Revenue Codes with Special Linkages

INDIANA HEALTH COVERAGE PROGRAMS

PROVIDER CODE TABLES

Revenue Codes with Special Procedure Code Linkages

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 Schedules for updates to coding, coverage, and benefit information. For information about using this code table, see the Claim Submission and Processing provider reference module.

Table 1 – Procedure Codes Linked to Revenue Code 260 – IV Therapy – General

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding

Table 4 – Procedure Code Linked to Revenue Code 724 – Labor Room/Delivery – Birthing Center

Table 5 – Procedure Codes Linked to Revenue Code 920 – Other Diagnostic Services – General

Table 6 – Procedure Codes Linked to Revenue Code 929 – Other Diagnostic Services

Table 7 – Procedure Codes Linked to Revenue Code 940 – Other Therapeutic Services – General

Table 8 – Procedure Codes Linked to Revenue Codes for Managed Care Billing Only (Revenue Codes 912, 913, and 960)

Published: September 16, 2021 1 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 1 – Procedure Codes Linked to Revenue Code 260 – IV Therapy – General Reviewed/Updated: June 8, 2021

Note: The procedure codes in this table may be billed with revenue code 260 to receive separate reimbursement when billed on the same date of service as a treatment room revenue code. Injection administration (including vaccine administration) is included in the reimbursement for treatment rooms. See the Outpatient Facility Services module for more information. All claims are subject to postpayment review. Procedure Code Description 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour 96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s) 96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 96371 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure) 96372 Injection beneath the skin or into muscle for therapy, diagnosis, or prevention 96373 Injection into artery for therapy, diagnosis, or prevention 96374 Injection of drug or substance into a vein for therapy, diagnosis, or prevention 96375 Injection of different drug or substance into a vein for therapy, diagnosis, or prevention 96521 Refilling and maintenance of portable pump 96522 Refilling and maintenance of implantable pump or reservoir for drug delivery 96523 Irrigation of implanted venous access drug delivery device Q0081 Infusion therapy, using other than chemotherapeutic drugs, per visit Table Revision History June 8, 2021, update: Added (correction): 96372–96375, 96521–96523, Q0081

Published: September 16, 2021 2 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0112 Cranial cervical orthotic, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated L0113 Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment L0120 Cervical, flexible, nonadjustable, prefabricated, off-the-shelf (foam collar) L0130 Cervical, flexible, thermoplastic collar, molded to patient L0140 Cervical, semi-rigid, adjustable (plastic collar) L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) L0160 Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, off-the-shelf L0170 Cervical, collar, molded to patient model L0172 Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-the-shelf L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension, prefabricated, off-the-shelf L0180 Cervical, multiple post collar, occipital/mandibular supports, adjustable L0190 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI, Guilford, Taylor types) L0200 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension L0220 Thoracic, rib belt, custom fabricated L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf L0452 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated L0454 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0455 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf

Published: September 16, 2021 3 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0456 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0457 Thoracic-lumbar-sacral orthotic (TLSO), flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf L0458 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0460 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0462 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0464 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, modular segmented spinal system, 4 rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0466 Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0467 Thoracic-lumbar-sacral orthotic (TLSO), sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf

Published: September 16, 2021 4 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0468 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0469 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf L0470 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0472 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with 2 anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment L0480 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated L0482 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated L0484 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

Published: September 16, 2021 5 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0486 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD- CAM model, custom fabricated L0488 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment L0490 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, 1 piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment L0491 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 2 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0492 Thoracic-lumbar-sacral orthotic (TLSO), sagittal-coronal control, modular segmented spinal system, 3 rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf L0622 Sacroiliac orthotic, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated L0623 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf L0624 Sacroiliac orthotic, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L- 5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf

Published: September 16, 2021 6 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0626 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0627 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf L0629 Lumbar-sacral orthotic, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0632 Lumbar-sacral orthotic (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0634 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated

Published: September 16, 2021 7 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0635 Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment L0636 Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0638 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated L0639 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L0640 Lumbar-sacral orthotic (LSO), sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated L0641 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf L0642 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Published: September 16, 2021 8 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L0643 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf L0649 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf L0700 Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral control, molded to patient model, (Minerva type) L0710 Cervical-thoracic-lumbar-sacral orthotic (CTLSO), anterior-posterior-lateral-control, molded to patient model, with interface material, (Minerva type) L0810 Halo procedure, cervical halo incorporated into jacket vest L0820 Halo procedure, cervical halo incorporated into plaster body jacket L0830 Halo procedure, cervical halo incorporated into Milwaukee type orthotic L0859 Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material L0861 Addition to halo procedure, replacement liner/interface material L0970 Thoracic-lumbar-sacral orthotic (TLSO), corset front L0972 Lumbar-sacral orthotic (LSO), corset front L0974 Thoracic-lumbar-sacral orthotic (TLSO), full corset L0976 Lumbar-sacral orthotic (LSO), full corset L0978 Axillary crutch extension L0999 Addition to spinal orthotic, not otherwise specified L1000 Cervical-thoracic-lumbar-sacral orthotic (CTLSO) (Milwaukee), inclusive of furnishing initial orthotic, including model

Published: September 16, 2021 9 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 10 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L1260 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), anterior thoracic derotation pad L1270 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), abdominal pad L1280 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), rib gusset (elastic), each L1290 Addition to thoracic-lumbar-sacral orthotic (TLSO), (low profile), lateral trochanteric pad L1300 Other scoliosis procedure, body jacket molded to patient model L1310 Other scoliosis procedure, postoperative body jacket L1499 Spinal orthotic, not otherwise specified L1600 Hip orthosis, abduction control of hip joints, flexible, Frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1610 Hip orthosis, abduction control of hip joints, flexible, (Frejka cover only), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1620 Hip orthosis, abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1630 Hip orthotic (HO), abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated L1640 Hip orthotic (HO), abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated L1650 Hip orthotic (HO), abduction control of hip joints, static, adjustable, (Ilfled type), prefabricated, includes fitting and adjustment L1652 Hip orthotic (HO), bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type L1660 Hip orthotic (HO), abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment L1680 Hip orthotic (HO), abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated L1685 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated L1686 Hip orthotic (HO), abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment L1690 Combination, bilateral, lumbo-sacral, hip, femur orthotic providing adduction and internal rotation control, prefabricated, includes fitting and adjustment L1700 Legg Perthes orthotic, (Toronto type), custom fabricated L1710 Legg Perthes orthotic, (Newington type), custom fabricated L1720 Legg Perthes orthotic, trilateral, (Tachdijan type), custom fabricated L1730 Legg Perthes orthotic, (Scottish Rite type), custom fabricated

