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INDIANA HEALTH COVERAGE PROGRAMS BR202050 DECEMBER 15, 2020

IHCP to cover HCPCS code B4105

Effective January 15, 2021, the Indiana Health Coverage Programs (IHCP) will cover
Healthcare Common Procedure Coding System (HCPCS) code B4105 – In-line cartridge
containing digestive enzyme(s) for enteral feeding, each.

Coverage applies to professional claims (CMS-1500 form or electronic equivalent) and

outpatient claims (UB-04 form or electronic equivalent) with dates of service (DOS) on or
after January 15, 2021. Coverage applies to all Traditional Medicaid and other IHCP
programs that include full Medicaid State Plan benefits. This procedure code may not be
covered under IHCP plans with limited benefits.

The following reimbursement information applies:

◼ Pricing: Manually priced at 75% of submitted manufacturer’s suggested retail price

(MSRP) or 120% of submitted cost invoice

◼ Prior Authorization (PA): Required

PA is required for all digestive enzyme cartridges for use with enteral tube feeding. For IHCP approval and
coverage of initial requests up to 3 months, all the following criteria must be met:

• Diagnosis of cystic fibrosis and exocrine pancreatic insufficiency (EPI)

• Evidence of failed standard pancreatic enzyme therapy (defined as not meeting target weight gain for a
minimum period of 6 weeks)
continued

MORE IN THIS ISSUE

◼ IHCP to mass reprocess or mass adjust inpatient claims for certain ICD-10 procedure codes
that denied incorrectly

◼ IHCP to mass reprocess or mass adjust professional claims for certain medical supplies that
denied inappropriately

◼ Providers may resubmit claims for FSW and MFP-FSW services that denied incorrectly

◼ Certain procedure codes no longer inpatient-only, reimbursement of claims that denied

◼ IHCP to update mileage rate for HCPCS code A0090

◼ IHCP will add noncovered procedure codes to Professional Fee Schedule

◼ IHCP to update case management code T1016 billed with modifier HH as noncovered

◼ Sandata EVV webinar (virtual training) sessions available January 2021

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• Requires nightly continuous tube feedings through gastrostomy tube no less than three times weekly to
achieve goal caloric intake

• For the initial PA or extensions of initial PA, providers must include additional documentation to support
medical necessity of the following orders:

• The need for special nutrients

• The need for a pump; see the Parenteral and Enteral Nutrition Pumps for Home Infusion section of
the Durable and Home Medical Equipment and Supplies provider reference module at
in.gov/medicaid/providers.

◼ Billing guidance:

• Allowable for provider specialty 250 – Durable Medical Equipment (DME)/Medical Supply Dealer

• Reimbursable in the outpatient setting

• Professional claims must include an attachment of the MSRP or cost invoice.

Reimbursement, PA, and billing information applies to services delivered under the fee-for-service (FFS) delivery system.
Individual managed care entities (MCEs) establish and publish reimbursement, PA, and billing criteria within the
managed care delivery system. Questions about managed care billing and PA should be directed to the MCE with which
the member is enrolled.

This coverage will be reflected in the next regular update to the Professional Fee Schedule and the Outpatient Fee
Schedule, accessible from the IHCP Fee Schedules web page at in.gov/medicaid/providers. This information will also be
reflected in the Durable and Home Medical Equipment and Supplies Codes and the Procedure Codes That Require
Attachments, available from the Code Sets page.

IHCP to mass reprocess or mass adjust inpatient claims for

certain ICD-10 procedure codes that denied incorrectly
The Indiana Health Coverage Programs (IHCP) has identified a claim
-processing issue that affects fee-for-service (FFS) inpatient claims
for the International Classification of Diseases, Tenth Revision,
Procedure Coding System (ICD-10-PCS) codes in Table 1, with
dates of service (DOS) from October 1, 2020, through November 2,
2020. Claims for these procedure codes may have denied incorrectly
for explanation of benefits (EOB) 4067 – ICD Proc Code not effective
for DOS (HDR).

