-E/M service performed on the
same day, see modifier 25.




Definition of Terms
Ipsilateral On the same side; affecting the same side of the body; the opposite of contralateral.
In paralysis, this term is used to describe findings on the same side of the body as the
brain or spinal cord lesions producing them.
Contralateral On the opposite side; originating in or affecting the opposite side of the body, the
opposite of homolateral and ipsilateral.




Coding Guidelines
“Some of the procedures or services listed in the CPT codebook that are commonly carried out as
an integral component of a total service or procedure have been identified by the inclusion of the
term “separate procedure.” The codes designated as “separate procedure” should not be reported
in addition to the code for the total procedure or service of which it is considered an integral
component.




However, when a procedure or service that is designated as a “separate procedure” is carried out
independently or considered to be unrelated or distinct from other procedures/services provided at
that time, it may be reported by itself, or in addition to other procedures/services by appending
modifier 59 to the specific “separate procedure” code to indicate that the procedure is not
considered to be a component of another procedure, but is a distinct, independent procedure. This
may represent a different session, different procedure or surgery, different site or organ system,
separate incision/excision, separate lesion, or separate injury (or area of injury in extensive
injuries).” (AMA1 )




“If a CPT code descriptor includes the term “separate procedure”, the CPT code may not be
reported separately with a related procedure. CMS interprets this designation to prohibit the
separate reporting of a “separate procedure” when performed with another procedure in an
anatomically related region often through the same skin incision, orifice, or surgical approach.


A CPT code with the “separate procedure” designation may be reported with another procedure if
it is performed at a separate patient encounter on the same date of service or at the same patient
encounter in an anatomically unrelated area often through a separate skin incision, orifice, or
surgical approach.” (CMS2 )




“From an NCCI perspective, the definition of different anatomic sites includes different organs,
different anatomic regions, or different lesions in the same organ. It does not include treatment of
contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent
soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment
structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic
treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of
a single anatomic site.” (CMS3 )


References:
https://www.modahealth.com/pdfs/reimburse/RPM051



Outpatient Facility Services Indiana Health

Outpatient Facility Services Indiana Health
Introduction


Outpatient facility services are services provided by an acute care hospital, a psychiatric hospital, an
ambulatory surgical center (ASC), a clinic1 , or other treatment room setting to individuals who are
registered as patients with the facility but not admitted as inpatients.


Note: If providers not employed by the facility take a tissue sample, blood sample, or
specimen and send it to the facility for tests, the service is classified as a nonpatient
(rather than an outpatient) facility service, because the patient did not directly receive the service from the facility.


The Indiana Health Coverage Programs (IHCP) covers outpatient facility services when such services are provided or prescribed by a physician, and when the services are medically necessary for the diagnosis or treatment of the member’s condition. The member’s medical condition, as described and documented in the medical record by the primary or attending physician, must justify the intensity of service provided.
This module contains general billing and reimbursement information for outpatient facility services, as well as information specific to each of the four categories of service defined within the CMS hospital outpatient prospective payment system (OPPS):
 Outpatient surgeries
 Treatment room visits
 Add-on services (including certain drugs, supplies, and medical equipment)
 Stand-alone services (including therapy, renal dialysis, laboratory, radiology, and chemotherapy)




Reimbursement for Outpatient Facility Services
Outpatient facility pricing calculates a flat rate for emergency department treatment rooms and
nonemergency department treatment rooms. Additionally, certain outpatient facility services are
reimbursed separately as add-ons or as stand-alone services. For a list of all revenue codes reimbursed by the IHCP, as well as outpatient payment information for relevant codes, see Revenue Codes, accessible from the Code Sets page at in.gov/medicaid/providers.
Rates for outpatient procedure codes and ASC pricing indicators assigned to procedure codes are listed in the Outpatient Fee Schedule, accessible from the IHCP Fee Schedules page at in.gov/medicaid/providers.
The ASC rates and effective dates associated with ASC pricing indicators are listed in the ASC Code/Rate table, also accessible from the IHCP Fee Schedules page.
Providers are reimbursed the lesser of their submitted charges or the Medicaid-allowed amount for
applicable outpatient facility services, except when the Hospital Assessment Fee (HAF) hospital adjustment factor has been applied. See the Hospital Assessment Fee module for more information.




Rate Reduction
For dates of service from January 1, 2014, through June 30, 2021, the IHCP implemented a 3% reduction
in reimbursement for inpatient and outpatient hospital services. The allowed amount for each detail line
of outpatient and outpatient crossover claims is calculated using the current reimbursement methodology.
Third party liability (TPL) is subtracted from the total allowed amount of the claim.
The rate reduction is not applicable for state-operated psychiatric hospitals or for disproportionate share
hospitals (DSHs).
For HAF-participating hospitals, the 3% rate reduction applies only to clinical laboratory services. For
all other services performed at a HAF-participating hospital, the allowed amount for each detail line of
outpatient and outpatient crossover claims is calculated using the current reimbursement methodology
multiplied by the outpatient hospital adjustment factor. The hospital adjustment factors and corresponding
dates are listed in the Hospital Assessment Fee module.