Published: September 16, 2021 11 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L1755 Legg Perthes orthotic, (Patten bottom type), custom fabricated L1810 Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1812 Knee orthosis, elastic with joints, prefabricated, off-the-shelf L1820 Knee orthotic, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment L1830 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf L1831 Knee orthotic, locking knee joint(s), positional orthotic, prefabricated, includes fitting and adjustment L1832 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf L1834 Knee orthotic (KO), without knee joint, rigid, custom fabricated L1836 Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the- shelf L1840 Knee orthotic (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated L1843 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1844 Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated L1845 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1846 Knee orthotic (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L1848 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf L1850 Knee orthosis, swedish type, prefabricated, off-the-shelf L1851 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

Published: September 16, 2021 12 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L1852 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf L1860 Knee orthotic (KO), modification of supracondylar prosthetic socket, custom fabricated (SK) L1900 Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf band, custom fabricated L1902 Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf L1904 Ankle orthosis, ankle gauntlet, custom-fabricated L1906 Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf L1907 Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated L1910 Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment L1920 Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated L1930 Ankle-foot orthotic (AFO), plastic or other material, prefabricated, includes fitting and adjustment L1932 Ankle-foot orthotic (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment L1940 Ankle-foot orthotic (AFO), plastic or other material, custom fabricated L1945 Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated L1950 Ankle-foot orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated L1951 Ankle-foot orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment L1960 Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated L1970 Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated L1971 Ankle-foot orthotic (AFO), plastic or other material with ankle joint, prefabricated, includes fitting and adjustment L1980 Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar ‘BK’ orthotic), custom fabricated L1990 Ankle-foot orthotic (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar ‘BK’ orthotic), custom fabricated L2000 Knee-ankle-foot orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthotic), custom fabricated L2005 Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated

Published: September 16, 2021 13 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L2006 Knee ankle foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated L2010 Knee-ankle-foot orthotic (KAFO), single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthotic), without knee joint, custom fabricated L2020 Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar ‘AK’ orthotic), custom fabricated L2030 Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar ‘AK’ orthotic), without knee joint, custom fabricated L2034 Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated L2035 Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment L2036 Knee-ankle-foot orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated L2037 Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated L2038 Knee-ankle-foot orthotic (KAFO), full plastic, with or without free motion knee, multi-axis ankle, custom fabricated L2040 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated L2050 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated L2060 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated L2070 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated L2080 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated L2090 Hip-knee-ankle-foot orthotic (HKAFO), torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/ belt, custom fabricated L2106 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, thermoplastic type casting material, custom fabricated L2108 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, custom fabricated L2112 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, soft, prefabricated, includes fitting and adjustment L2114 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, semi-rigid, prefabricated, includes fitting and adjustment L2116 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, rigid, prefabricated, includes fitting and adjustment

Published: September 16, 2021 14 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 15 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 16 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L2622 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each L2624 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each L2627 Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables L2628 Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables L2630 Addition to lower extremity, pelvic control, band and belt, unilateral L2640 Addition to lower extremity, pelvic control, band and belt, bilateral L2650 Addition to lower extremity, pelvic and thoracic control, gluteal pad, each L2660 Addition to lower extremity, thoracic control, thoracic band L2670 Addition to lower extremity, thoracic control, paraspinal uprights L2680 Addition to lower extremity, thoracic control, lateral support uprights L2750 Addition to lower extremity orthotic, plating chrome or nickel, per bar L2755 Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only L2760 Addition to lower extremity orthotic, extension, per extension, per bar (for lineal adjustment for growth) L2768 Orthotic side bar disconnect device, per bar L2780 Addition to lower extremity orthotic, noncorrosive finish, per bar L2785 Addition to lower extremity orthotic, drop lock retainer, each L2795 Addition to lower extremity orthotic, knee control, full kneecap L2800 Addition to lower extremity orthotic, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthotic only L2810 Addition to lower extremity orthotic, knee control, condylar pad L2820 Addition to lower extremity orthotic, soft interface for molded plastic, below knee section L2830 Addition to lower extremity orthotic, soft interface for molded plastic, above knee section L2840 Addition to lower extremity orthotic, tibial length sock, fracture or equal, each L2850 Addition to lower extremity orthotic, femoral length sock, fracture or equal, each L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each L2999 Lower extremity orthotic, not otherwise specified L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each L3001 Foot, insert, removable, molded to patient model, Spenco, each L3002 Foot insert, removable, molded to patient model, Plastazote or equal, each L3003 Foot insert, removable, molded to patient model, silicone gel, each L3010 Foot insert, removable, molded to patient model, longitudinal arch support, each L3020 Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

Published: September 16, 2021 17 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 18 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L3260 Surgical boot/shoe, each L3265 Plastazote sandal, each L3600 Transfer of an orthotic from one shoe to another, caliper plate, existing L3610 Transfer of an orthotic from one shoe to another, caliper plate, new L3620 Transfer of an orthotic from one shoe to another, solid stirrup, existing L3630 Transfer of an orthotic from one shoe to another, solid stirrup, new L3640 Transfer of an orthotic from one shoe to another, Dennis Browne splint (Riveton), both shoes L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf L3660 Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf L3670 Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the- shelf L3671 Shoulder orthotic (SO), shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3674 Shoulder orthotic, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3675 Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf L3677 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L3678 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the-shelf L3702 Elbow orthotic (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf L3720 Elbow orthotic (EO), double upright with forearm/arm cuffs, free motion, custom fabricated L3730 Elbow orthotic (EO), double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated L3740 Elbow orthotic (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated L3760 Elbow orthotic (EO), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the- shelf

Published: September 16, 2021 19 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L3763 Elbow-wrist-hand orthotic (EWHO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3764 Elbow-wrist-hand orthotic (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3765 Elbow-wrist-hand-finger orthotic (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3766 Elbow-wrist-hand-finger orthotic (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3806 Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L3808 Wrist-hand-finger orthotic (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each L3900 Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated L3901 Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom fabricated L3904 Wrist-hand-finger orthotic (WHFO), external powered, electric, custom fabricated L3905 Wrist-hand orthotic (WHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3906 Wrist-hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3908 Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the- shelf L3912 Hand finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the- shelf L3913 Hand finger orthotic (HFO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3915 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Published: September 16, 2021 20 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L3916 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf L3917 Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L3918 Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf L3919 Hand orthotic (HO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3921 Hand finger orthotic (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off- the-shelf L3925 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the- shelf L3927 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf L3929 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L3930 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf L3931 Wrist-hand-finger orthotic (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment L3933 Finger orthotic (FO), without joints, may include soft interface, custom fabricated, includes fitting and adjustment L3935 Finger orthotic, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment L3956 Addition of joint to upper extremity orthotic, any material; per joint L3960 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning, airplane design, prefabricated, includes fitting and adjustment L3961 Shoulder elbow wrist hand orthotic (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Published: September 16, 2021 21 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L3962 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment L3967 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3971 Shoulder-elbow-wrist-hand orthotic (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3973 Shoulder-elbow-wrist-hand orthotic (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3975 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3976 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3977 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3978 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment L3980 Upper extremity fracture orthotic, humeral, prefabricated, includes fitting and adjustment L3981 Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments L3982 Upper extremity fracture orthotic, radius/ulnar, prefabricated, includes fitting and adjustment L3984 Upper extremity fracture orthotic, wrist, prefabricated, includes fitting and adjustment L3995 Addition to upper extremity orthotic, sock, fracture or equal, each L3999 Upper limb orthotic, not otherwise specified L4000 Replace girdle for spinal orthotic (cervical-thoracic-lumbar-sacral orthotic (CTLSO) or spinal orthotic SO) L4002 Replacement strap, any orthotic, includes all components, any length, any type L4010 Replace trilateral socket brim L4020 Replace quadrilateral socket brim, molded to patient model L4030 Replace quadrilateral socket brim, custom fitted L4040 Replace molded thigh lacer, for custom fabricated orthotic only

