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Revenue Codes with Special Linkages

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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
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