The claim-processing system has been corrected. Claims or claim

details processed during the indicated time frame for the ICD-10
procedure codes in Table 1 that denied for EOB 4067 will be mass
reprocessed or mass adjusted, as appropriate. Providers should see reprocessed or adjusted claims on Remittance
Advices (RAs) beginning January 20, 2021, with internal control numbers (ICNs)/Claim IDs that begin with 80
(reprocessed denied claims) or 52 (mass replacements non-check related).
continued

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Table 1 – ICD-10 procedure codes that denied inappropriately for claims with DOS from
October 1, 2020 through November 2, 2020

Procedure Description
code

XW013F5 Introduce New Tech Therap in Subcu, Perc, New Tech 5

XW033E5 Introduce Remdesivir in Periph Vein, Perc, New Tech 5
XW033F5 Introduce New Tech Therap in Periph Vein, Perc, New Tech 5
XW033G5 Introduce Sarilumab in Periph Vein, Perc, New Tech 5
XW033H5 Introduce Tocilizumab in Periph Vein, Perc, New Tech 5
XW043E5 Introduce Remdesivir in Central Vein, Perc, New Tech 5
XW043F5 Introduce New Tech Therap in Central Vein, Perc, New Tech 5
XW043G5 Introduce Sarilumab in Central Vein, Perc, New Tech 5
XW043H5 Introduce Tocilizumab in Central Vein, Perc, New Tech 5
XW0DXF5 Introduce New Tech Therap in Mouth/Phar, Extern, New Tech 5
XW13325 Transfuse Convalesc Plasma in Periph Vein, Perc, New Tech 5
XW14325 Transfuse Convalesc Plasma in Central Vein, Perc, New Tech 5

IHCP to mass reprocess or mass adjust professional claims

for certain medical supplies that denied inappropriately
The Indiana Health Coverage Programs (IHCP) has identified a claim-processing issue that affects professional claims
for the Healthcare Common Procedure Coding System (HCPCS) codes in Table 2. Claims processed from February 13,
2017, through October 28, 2020, may have denied inappropriately for explanation of benefit (EOB) 4013 – This
procedure code is not covered for this date of service.

The claim-processing system has been corrected. Claims or claim details processed during the indicated time frame for
the codes in Table 2 that denied incorrectly with EOB 4013 will be mass reprocessed or mass adjusted as appropriate.
Providers should see the reprocessed or adjusted claims on Remittance Advices (RAs) beginning December 30, 2020,
with internal control numbers (ICNs)/Claim IDs that begin with 80 (reprocessed denied claims) or 52 (mass replacements
non-check related).

Table 2 – Procedure codes that may have denied inappropriately for claims processed from
February 13, 2017, through October 28, 2020

Procedure Description
code
A4435 Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system),
with or without filter, each
A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each
A5083 Continent device, stoma absorptive cover for continent stoma

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Providers may resubmit claims for FSW and MFP-FSW

services that denied incorrectly
The Indiana Health Coverage Programs (IHCP) identified a
claim-processing issue that affects fee-for-service (FFS)
claims for the Family Supports Waiver (FSW) and Money
Follows the Person Family Supports Waiver (MFP-FSW)
procedure code and modifier combinations in Table 3 for
claims with dates of service (DOS) from July 16, 2020,
through October 13, 2020. Claim details for these services
may have denied incorrectly with explanation of benefits
(EOB) 4021 – Procedure code is not covered for the dates of
service for the program billed. Please verify and resubmit.

The claim-processing system has been corrected. Beginning immediately, providers may resubmit FFS claims for the
procedure code and modifier combinations in Table 3 processed during the indicated time frame that may have denied
incorrectly with EOB 4021, for reimbursement consideration. Claims resubmitted beyond the original filing limit must
include a copy of this banner page as an attachment and must be submitted within 180 days of the banner page’s
publication date.

As announced in IHCP Bulletin BT202083, the services were added to FSW, effective for claims with DOS on or after
July 16, 2020. These changes are reflected in the Professional Fee Schedule, accessible from the IHCP Fee Schedules
page at in.gov/medicaid/providers.