Published: September 16, 2021 22 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L4045 Replace nonmolded thigh lacer, for custom fabricated orthotic only L4050 Replace molded calf lacer, for custom fabricated orthotic only L4055 Replace nonmolded calf lacer, for custom fabricated orthotic only L4060 Replace high roll cuff L4070 Replace proximal and distal upright for KAFO L4080 Replace metal bands KAFO, proximal thigh L4090 Replace metal bands KAFO-AFO, calf or distal thigh L4100 Replace leather cuff KAFO, proximal thigh L4110 Replace leather cuff KAFO-AFO, calf or distal thigh L4130 Replace pretibial shell L4205 Repair of orthotic device, labor component, per 15 minutes L4210 Repair of orthotic device, repair or replace minor parts L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf L4370 Pneumatic full leg splint, prefabricated, off-the-shelf L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf L4392 Replacement, soft interface material, static AFO L4394 Replace soft interface material, foot drop splint L4396 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise L4397 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf L4398 Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf L4631 Ankle-foot orthotic, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated L5000 Partial foot, shoe insert with longitudinal arch, toe filler L5010 Partial foot, molded socket, ankle height, with toe filler

Published: September 16, 2021 23 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 24 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L5450 Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee L5460 Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee L5500 Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed L5505 Initial, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed L5510 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model L5520 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed L5530 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model L5535 Preparatory, below knee PTB type socket, nonalignable system, no cover, SACH foot, prefabricated, adjustable open end socket L5540 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model L5560 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model L5570 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed L5580 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model L5585 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket L5590 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model L5595 Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model L5600 Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence system L5611 Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with friction swing phase control L5613 Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with hydraulic swing phase control L5614 Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control

Published: September 16, 2021 25 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 26 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 27 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 28 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L5790 Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) L5810 Addition, endoskeletal knee-shin system, single axis, manual lock L5811 Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material L5812 Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock L5818 Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control L5840 Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control L5845 Addition, endoskeletal knee-shin system, stance flexion feature, adjustable L5850 Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist L5855 Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type L5859 Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) L5910 Addition, endoskeletal system, below knee, alignable system L5920 Addition, endoskeletal system, above knee or hip disarticulation, alignable system L5925 Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock L5930 Addition, endoskeletal system, high activity knee control frame

Published: September 16, 2021 29 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 30 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L6010 Partial hand, little and/or ring finger remaining L6020 Partial hand, no finger remaining L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self- suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s) L6050 Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad L6055 Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad L6100 Below elbow, molded socket, flexible elbow hinge, triceps pad L6110 Below elbow, molded socket (Muenster or Northwestern suspension types) L6120 Below elbow, molded double wall split socket, step-up hinges, half cuff L6130 Below elbow, molded double wall split socket, stump activated locking hinge, half cuff L6200 Elbow disarticulation, molded socket, outside locking hinge, forearm L6205 Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm L6250 Above elbow, molded double wall socket, internal locking elbow, forearm L6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm L6310 Shoulder disarticulation, passive restoration (complete prosthesis) L6320 Shoulder disarticulation, passive restoration (shoulder cap only) L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm L6360 Interscapular thoracic, passive restoration (complete prosthesis) L6370 Interscapular thoracic, passive restoration (shoulder cap only) L6380 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow L6382 Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow L6384 Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic L6386 Immediate postsurgical or early fitting, each additional cast change and realignment L6388 Immediate postsurgical or early fitting, application of rigid dressing only L6400 Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6450 Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6500 Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

Published: September 16, 2021 31 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L6550 Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6570 Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient model L6582 Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formed L6584 Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient model L6586 Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct formed L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient model L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formed L6600 Upper extremity additions, polycentric hinge, pair L6605 Upper extremity additions, single pivot hinge, pair L6610 Upper extremity additions, flexible metal hinge, pair L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type L6615 Upper extremity addition, disconnect locking wrist unit L6616 Upper extremity addition, additional disconnect insert for locking wrist unit, each L6620 Upper extremity addition, flexion/extension wrist unit, with or without friction L6621 Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device L6623 Upper extremity addition, spring assisted rotational wrist unit with latch release L6624 Upper extremity addition, flexion/extension and rotation wrist unit L6625 Upper extremity addition, rotation wrist unit with cable lock L6628 Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal L6630 Upper extremity addition, stainless steel, any wrist

Published: September 16, 2021 32 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 33 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L6694 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism L6695 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism L6696 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only L6697 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only L6698 Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert L6703 Terminal device, passive hand/mitt, any material, any size L6704 Terminal device, sport/recreational/work attachment, any material, any size L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric L6712 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric L6713 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement L6721 Terminal device, hook or hand, heavy-duty, mechanical, voluntary opening, any material, any size, lined or unlined L6722 Terminal device, hook or hand, heavy-duty, mechanical, voluntary closing, any material, any size, lined or unlined L6805 Addition to terminal device, modifier wrist unit L6810 Addition to terminal device, precision pinch device L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device

Published: September 16, 2021 34 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 274. No other procedure codes will be reimbursed when billed with revenue code 274, and revenue code 274 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power L6884 Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power L6885 Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment L6895 Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated L6900 Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining L6905 Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining L6910 Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining L6915 Hand restoration (shading and measurements included), replacement glove for above L6920 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and 1 charger, switch control of terminal device L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device L6930 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device L6935 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device L6940 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device L6950 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, 2 batteries and one charger, switch control of terminal device L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device

Published: September 16, 2021 35 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 36 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 37 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 38 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 39 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 2 – Procedure Codes Linked to Revenue Code 274 – Prosthetic/Orthotic Devices Reviewed/Updated: July 1, 2020

Published: September 16, 2021 40 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description 90283 Immune globulin (IgIV), human, for intravenous use 90287 Botulinum antitoxin, equine, any route 90288 Botulism immune globulin, human, for intravenous use 90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use 90371 Hepatitis B immune globulin (HBIg), human, for intramuscular use 90375 Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use 90376 Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use 90377 Rabies immune globulin for injection beneath the skin and/or into muscle 90384 Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use 90389 Tetanus immune globulin (TIg), human, for intramuscular use 90396 Varicella-zoster immune globulin, human, for intramuscular use 90399 Unlisted immune globulin 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use 90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use 90620 Vaccine for meningococcus for injection into muscle 90621 Vaccine for meningococcus for injection into muscle 90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use 90644 Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use 90649 Human papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use 90650 Human papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use 90651 Vaccine for human papilloma virus (3 dose schedule) injection into muscle 90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use 90675 Rabies vaccine, for intramuscular use 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use 90716 Varicella virus vaccine, live, for subcutaneous use 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use