Outpatient Service within 3 Days before an Inpatient Stay
Outpatient services rendered within 3 days preceding an inpatient admission to the same facility for the
same or related diagnosis are considered part of the corresponding inpatient admission.
Note: “Same or related diagnosis” refers to the primary diagnosis code and is based on the
first three digits of the ICD code.
In this situation, the outpatient services will not be reimbursed separately from the inpatient claim:
 If an outpatient claim is submitted for the services and is paid before the inpatient claim is
submitted, the inpatient claim will be denied with explanation of benefits (EOB) 6515 – Inpatient
services performed three days after outpatient DOS [date of service]. To resolve this denial,
providers should void the outpatient claim in history, incorporate the outpatient services into the
inpatient claim, and resubmit the corrected inpatient claim.
 If an outpatient claim is submitted after the inpatient claim has been paid, the outpatient claim will
be denied with EOB6516 – Outpatient services performed three days prior to inpatient admission.
This EOB indicates that the inpatient claim may be adjusted to reflect the outpatient services
provided to the patient.
Inpatient claims billed with outpatient charges for services rendered at the same facility within 3 days
before an admission should reflect the from and through dates of the inpatient stay, not the date the
outpatient services were rendered. However, for all services on the inpatient claim, including services
rendered as outpatient procedures prior to admission, providers must enter the date that the procedure was actually performed in fields 74 and 74a–e of the UB-04 claim form (or in the corresponding fields of the electronic claim).
Providers are required to submit an inpatient claim only when both the outpatient and inpatient services
occur at their facility. This policy is not applicable when the outpatient and inpatient services are provided
by different facilities.
Outpatient services provided within 3 days preceding a less-than-24-hour inpatient stay are billed as an
outpatient service.




Inpatient Stays Less than 24 Hours
Providers should bill inpatient stays that are less than 24 hours in duration as an outpatient service. See the
Inpatient Hospital Services module for exceptions to this rule.
Observation Billing
Observation services (including the use of a bed and periodic monitoring by a hospital’s nursing staff) are
reimbursable when they are furnished by a hospital on the hospital’s premises and they are reasonable and
necessary to evaluate the patient’s condition or determine the need for possible admission to the hospital as
an inpatient.
Providers can retain members for more than one 23-hour observation period when the member has not
met criteria for admission but the treating physician believes that allowing the member to leave the facility
would likely put the member at serious risk. This observation period can last not more than 3 days or
72 hours and is billed as an outpatient claim.
Observation services rendered as outpatient procedures but occurring within 72 hours of an admission must
be billed as an inpatient claim, as described in the Outpatient Service within 3 Days before an Inpatient Stay
section.



Outpatient Surgeries
The IHCP reimburses an all-inclusive ASC rate for outpatient surgeries provided in a hospital or an ASC.
This rate includes all services related to the surgery, with the exception of certain durable medical
equipment (DME) implanted during the surgery. For a list of items that are separately reimbursable for the
outpatient surgery; see the Implantable DME Separately Reimbursable in the Outpatient Setting table in
Surgical Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. The facility
provider should submit claims for these items, and only these items, on the professional claim (CMS-1500
claim form or electronic equivalent) for separate reimbursement in addition to the institutional claim.
See the Surgical Services module for more information about outpatient surgery billing and reimbursement.
Note: The IHCP does not cover surgical or other invasive procedures to treat particular
medical conditions when the practitioner performs the surgery or invasive
procedure erroneously. The IHCP also does not cover services related to these
noncovered procedures. All services provided in the operating room when an error
occurs, and all related services provided during the same hospitalization in which
the error occurred, are not covered. See the Provider Preventable Conditions
section in the Surgical Services module for more information.




Treatment Room Visits
For purposes of the IHCP’s outpatient prospective payment system, treatment rooms include emergency
rooms, clinics, cast rooms, labor and delivery rooms, and observation hours. The IHCP allows multiple
treatment room visits of differing types on the same day. Overutilization is subject to postpayment review.
The IHCP reimburses emergency room services for the treatment of ill and injured patients who require
immediate, unscheduled medical or surgical care. The IHCP reimburses clinic services for diagnostic,
preventative, curative, and rehabilitative services provided to ambulatory patients.
The Revenue Codes and Outpatient Payment Methodologies table indicates which revenue codes
are treatment room revenue codes. See Revenue Codes, accessible from the Code Sets page at
in.gov/medicaid/providers.
Note: When surgeries are performed in a treatment room, the appropriate surgical
Current Procedural Terminology (CPT®2 ) code should accompany the treatment
room revenue code, and reimbursement is based on the ASC methodology. (See the
Surgical Services module for details.) Facilities should otherwise not use a surgical
CPT code in addition to the treatment room revenue code.
Providers may bill stand-alone services in conjunction with treatment room services. Stand-alone services
include services such as therapies, dialysis, radiology, and laboratory. See the Stand-Alone Services section
of this document for details.
The IHCP allows certain add-on services, described in the Add-On Services section of this document, if
they are billed in conjunction with a treatment room visit. All other add-on services are denied if billed in
conjunction with a treatment room service.