Table 3 – Procedure codes for FSW and MFP-FSW services that may have denied inappropriately
for claims with DOS from July 16, 2020, through October 13, 2020

Service Code Modifiers

Environmental Modification, Install S5165 U7 U5 NU
Environmental Modification, Maintain S5165 U7 U5 U8
Remote Supports, 1 Participant A9279 U7 U5 UA
Remote Supports, 2 Participants A9279 U7 U5 U2
Remote Supports, 3 Participants A9279 U7 U5 U3
Remote Supports, 4 Participants A9279 U7 U5 U4

Certain procedure codes no longer inpatient-only,

reimbursement of claims that denied
Effective January 20, 2021, the Indiana Health Coverage Programs (IHCP) will update the claim-processing system
(CoreMMIS) for pricing on the outpatient services in Table 4 and Table 5 below. The Current Procedural Terminology
(CPT®1) codes for the services were previously identified as Inpatient-Only (IPO) on the IHCP Outpatient Fee Schedule.
In order to better align reimbursement of outpatient services with nationwide standards, the IHCP will follow Medically
Unlikely Edits (MUEs) for Medicaid services.
continued

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Pricing for the procedure codes in Table 4 and Table 5 for outpatient services is retroactively effective for claims with
dates of service (DOS) on or after January 1, 2020.

This banner page article supersedes previously published guidance,

and revises guidance in the Inpatient Hospital Services provider
reference module, accessible from in.gov/medicaid/providers.

The IHCP identified a claim-processing issue that affects fee-for-

service (FFS) outpatient claims for the procedure codes in Tables 4
and 5, for claims with DOS on or after January 1, 2020. Claims or
claim details for the codes may have denied for one of the following
explanation of benefits (EOB):

◼ 4013 – This procedure code is not covered for this date of

service

◼ 4801– Procedure code not covered for benefit plan

The claim-processing system has been updated. Claims processed during the indicated time frame for the codes that
denied for EOB 4013 or EOB 4801 will be mass reprocessed or mass adjusted, as appropriate. Providers should see
reprocessed or adjusted claims on Remittance Advices (RAs) beginning February 3, 2021, with internal control numbers
(ICNs)/Claim IDs that begin with 80 (reprocessed denied claim) or 52 (mass replacements non-check related).

Reimbursement, PA, and billing information applies to services delivered under the FFS delivery system. Individual
managed care entities (MCEs) establish and publish reimbursement, PA, and billing criteria within the managed care
delivery system. Questions about managed care billing and PA should be directed to the MCE with which the member is
enrolled.

This information will be reflected in the next regular update to the Outpatient Fee Schedule, accessible from the
IHCP Fee Schedules page at in.gov/medicaid/providers.
1
CPT copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association.

Table 4 – Procedure codes with manual pricing reimbursable in the outpatient setting,
effective retroactively for claims with DOS on or after January 1, 2020

Procedure Description Manual pricing

code (percentage of
billed amount)

21602 Removal of tumor from chest wall including ribs with plastic reconstruction 10%

21603 Removal of tumor from chest wall including ribs with plastic reconstruction 10%
and removal of lymph nodes from chest cavity

22634 Fusion of lower spine bones with removal of disc, posterior or posterolateral 10%
approach

continued

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Table 4 – Procedure codes with manual pricing reimbursable in the outpatient setting,
effective retroactively for claims with DOS on or after January 1, 2020 (continued)

Procedure Description Manual pricing

code (percentage of
billed amount)
33017 Drainage of heart sac with insertion of catheter accessed through skin, 10%
using fluoroscopy and/or ultrasound guidance imaging guidance, in patient 6
years or older
33018 Drainage of heart sac with insertion of catheter accessed through skin, 10%
using fluoroscopy and/or ultrasound guidance imaging guidance, in patient 5
years or older or any age with congenital heart defect
33019 Drainage of heart sac with insertion of catheter accessed through skin, 10%
using imaging guidance, using CT imaging guidance
33858 Repair of ascending aorta with graft on heart-lung machine, for separation 10%
of wall of aorta (dissection)
33859 Repair of ascending aorta with graft on heart-lung machine, for disease 10%
other than separation of wall of aorta (dissection)
33871 Repair of transverse arch of aorta with graft on heart-lung machine 10%
34717 Repair of groin artery on one side with graft inserted through artery, 10%
performed at same time as repair of aorta
34718 Repair of groin artery on one side with graft inserted through artery, 10%
performed at same time as repair of aorta
35702 Exploration of artery of arm 10%
35703 Exploration of artery of leg 10%
49013 Exploration and packing of wound in pelvic region 15%
49014 Re-exploration of wound in pelvic region with removal of wound packing and 15%
repacking, if necessary