Published: September 16, 2021 41 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use 90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MenACWY), for intramuscular use 90736 Zoster (shingles) vaccine, live, for subcutaneous injection 90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use 90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use 90749 Unlisted vaccine/toxoid 90750 Shingrix (zoster vaccine recombinant, adjuvanted) 91300 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use 91301 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use 91303 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use A9513 Lutetium Lu 177, dotatate, therapeutic, 1 millicurie A9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie A9606 Radium RA-223 dichloride, therapeutic, per microcurie C1716 Brachytherapy source, non-stranded, gold-198, per source C1717 Brachytherapy source, non-stranded, high dose rate iridium 192, per source C1719 Brachytherapy source, non-stranded, non-high dose rate iridium-192, per source C2616 Brachytherapy source, non-stranded, yttium-90, per source C2634 Brachytherapy source, non-stranded, high activity, iodine-125, greater than 1.01 mci (NIST), per source C2635 Brachytherapy source, non-stranded, high activity, palladium-103, greater than 2.2 mci (NIST), per source C2636 Brachytherapy linear source, non-stranded, palladium-103, per 1 mm C2637 Brachytherapy source, non-stranded, Ytterbium-169, per source C2638 Brachytherapy source, stranded, iodine-125, per source C2639 Brachytherapy source, non-stranded, iodine-125, per source C2640 Brachytherapy source, stranded, palladium-103, per source

Published: September 16, 2021 42 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description C2641 Brachytherapy source, non-stranded, palladium-103, per source C2642 Brachytherapy source, stranded, cesium-131, per source C2643 Brachytherapy source, non-stranded, cesium-131, per source C2644 Brachytherapy source, cesium-131 chloride solution, per millicurie C2645 Brachytherapy planar source, palladium-103, per square millimeter C2698 Brachytherapy source, stranded, not otherwise specified, per source C2699 Brachytherapy source, non-stranded, not otherwise specified, per source C9046 Cocaine hydrochloride nasal solution for topical administration, 1 mg C9065 Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg C9075 Injection, casimersen, 10 mg C9076 Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose C9077 Injection, cabotegravir and rilpivirine, 2mg/3mg C9078 Injection, trilaciclib, 1 mg C9079 Injection, evinacumab-dgnb, 5 mg C9080 Injection, melphalan flufenamide hydrochloride, 1 mg C9248 Injection, clevidipine butyrate, 1 mg C9250 Human plasma fibrin sealant, vapor-heated, solvent-detergent (Artiss), 2 ml C9254 Injection, lacosamide, 1 mg C9257 Injection, bevacizumab, 0.25 mg C9358 Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm C9360 Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm C9460 Injection, cangrelor, 1 mg C9462 Injection, delafloxacin, 1 mg C9488 Injection, conivaptan hydrochloride, 1 mg J0121 Injection, omadacycline, 1 mg J0129 Injection, abatacept, 10 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) J0130 Injection abciximab, 10 mg J0132 Injection, acetylcysteine, 100 mg J0135 Injection, adalimumab, 20 mg J0178 Injection, aflibercept, 1 mg J0179 Injection, brolucizumab-dbll, 1 mg

Published: September 16, 2021 43 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 44 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J0583 Injection, bivalirudin, 1 mg J0584 Injection, burosumab-twza 1 mg J0585 Injection, onabotulinumtoxinA, 1 unit J0586 Injection, abobotulinumtoxinA, 5 units J0587 Injection, rimabotulinumtoxinB, 100 units J0588 Injection, incobotulinumtoxinA, 1 unit J0593 Injection, lanadelumab-flyo, 1 mg (code may be used for Medicare when drug administered under direct supervision of a physician, not for use when drug is self-administered) J0594 Injection, busulfan, 1 mg J0596 Injection, C1 esterase inhibitor (recombinant), Ruconest, 10 units J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units J0599 Injection, C-1 esterase inhibitor (human), (Haegarda), 10 units J0600 Injection, edetate calcium disodium, up to 1,000 mg J0606 Injection, etelcalcetide, 0.1 mg J0630 Injection, calcitonin salmon, up to 400 units J0637 Injection, caspofungin acetate, 5 mg J0638 Injection, canakinumab, 1 mg J0641 Injection, levoleucovorin calcium, 0.5 mg J0691 Injection, lefamulin, 1 mg J0693 Injection, cefiderocol, 5 mg J0712 Injection, ceftaroline fosamil, 10 mg J0714 Injection, ceftazidime and avibactam, 0.5 g/0.125 gm J0716 Injection, Centruroides immune F(ab)2, up to 120 mg J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) J0740 Injection, cidofovir, 375 mg J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg J0791 Injection, crizanlizumab-tmca, 5 mg J0800 Injection, corticotropin, up to 40 units J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg J0840 Injection, crotalidae polyvalent immune fab (ovine), up to 1 g J0841 Injection, crotalidae immune F(ab')2 (equine), 120 mg J0850 Injection, cytomegalovirus immune globulin intravenous (human), per vial J0875 Injection, dalbavancin, 5 mg J0878 Injection, daptomycin, 1 mg

Published: September 16, 2021 45 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) J0883 Argatroban nonesrd use 1mg J0884 Argatroban esrd dialysis 1mg J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units J0887 Injection, epoetin beta, 1 microgram, (for ESRD on dialysis) J0888 Injection, epoetin beta, 1 microgram, (for non-ESRD use) J0890 Injection, peginesatide, 0.1 mg (for ESRD on dialysis) J0894 Injection, decitabine, 1 mg J0896 Injection, luspatercept-aamt, 0.25 mg J0897 Injection, denosumab, 1 mg J1095 Injection, dexamethasone 9 percent, intraocular, 1 microgram J1096 Dexamethasone, lacrimal ophthalmic insert, 0.1 mg J1097 Phenylephrine 10.16 mg/ml and ketorolac 2.88 mg/ml ophthalmic irrigation solution, 1 ml J1110 Injection, dihydroergotamine mesylate, per 1 mg J1162 Injection, digoxin immune fab (ovine), per vial J1190 Injection, dexrazoxane HCl, per 250 mg J1212 Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml J1267 Injection, doripenem, 10 mg J1270 Injection, doxercalciferol, 1 mcg J1290 Injection, ecallantide, 1 mg J1300 Injection, eculizumab, 10 mg J1301 Injection, edaravone, 1 mg J1303 Injection, ravulizumab-cwvz, 10 mg J1322 Injection, elosulfase alfa, 1 mg J1324 Injection, enfuvirtide, 1 mg J1335 Injection, ertapenem sodium, 500 mg J1410 Injection, estrogen conjugated, per 25 mg J1427 Injection, viltolarsen, 10 mg J1428 Injection, eteplirsen, 10 mg J1429 Injection, golodirsen, 10 mg J1430 Injection, ethanolamine oleate, 100 mg J1438 Injection, etanercept, 25 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) J1439 Injection, ferric carboxymaltose, 1 mg