Under the fee-for-service reimbursement methodology, treatment room services are reimbursed at a flat
rate that includes most drugs, injections, and supplies. The following policies and billing guidelines apply:
 Administration of injections – Reimbursement for the administration of therapeutic or diagnostic
injections, including vaccines, is incorporated in the established rate for the treatment room in which
the injection was administered (such as 450 – Emergency room or 510 – Clinic). Therefore:
– When other services besides the injection are provided in the treatment room setting,
administration of the injection is not separately reimbursable.
– If a patient receives only an injection service in the treatment room, and no other service is
provided, the provider is instructed to bill only revenue code 260 – IV therapy – General along
with the procedure code for the administration of the injection. No treatment room revenue code
should be billed.
 Infusions – The IHCP considers infusions to be a stand-alone service. Therefore:
– When infusions are performed in conjunction with other services in a treatment room, providers
may bill revenue code 260 along with the procedure code for the administration of the infusion,
on a separate detail line from the treatment room revenue code.
– When performing only an infusion, providers may bill only revenue code 260 along with the
procedure code for the administration of the infusion. No treatment room revenue code should
be billed.
 Orthotic and prosthetic devices – The IHCP allows separate reimbursement for certain designated
orthotic and prosthetic devices when provided in conjunction with treatment room services and billed
with revenue code 274 – Orthotic/prosthetic devices.
 Drugs – The IHCP allows separate reimbursement for certain designated drugs when provided in
conjunction with treatment room services and billed with revenue code 636 – Drugs Requiring
Detailed Coding.
For procedure codes that can billed with revenue codes 260, 274, and 636 for separate reimbursement in
addition to the treatment room rate, see Revenue Codes Linked to Specific Procedure Codes, accessible
from the Code Sets page at in.gov/medicaid/providers. For special procedure code linkages for revenue
code 724 – Birthing center, see the Obstetrical and Gynecological Services module.
Note: Although revenue code 451 (Emergency room – Emergency Medical Treatment and
Labor Act (EMTALA) emergency medical screening services) is sometimes classified
as a treatment room code, it is more accurately described as a “triage” code, used
for screening costs when a patient presents in the ER for a nonemergency condition.
When revenue code 451 is billed, all other lines on the claim for that date of service
will be denied.


Add-On Services
The IHCP reimburses add-on services at a flat, statewide rate when billed with a stand-alone procedure. In
addition, some add-on services are also separately reimbursable if billed in conjunction with a treatment
room revenue code. Add-on services are not separately reimbursable if provided on the same day as an
outpatient surgery. Each add-on revenue code is restricted to one unit per provider per date of service.
The Revenue Codes and Outpatient Payment Methodologies table indicates which revenue codes are used
for add-on services and indicates whether the add-on revenue code is separately reimbursable from a
treatment room code. See Revenue Codes accessible from the Code Sets page at in.gov/medicaid/providers.



Stand-Alone Services
Stand-alone services include therapies, diagnostic testing, dialysis, laboratory services, and radiology
procedures performed in an outpatient setting. Providers can bill stand-alone services separately or in
conjunction with treatment room services. Stand-alone services are not separately reimbursable with
outpatient surgeries if provided on the same day as the surgery. Certain stand-alone revenue codes are
restricted to one unit per provider per date of service.
The IHCP reimburses stand-alone services such as dialysis and physical, occupational, and speech therapies
at an established flat statewide rate. Laboratory and radiology services are reimbursed at the lower of the
charge submitted on the claim or the Fee Schedule amount.
The Revenue Codes and Outpatient Payment Methodologies table indicates which revenue codes are used
for stand-alone services and whether the stand-alone revenue code is restricted to one unit per date of
service. See Revenue Codes on the Code Sets page at in.gov/medicaid/providers.
Stand-Alone Chemotherapy and Radiation Services
Providers should bill all outpatient facility chemotherapy and radiation treatment services on the
institutional claim (UB-04 claim form or electronic equivalent).
Chemotherapy services consist of five components that are separately reimbursable when billed as follows:
 Administration of chemotherapy agent – Bill using revenue codes 331, 332, or 335, along with
the appropriate chemotherapy CPT codes (96401 through 96549).
 Chemotherapy agent – Bill using revenue code 636 – Drugs requiring detailed coding, along with
the appropriate Healthcare Common Procedure Coding System (HCPCS) code. Preparation of
chemotherapy agents is included in the service for administration of the agent.
 IV solution – Bill using revenue code 258.
 IV equipment – Bill using revenue code 261. No reimbursement will be made for other revenue
codes associated with supplies.
 Treatment room services – Bill using revenue codes 45X, 48X, 51X, 52X, or 76X.
Radiation treatment services consist of two components that are separately reimbursable when billed as follows:
 Administration of radiation treatment – Bill using revenue codes 330, 333, or 339, along with the
appropriate radiation treatment CPT code (77261 through 77799).
 Treatment room services – Bill using revenue codes 45X, 48X, 51X, 52X, or 76X


References: https://www.in.gov/medicaid/files/outpatient%20facility%20services.pdf