Table 5 – Procedure codes with ambulatory surgical center (ASC) pricing reimbursable in the outpatient
setting, effective retroactively for claims with DOS on or after January 1, 2020

Procedure Description ASC

code pricing
code

22633 Fusion of lower spine bones with removal of disc, posterior or posterolateral M
approach
27130 Replacement of thigh bone and hip joint prosthesis M

30801 Destruction of soft tissue of nasal passages 8

63265 Removal of upper spine bone and growth G

63266 Removal of middle spine bone and growth G

63267 Removal of lower spine bone and growth G

63268 Removal of sacral spine bone and growth G

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IHCP to update mileage rate for HCPCS code A0090

Effective immediately, the Indiana Health Coverage Programs (IHCP) will
update the mileage rate for Healthcare Common Procedure Coding System
(HCPCS) code A0090 – Non-emergency transportation, per mile - vehicle
provided by individual (family member, self, neighbor) with vested interest. The
rate is increasing from $0.38 per mile to $0.39 per mile, retroactive to March 1,
2020, and is being updated in the claim-processing system (CoreMMIS) and
the IHCP Professional Fee Schedule. The mileage rate for code A0090 is tied
to the mileage rate State employees receive, and the Indiana Department of
Administration (IDOA) increased the mileage reimbursement for State employees to $0.39, effective March 1, 2020.

As a reminder, IHCP members served via the fee-for-service (FFS) delivery system receive nonemergency transportation
(NEMT) services brokered through Southeastrans. There are no changes to the reimbursement rate by Southeastrans.

Within the managed care delivery system, individual managed care entities (MCEs) establish their own coverage criteria,
prior authorization (PA) requirements, billing procedures, and reimbursement methodologies. For questions about
services covered under the managed care delivery system, providers should contact the member’s MCE or refer to the
MCE provider manual.

The change is to reflect the updated rate by the IDOA on the Professional Fee Schedule, accessible from the IHCP Fee
Schedules page at in.gov/medicaid/providers.

IHCP will add noncovered procedure codes to Professional

Fee Schedule
The Indiana Health Coverage Programs (IHCP) will update the Professional Fee Schedule to include the noncovered
Healthcare Common Procedure Coding System (HCPCS) codes and Current Procedural Terminology (CPT®1) codes in
Table 6, to align with the claim-processing system (CoreMMIS).

This information will be reflected in the next regular update to the Professional Fee Schedule, accessible from the
IHCP Fee Schedules page at in.gov/medicaid/providers.
1
CPT copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical
Association.

Table 6 – Noncovered procedure codes to be included in the Professional Fee Schedule

Procedure Description
code

0101T High energy shock wave therapy of musculoskeletal system

0394T High dose rate electronic brachytherapy
0395T High dose rate electronic brachytherapy
10040 Acne surgery
54411 Removal and replacement of infected components of inflatable penile prosthesis

continued

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Table 6 – Noncovered procedure codes to be included in the Professional Fee Schedule (continued)