Published: September 16, 2021 46 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J1442 Injection, filgrastim (G-CSF), 1 microgram J1443 Injection, ferric pyrophosphate citrate solution, 0.1 mg of iron J1444 Injection, ferric pyrophosphate citrate powder, 0.1 mg of iron J1447 Injection, tbo-filgrastim, 1 microgram J1451 Injection, fomepizole, 15 mg J1452 Injection, fomivirsen sodium, intraocular, 1.65 mg J1453 Injection, fosaprepitant, 1 mg J1454 Injection, fosnetupitant 235 mg and palonosetron 0.25 mg J1457 Injection, gallium nitrate, 1 mg J1458 Injection, galsulfase, 1 mg J1459 Injection, immune globulin (Privigen), intravenous, nonlyophilized (e.g., liquid), 500 mg J1554 Injection, immune globulin (Asceniv), 500 mg J1555 Injection, immune globulin (Cuvitru), 100 mg J1556 Injection, immune globulin (Bivigam), 500 mg J1557 Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg J1558 Injection, immune globulin (Xembify), 100 mg J1559 Injection, immune globulin (Hizentra), 100 mg J1560 Injection, gamma globulin, intramuscular, over 10 cc J1561 Injection, immune globulin, (Gamunex/Gamunex-C/Gammaked), nonlyophilized (e.g., liquid), 500 mg J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg J1568 Injection, immune globulin, (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg J1569 Injection, immune globulin, (Gammagard liquid), nonlyophilized, (e.g., liquid), 500 mg J1570 Injection, ganciclovir sodium, 500 mg J1572 Injection, immune globulin, (Flebogamma/Flebogamma DIF), intravenous, nonlyophilized (e.g., liquid), 500 mg J1573 Injection, hepatitis b immune globulin (HepaGam B), intravenous, 0.5 ml J1575 Injection, immune globulin/hyaluronidase, (HyQvia), 100 mg immuneglobulin J1595 Injection, glatiramer acetate, 20 mg J1599 Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg J1602 Injection, golimumab, 1 mg, for intravenous use J1610 Injection, glucagon HCl, per 1 mg J1627 Injection, granisetron, extended-release, 0.1 mg

Published: September 16, 2021 47 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 48 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 49 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 50 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J3262 Injection, tocilizumab, 1 mg J3285 Injection, treprostinil, 1 mg J3300 Injection, triamcinolone acetonide, preservative free, 1 mg J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg J3305 Injection, trimetrexate glucuronate, per 25 mg J3315 Injection, triptorelin pamoate, 3.75 mg J3316 Injection, triptorelin, extended-release, 3.75 mg J3357 Injection, ustekinumab, 1 mg J3358 Ustekinumab, for intravenous injection, 1 mg J3364 Injection, urokinase, 5,000 i.u. vial J3365 Injection, IV, urokinase, 250,000 i.u. vial J3380 Injection, vedolizumab, 1 mg J3385 Injection, velaglucerase alfa, 100 units J3397 Injection, vestronidase alfa-vjbk, 1 mg J3398 Injection, voretigene neparvovec-rzyl, 1 billion vector genomes J3399 Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x1015 vector genomes J3465 Injection, voriconazole, 10 mg J3471 Injection, hyaluronidase, ovine, preservative free, per 1 USP unit (up to 999 USP units) J3472 Injection, hyaluronidase, ovine, preservative free, per 1,000 USP units J3473 Injection, hyaluronidase, recombinant, 1 USP unit J3486 Injection, ziprasidone mesylate, 10 mg J3489 Injection, zoledronic acid, 1 mg J3490 Unclassified drugs J3590 Unclassified biologics J7168 Prothrombin complex concentrate (human), Kcentra, per i.u. of factor IX activity J7169 Injection, coagulation factor Xa (recombinant), inactivated-zhzo (Andexxa), 10 mg J7170 Injection, emicizumab-kxwh, 0.5 mg J7175 Injection, factor X, (human), 1 i.u. J7177 Injection, human fibrinogen concentrate (Fibryga), 1 mg J7178 Injection, human fibrinogen concentrate, 1 mg J7179 Vonvendi injection 1 i.u. VWF:RCo J7180 Injection, factor XIII (antihemophilic factor, human), 1 i.u. J7181 Injection, factor XIII A-subunit, (recombinant), per i.u. J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (NovoEight), per i.u.

Published: September 16, 2021 51 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J7183 Injection, von Willebrand factor complex (human), Wilate, 1 i.u. VWF:RCo J7185 Injection, factor VIII (antihemophilic factor, recombinant) (Xyntha), per i.u. J7186 Injection, antihemophilic factor VIII/von Willebrand factor complex (human), per factor VIII i.u. J7187 Injection, von Willebrand factor complex (Humate-P), per i.u. VWF:RCo J7188 Injection, factor VIII (antihemophilic factor, recombinant), (Obizur), per i.u. J7189 Factor VIIa (antihemophilic factor, recombinant), per 1 mcg J7190 Factor VIII (antihemophilic factor, human) per i.u. J7191 Factor VIII (antihemophilic factor [porcine]), per i.u. J7192 Factor VIII (antihemophilic factor, recombinant) per i.u., not otherwise specified J7193 Factor IX (antihemophilic factor, purified, nonrecombinant) per i.u. J7194 Factor IX complex, per i.u. J7195 Injection, factor IX (antihemophilic factor, recombinant) per i.u., not otherwise specified J7196 Injection, antithrombin recombinant, 50 i.u. J7198 Antiinhibitor, per i.u. J7199 Hemophilia clotting factor, not otherwise classified J7200 Injection, factor IX, (antihemophilic factor, recombinant), Rixubis, per i.u. J7201 Injection, factor IX, FC fusion protein (recombinant), per i.u. J7202 Injection, factor IX Idelvion J7203 Injection factor IX, (antihemophilic factor, recombinant), glycopegylated, (Rebinyn), 1 i.u. J7204 Injection, factor VIII, antihemophilic factor (recombinant), (Esperoct), glycopegylated-exei, per i.u. J7205 Injection, factor VIII FC fusion (recombinant), per i.u. J7207 Factor VIII pegylated recomb J7208 Injection, factor VIII, (antihemophilic factor, recombinant), PEGylated-aucl, (Jivi), 1 i.u. J7209 Factor VIII NUWIQ recomb 1 i.u. J7210 Injection, factor VIII, (antihemophilic factor, recombinant), (Afstyla), 1 i.u. J7211 Injection, factor VIII, (antihemophilic factor, recombinant), (Kovaltry), 1 i.u. J7212 Factor VIIa (antihemophilic factor, recombinant)-jncw (Sevenfact), 1 microgram J7296 Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 3 year duration J7298 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration J7300 Intrauterine copper contraceptive J7301 Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg J7303 Contraceptive supply, hormone containing vaginal ring, each

Published: September 16, 2021 52 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J7304 Contraceptive supply, hormone containing patch, each J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies J7307 Etonogestrel (contraceptive) implant system, including implant and supplies J7308 Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (354 mg) J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g J7310 Ganciclovir, 4.5 mg, long-acting implant J7311 Fluocinolone acetonide, intravitreal implant J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg J7313 Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg J7314 Injection, fluocinolone acetonide, intravitreal implant (Yutiq), 0.01 mg J7316 Injection, ocriplasmin, 0.125 mg J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose J7330 Autologous cultured chondrocytes, implant J7340 Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml J7351 Injection, bimatoprost, intracameral implant, 1 microgram J7402 Mometasone furoate sinus implant, (Sinuva), 10 micrograms J7501 Azathioprine, parenteral, 100 mg J7503 Tacrolimus, extended release, oral, 0.25 mg J7504 Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg J7505 Muromonab-CD3, parenteral, 5 mg J7508 Tacrolimus, extended release, oral, 0.1 mg J7511 Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg J7513 Daclizumab, parenteral, 25 mg J7525 Tacrolimus, parenteral, 5 mg J7677 Revefenacin inhalation solution, FDA-approved final product, non-compounded, administered through DME, 1 microgram J7686 Treprostinil, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, 1.74 mg J7799 Not otherwise classified drugs, other than inhalation drugs, administered through DME J8499 Prescription drug, oral, nonchemotherapeutic, not otherwise specified

Published: September 16, 2021 53 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 54 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 55 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 56 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 57 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description J9355 Injection, trastuzumab, 10 mg J9356 Injection, trastuzumab, 10 mg and hyaluronidase-oysk J9357 Injection, valrubicin, intravesical, 200 mg J9358 Injection, fam-trastuzumab deruxtecan-nxki, 1 mg J9360 Injection, vinblastine sulfate, 1 mg J9370 Vincristine sulfate, 1 mg J9371 Injection, vincristine sulfate liposome, 1 mg J9390 Injection, vinorelbine tartrate, 10 mg J9395 Injection, fulvestrant, 25 mg J9400 Injection, ziv-aflibercept, 1 mg J9600 Injection, porfimer sodium, 75 mg J9999 Not otherwise classified, antineoplastic drugs M0201 COVID-19 vaccine administration inside a patient’s home; reported only once per individual home per date of service when only COVID-19 vaccine administration is performed at the patient’s home M0243 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring M0244 Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider based to the hospital during the COVID-19 public health emergency M0245 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring M0246 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider based to the hospital during the COVID-19 public health emergency M0247 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring M0248 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency M0249 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose M0250 Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

Published: September 16, 2021 58 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Note: The procedure codes on this table may be separately reimbursed in the outpatient setting when billed with revenue code 636. No other procedure codes will be reimbursed when billed with revenue code 636, and revenue code 636 will not be reimbursed when billed without a procedure code on this list. See the Outpatient Facility Services module for more information. Procedure Code Description P9045 Infusion, albumin (human), 5%, 250 ml P9046 Infusion, albumin (human), 25%, 20 ml P9047 Infusion, albumin (human), 25%, 50 ml Q0138 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use) Q0139 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis) Q0167 Dronabinol, 2.5 mg, oral, FDA approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen Q0180 Dolasetron mesylate, 100 mg, oral, FDA approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 24-hour dosage regimen Q0181 Unspecified oral dosage form, FDA approved prescription antiemetic, for use as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy treatment, not to exceed a 48-hour dosage regimen Q0243 Injection, casirivimab and imdevimab, 2400 mg Q0244 Injection, casirivimab and imdevimab, 1200 mg Q0245 Injection, bamlanivimab and etesevimab, 2100 mg Q0247 Injection, sotrovimab, 500 mg Q0249 Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg Q2017 Injection, teniposide, 50 mg Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD19 CAR T cells, including leukapheresis and dose preparationprocedures, perinfusion Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis and all other preparatory procedures, per infusion (Provenge) Q2049 Injection, doxorubicin hydrochloride, liposomal, imported Lipodox, 10 mg Q2050 Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR positive viable T cells, including leukapheresis and dose preparation procedures, per therapeutic dose Q3027 Injection, interferon beta-1a, 1 mcg for intramuscular use Q3028 Injection, interferon beta-1a, 1 mcg for subcutaneous use Q4100 Skin substitute, not otherwise specified Q4101 Apligraf, per sq cm Q4102 Oasis wound matrix, per sq cm

Published: September 16, 2021 59 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 60 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 61 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 62 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Published: September 16, 2021 63 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 – Procedure Codes Linked to Revenue Code 636 – Drugs Requiring Detailed Coding Reviewed/Updated: August 17, 2021

Table 3 Revision History August 17, 2021, update: Added (effective June 24, 2021): M0249, M0250, Q0249 July 1, 2021, update: Added (effective July 1, 2021): C9075– C9080, C9077, J1951, J7168, J9348, J9353, Q5123 Removed (effective July 1, 2021): C9132 Added (effective June 8, 2021): M0201 Added (effective June 3, 2021): Q0244 Added (effective May 26, 2021): M0247, M0248, Q0247 June 15, 2021, update: Added (effective May 6, 2021): M0244, M0246

Published: September 16, 2021 64 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 Revision History May 11, 2021, update: Removed (effective April 16, 2021): Q0239, M0239 April 1, 2021, update: Added (effective April 1, 2021): J1427, J1554, J7402, J9037, J9349, Q2053 Removed (effective April 1, 2021): C9069, C9070, C9072, C9073, C9122 March 30, 2021, update: Added (effective February 27, 2021): 91303 Added (effective February 9, 2021): M0245, Q0245 February 12, 2021, update: Added (effective August 1, 2020): J0221 February 9, 2021, update: Added (effective January 1, 2021): 90377, C9069, C9070, C9072, C9073, J0693, J1823, J7212, J9144, J9223, J9281, J9316, J9317, M0239, M0243, Q0239, Q0243, Q5122, S0013 Removed (effective January 1, 2021): C9062, C9064, C9066 December 29, 2020, update: Added (effective December 18, 2020): 91301 Added (effective December 11, 2020): 91300 December 10, 2020, update: Added (effective December 10, 2020): J9118 October 8, 2020, update: Added (effective October 8, 2020): Q5121 October 1, 2020, update: Added (effective October 1, 2020): C9062, C9064–C9066, J0121, J1632, J1738, J3032, J3241, J7351, J9227, Q4249, Q4250, Q4254, Q4255 Removed (effective October 1, 2020): C9055, C9061, C9063 July 16, 2020, update: Added (effective July 16, 2020): Q5112, Q5113 July 1, 2020, update: Added (effective July 1, 2020): C9061, C9063, C9122, J0223, J0691, J0791, J0896, J1429, J1558, J3399, J7169, J7204, J9177, J9198, J9246, J9358, Q4227–Q4242, Q4244–Q4248, Q5119, Q5120 Removed (effective July 1, 2020): C9041, C9053, C9054, C9056, C9058 Revised description (effective July 1, 2020): J7321, J9245, Q4176 May 1, 2020, update: Added (effective May 1, 2020): Q5116 April 24, 2020, update: Added (effective April 24, 2020): Q5118 April 1, 2020, update: Added (effective April 1, 2020): C9053, C9056, C9058 March 17, 2020, update: Removed (effective August 19, 2019): J0221 February 21, 2020, update: Added (effective February 21, 2020): Q5114, Q5115 January 1, 2020, update: Added (effective January 1, 2020): C9054, C9055, J0179, J9199, J9309 December 13, 2019, update: Added (effective December 13, 2019): Q5107 November 29, 2019, update: Added (effective November 29, 2019): J1095 November 14, 2019, update: Added (effective October 1, 2019): J1096