Procedure Description
code
54417 Removal and replacement of infected non-inflatable penile prosthesis
89320 Semen evaluation volume, sperm count, motility and analysis
99360 Prolonged physician standby service, each 30 minutes
99500 Home visit for assessment and monitoring of pregnancy, fetal heart rate and diabetes status
99503 Home visit for respiratory therapy care
99505 Home visit for care of large bowel or bladder opening
99506 Home visit for injections into a muscle
99507 Home visit for care and maintenance of catheters
99510 Home visit for individual, family, or marriage counseling
99511 Home visit for impacted stool management and enema administration
A0160 Non-emergency transportation: per mile - case worker or social worker
D2951 Pin retention-per tooth, in addition to restoration
G0498 Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/
clinic setting using office/clinic pump/supplies, with continuation of the infusion in the community
setting (e.g., home, domiciliary, rest home or assisted living) using a portable pump provided by
the office/clinic, includes follow up office/clinic visit at the conclusion of the infusion
G8882 Sentinel lymph node biopsy procedure not performed, reason not given
G9361 Medical indication for induction [documentation of reason(s) for elective delivery (c-section) or
early induction (e.g., hemorrhage and placental complications, hypertension, preeclampsia and
eclampsia, rupture of membranes-premature or prolonged, maternal conditions complicating
pregnancy/delivery, fetal conditions complicating pregnancy/delivery, late pregnancy, prior
uterine surgery, or participation in clinical trial)]
S8265 Haberman feeder for cleft lip/palate

IHCP to update case management code T1016 billed with

modifier HH as noncovered
Effective January 15, 2021, the Indiana Health Coverage Programs
(IHCP) will update the claim-processing system (CoreMMIS) to make
the following code and modifier combination noncovered: Healthcare
Common Procedure Coding System (HCPCS) code T1016 – Case
management, each 15 minutes when billed with modifier HH –
Integrated mental health/substance abuse program. This change is to
align with IHCP policy.

No previous claims for the code and modifier combination T1016 HH

are affected by this update.

This revision will be reflected in the next regular update to the Professional Fee Schedule, accessible from the IHCP Fee
Schedules page at in.gov/medicaid/providers.

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Sandata EVV webinar (virtual training) sessions available

January 2021
The 21st Century Cures Act directs state Medicaid programs to require personal care service and home health service
providers to use an Electronic Visit Verification (EVV) system to document the services rendered. For more information
and resources, see the Electronic Visit Verification web page at in.gov.medicaid/providers.

Required training

Enrolled providers are required to complete EVV training before

receiving their Sandata EVV Portal Welcome Kits, which will
include their EVV login credentials. Each provider or agency will
enroll no more than two representatives per IHCP Provider ID to
attend a training session. Training will be completed using the
train-the-trainer (TTT) approach (model) so that those attending
training can then train other EVV Portal administrators and
caregivers within their organizations. It is expected that one of
the training representatives will be an EVV administrator.

Because of the current public health emergency for the

coronavirus disease 2019 (COVID-19), instructor-led classroom sessions are not available. However, webinar (virtual
training) sessions will be available in January 2021 as shown in Table 7.

Readiness

Providers are strongly encouraged to review the checklist in Indiana Health Coverage Programs (IHCP) Bulletin
BT201942 in preparation for implementing an EVV system.

Note: The federal requirement for providers of personal services to use an EVV system for documenting services
rendered was changed to January 1, 2021, after the bulletin was published. Personal care services providers and
agencies should complete all steps outlined in BT201942 before January 1, 2021.

Registration

To register for a webinar session, follow the steps in the Indiana Family and Social Services Administration (FSSA) EVV
Agency Provider Training Registration Quick Reference Guide (QRG) located on the Electronic Visit Verification Training
page at in.gov/medicaid/providers. Providers are encouraged to register early because webinar class sizes are limited,
and sessions are expected to fill quickly.

EVV webinar sessions dates and times

Each webinar session will consist of 2 hours of training each day, for 3 consecutive days, allowing for some flexibility
around providers’ schedules. Providers will be required to complete all three days of webinar sessions before receiving
their welcome kits.

See Table 7 for training session dates and times. Each session is limited to 100 attendees, so please register early to
reserve your training.

continued

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Table 7 – EVV webinar (virtual training) sessions

Date (3 consecutive days) Eastern Time

January 12 – 14, 2021 1 p.m. – 3 p.m.

January 26 – 28, 2021 1 p.m. – 3 p.m.

More information

More information will be available in future IHCP communications. For any immediate concerns or questions, please
email mailto:[email protected].

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