Published: September 16, 2021 65 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 Revision History October 24, 2019, update: Added (effective October 24, 2019): C9041 October 1, 2019, update: Added (effective October 1, 2019): J0222, J0291, J0593, J1097, J1303, J1943, J1944, J2798, J3031, J3111, J7314, J9119, J9204, J9210, J9269, J9313, Q4205, Q4206, Q4208–Q4222, Q4226, Q5117 Removed (effective October 1, 2019): C9035–C9040, C9043–C9045, C9049, C9050, C9052, C9447, J1942 Added (effective October 18, 2018): 90585, 90586, 90670, 90710, J0350, J0395, J0600, J0800, J1212, J1430, J1438, J1560, J1830, J1945, J2504, J2760, J2993, J3305, J7296, J7297, J7298, J7300, J7301, J7310, J7327, J7330, J7501, J7504, J7505, J7511, J7513, J7525, J9216 Omitted (applicable for table from October 18, 2018, through December 31, 2018): C9497 August 16, 2019, update: Added (effective August 16, 2019): Q5111 July 11, 2019, update: Added (effective July 11, 2019): C9037, J0714, J0875, J1110, J1452, J1573, J1640, J1730, J2062, J2407, J2515, J2547, J2730, J2995, J3070, J3090, J3145, J3243, J3304, J9212, Q5101 July 1, 2019, update: Added (effective July 1, 2019): C9049, C9050, C9052, J1444, J7208, J7677, J9030, J9036, J9356 Removed (effective July 1, 2019): C9141, J9031 April 16, 2019, update: Added (effective April 1, 2019): C9040, C9043–C9046, C9141 January 1, 2019, update: Added (effective January 1, 2019): A9513, C9035, C9036, C9038, C9039, J0185, J0517, J0567, J0584, J0599, J0841, J1301, J1454, J1628, J1746, J2186, J2797, J3245, J3316, J3397, J3398, J7170, J7177, J7203, J9044, J9057, J9153, J9173, J9229, J9311, J9312, Q2042, Q4183, Q4184, Q4185, Q4186, Q4187–Q4198, Q4200–Q4204 Removed (effective January 1, 2019): C9014–C9016, C9024, C9028–C9033, C9463–C9468, C9493, J0833, J9310, Q2040, Q4131, Q4172, Q9995 October 1, 2018, update: Added (effective October 1, 2018): C9033, Q5108, Q5110 September 21, 2018, update: Added (effective September 21, 2018): A9527, C1716, C1717, C1719, C2616, C2634–C2645, C2698, C2699, J9320 Added (effective September 7, 2018): 90750 Added (effective January 1, 2018): Q4176–Q4182 Added (effective February 2, 2017): J2860, J7503 Added (effective January 1, 2017): J2724 August 31, 2018, update: Added (effective August 31, 2018): 90644, 90698, C9257, C9358, C9360, J0215, J0220, J0348, J0364, J0594, J0740, J1324, J1595, J1655, J1743, J2170, J3465, J7303, J7304, J7306–J7308, J7321, J7323–J7326, J9261 Added (effective January 1, 2018): J0606 July 1, 2018, update: Added (effective July 1, 2018): C9030, C9031, C9032, Q5105, Q9991, Q9992, Q9995 June 8, 2018, update: Added (effective January 1, 2017): J7340 June 1, 2018, update: Added (effective June 1, 2018): J7186 April 1, 2018, update: Added (effective April 1, 2018): C9462–C9468, Q2041, Q5103, Q5104 Removed (effective April 1, 2018): Q5102

Published: September 16, 2021 66 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 3 Revision History March 6, 2018, update: Removed (effective March 6, 2018): J0606 Added for retroactive coverage (effective October 1, 2017): C9494 Removed (effective December 31, 2017): C9494 February 16, 2018, update: Added (effective February 16, 2018): Q2043 February 2, 2018, update: Added (effective February 2, 2018): J0887, J0888 January 1, 2018, update: Added (effective January 1, 2018): C9014–C9016, C9024, C9028, C9029, J0565, J0606, J1428, J1555, J1627, J1726, J2326, J2350, J3358, J7210, J7211, J9022, J9023, J9203, J9285, Q2040 Removed (effective January 1, 2018): C9140, C9483–C9486, C9489, C9491, J9300, Q9986, Q9989 Updated description (effective January 1, 2018): 90620, 90621, 90651, Q4132, Q4133, Q4148, Q4156, Q4158, Q4162, Q4163 October 12, 2017, update: Added (effective October 12, 2017): C9489 October 1, 2017, update: Added (effective October 1, 2017): C9491, C9493 July 1, 2017, update: Added (effective July 1, 2017): Q9986, Q9989 Removed (effective July 1, 2017): C9487 May 11, 2017, update: Added (effective May 11, 2017): J8565, Q4112–Q4114, Q4117, Q4122, Q4123, Q4125–Q4128, Q4130–Q4136, Q4145, Q4150–Q4175 Added (effective July 1, 2016): J9225, J9226

Table 4 – Procedure Code Linked to Revenue Code 724 – Labor Room/Delivery – Birthing Center Reviewed/Updated: July 1, 2020

Note: The procedure code on this table is the only code allowable for reimbursement with revenue code 724. No other procedure codes will be reimbursed when billed with revenue code 724. See the Obstetrical and Gynecological Services module for more information. Procedure Code Description S4005 Interim labor facility global (labor occurring but not resulting in delivery)

Published: September 16, 2021 67 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 5 – Procedure Codes Linked to Revenue Code 920 – Other Diagnostic Services – General Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 920. No other procedure codes will be reimbursed when billed with revenue code 920, and revenue code 920 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description 90867 Transcranial magnetic stimulation treatment (stimulates nerve cells in brain to improve symptoms of depression) [initial, including cortical mapping, motor threshold determination, delivery and management] 90868 Transcranial magnetic stimulation treatment (stimulates nerve cells in brain to improve symptoms of depression), per session [subsequent delivery and management per session] 90869 Transcranial magnetic stimulation treatment (stimulates nerve cells in brain to improve symptoms of depression) [subsequent motor threshold redetermination with delivery and management] 92542 Positional nystagmus test, minimum of 4 positions, with recording 92546 Sinusoidal vertical axis rotational testing 92548 Computerized dynamic posturography 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 Transcranial Doppler study of the intracranial arteries; limited study 93890 Transcranial Doppler study of the intracranial arteries; vasoreactivity study 93892 Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection 93893 Transcranial Doppler study of the intraranial arteries; emboli detection with intravenous microbubble injection 93998 Unlisted noninvasive vascular diagnostic study 95249 Continuous monitoring of glucose in tissue fluid using sensor under skin 95250 Ambulatory continuous glucose (sugar) monitoring for a minimum of 72 hours 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist 95808 Sleep monitoring of patient in sleep lab 95810 Sleep monitoring of patient (6 years or older) in sleep lab 95811 Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube 95857 Cholinesterase inhibitor challenge test for myasthenia gravis 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements 95971 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements 95972 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements

Published: September 16, 2021 68 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 5 – Procedure Codes Linked to Revenue Code 920 – Other Diagnostic Services – General Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 920. No other procedure codes will be reimbursed when billed with revenue code 920, and revenue code 920 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description 95976 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with simple cranial nerve stimulator programming 95977 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with complex cranial nerve stimulator programming 95981 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, without reprogramming 95982 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, with reprogramming 95983 Electronic analysis of implanted brain, spinal cord or peripheral stimulation device with brain stimulator programming, first 15 minutes face-to-face time with qualified health care professional 96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics 96001 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements during walking 99172 Visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening of the determination(s) for contrast sensitivity, vision under glare 99173 Screening test of visual acuity, quantitative, bilateral 99174 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report 99177 Instrument based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis Table 5 Revision History April 23, 2019, update: Added (effective April 23, 2019): 95976, 95977, 95983 April 9, 2019, update: Added (effective March 21, 2019): 90867, 90868, 90869 March 26, 2019, update: Added (effective March 26, 2019): 95808, 95810, 95811 January 1, 2019, update: Removed (effective January 1, 2019): 95974, 95978 March 6, 2018, update: Added (effective January 1, 2018): 95249 Added (correction): 99173, 99174 January 1, 2018, update: Updated description (effective January 1, 2018): 95250

Published: September 16, 2021 69 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 6 – Procedure Codes Linked to Revenue Code 929 – Other Diagnostic Services Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 929. No other procedure codes will be reimbursed when billed with revenue code 929, and revenue code 929 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description 92542 Positional nystagmus test, minimum of 4 positions, with recording 92543 Assessment and recording of balance system during irrigation of both ears 92546 Sinusoidal vertical axis rotational testing 92548 Computerized dynamic posturography 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 Transcranial Doppler study of the intracranial arteries; limited study 93890 Transcranial Doppler study of the intracranial arteries; vasoreactivity study 93892 Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection 93893 Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93998 Unlisted noninvasive vascular diagnostic study 95249 Continuous monitoring of glucose in tissue fluid using sensor under skin 95250 Ambulatory continuous glucose (sugar) monitoring for a minimum of 72 hours 95782 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95783 Polysomnography; younger than 6 years, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist 95808 Sleep monitoring of patient in sleep lab 95810 Sleep monitoring of patient (6 years or older) in sleep lab 95811 Sleep monitoring of patient (6 years or older) in sleep lab with continued pressured respiratory assistance by mask or breathing tube 95857 Cholinesterase inhibitor challenge test for myasthenia gravis 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements 95971 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient compliance measurements

Published: September 16, 2021 70 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 6 – Procedure Codes Linked to Revenue Code 929 – Other Diagnostic Services Reviewed/Updated: July 1, 2020

Table 6 Revision History July 1, 2020, update: Added (correction): 92543 April 23, 2019, update: Added (effective April 23, 2019): 95976, 95977, 95983 March 26, 2019, update: Added (effective March 26, 2019): 95808, 95810, 95811 January 1, 2019, update: Removed (effective January 1, 2019): 95974, 95978 March 6, 2018, update: Added (effective January 1, 2018): 95249 January 1, 2018, update: Updated description (effective January 1, 2018): 95250

Published: September 16, 2021 71 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 7 – Procedure Codes Linked to Revenue Code 940 – Other Therapeutic Services – General Reviewed/Updated: July 1, 2020

Note: The procedure codes in this table may be separately reimbursed in the outpatient setting when billed with revenue code 940. No other procedure codes will be reimbursed when billed with revenue code 940, and revenue code 940 will not be reimbursed when billed without a procedure code on this list. Procedure Code Description 0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space 90868 Transcranial magnetic stimulation treatment (stimulates nerve cells in brain to improve symptoms of depression), per session [subsequent delivery and management per session] 90869 Transcranial magnetic stimulation treatment (stimulates nerve cells in brain to improve symptoms of depression) [subsequent motor threshold redetermination with delivery and management] 96999 Unlisted special dermatological service or procedure 97610 Low frequency, non-contact, non-thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day 99195 Phlebotomy, therapeutic (separate procedure) Table 7 Revision History April 9, 2019, update: Added (effective March 21, 2019): 90868, 90869 May 11, 2018, update: Added (effective February 13, 2017): 99195 November 24, 2017, update: Added (effective July 1, 2017): 0474T

Published: September 16, 2021 72 Indiana Health Coverage Programs Revenue Codes with Special Procedure Code Linkages

Table 8 – Procedure Codes Linked to Revenue Codes for Managed Care Billing Only Reviewed/Updated: July 1, 2020

Note: For managed care entities (MCEs) only, the procedure codes in this table may be separately reimbursed in the outpatient setting when billed with the revenue codes indicated. No other procedure codes will be reimbursed when billed with the revenue codes indicated, and the revenue codes indicated will not be reimbursed when billed without the procedure codes listed. All revenue codes on this table remain noncovered for fee-for-service (FFS) claims. Revenue Code 912 – Behavioral Health Treatments/Services – Partial Hospitalization – Less Intensive Procedure Code Description H0035 Mental health partial hospitalization, treatment, less than 24 hours Revenue Code 913 – Behavioral Health Treatments/Services – Partial Hospitalization – Intensive Procedure Code Description H0035 Mental health partial hospitalization, treatment, less than 24 hours Revenue Code 960 – Professional Fees (see also 097X and 098X) – General Procedure Code Description 99354 TH Notification of Pregnancy Table 8 Revision History July 1, 2019, update: Removed (effective July 1, 2019): Revenue codes 905 and 906 June 13, 2017, update: Added (effective July 1, 2016): Revenue codes 912 and 913 linked with procedure code H0035 Added (correction): Revenue code 960 linked with procedure code 99354 TH

Published: September 16, 2021 73