Procedure Codes That Require Attachments
INDIANA HEALTH COVERAGE PROGRAMSPROVIDER CODE TABLESProcedure Codes That Require AttachmentsNote: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or nationalcoding updates, inclusion of a code on the code tables does not necessarily indicate currentcoverage. See IHCP Banner Pages and Bulletins and the IHCP Fee Schedules for updatesto coding, coverage, and benefit information.For information about using this code table, see the Claim Submission and Processingprovider reference module.The Healthcare Common Procedure Coding System (HCPCS) codes in this table require that providers submitattachments with the claims for the claims to be processed. The IHCP denies claims using these codes thatproviders submit without attachments.Note:Certain ICD-10 procedure codes also require attachments. For a list of ICD-10 procedurecodes that require a hysterectomy informed consent and acknowledgement statement, seeObstetrical and Gynecological Services Codes, accessible from the Code Sets page atin.gov/medicaid/providers.Procedure Codes That Require AttachmentsReviewed/Updated: April 30, sia for intraperitoneal procedures in lower abdomenincluding laparoscopy; radical hysterectomyHysterectomy informed consent andacknowledgement statement00851Anesthesia for intraperitoneal procedures in lower abdomenincluding laparoscopy; tubal ligation/transectionConsent for Sterilization form00921Anesthesia for procedures on male genitalia (including openurethral procedures); vasectomy, unilateral/bilateralConsent for Sterilization form00944Anesthesia for vaginal procedures (including biopsy of labia,vagina, cervix or endometrium); vaginal hysterectomyHysterectomy informed consent andacknowledgement statement01962Anesthesia for urgent hysterectomy following deliveryHysterectomy informed consent andacknowledgement statement01963Anesthesia for cesarean hysterectomy without any laboranalgesia/anesthesia careHysterectomy informed consent andacknowledgement statement01966Anesthesia for induced abortion proceduresPhysician/practitioner notes oroperative report01969Anesthesia for cesarean hysterectomy following neuraxial laboranalgesia/anesthesia (List separately in addition to code forprimary procedure performed)Hysterectomy informed consent andacknowledgement statement19499Unlisted procedure, breastPhysician/practitioner notes oroperative reportPublished: May 4, 20211
Indiana Health Coverage ProgramsProcedure Codes That Require AttachmentsProcedure Codes That Require AttachmentsReviewed/Updated: April 30, my, mandible, segmental; with genioglossusadvancementPhysician/practitioner notes oroperative report21299Unlisted craniofacial and maxillofacial procedurePhysician/practitioner notes oroperative report21499Unlisted musculoskeletal procedure, headPhysician/practitioner notes oroperative report26499Correction claw finger, other methodsPhysician/practitioner notes oroperative report27499Decompression fasciotomy, thigh and/or knee, multiplecompartments; with debridement of nonviable muscle and/ornervePhysician/practitioner notes oroperative report28299Correction, hallux valgus (bunion), with or withoutsesamoidectomy; by double osteotomyPhysician/practitioner notes oroperative report29799Unlisted procedure, casting or strappingPhysician/practitioner notes oroperative report38999Unlisted procedure, hemic or lymphatic systemPhysician/practitioner notes oroperative report42699Unlisted procedure, salivary glands or ductsPhysician/practitioner notes oroperative report42999Unlisted procedure, pharynx, adenoids, or tonsilsPhysician/practitioner notes oroperative report43999Unlisted procedure, stomachPhysician/practitioner notes oroperative report44799Unlisted procedure, intestinePhysician/practitioner notes oroperative report45126Pelvic exenteration for colorectal malignancy, withproctectomy (with or without colostomy), with removal ofbladder and ureteral transplantations, and/or hysterectomy, orcervicectomy, with or without removal of tube(s), with orwithout removal of ovary(s), or any combination thereofHysterectomy informed consent andacknowledgement statement50549Unlisted laparoscopy procedure, renalPhysician/practitioner notes oroperative report51597Pelvic exenteration, complete, for vesical, prostatic or urethralmalignancy, with removal of bladder and ureteraltransplantations, with or without hysterectomy and/orabdominoperineal resection of rectum and colon andcolostomy, or any combination thereofHysterectomy informed consent andacknowledgement statement51925Closure of vesicouterine fistula; with hysterectomyHysterectomy informed consent andacknowledgement statement55250Vasectomy, unilateral or bilateral (separate procedure),including postoperative semen examination(s)Consent for Sterilization form55550Laparoscopy, surgical, with ligation of spermatic veins forvaricoceleSterilization consent/acknowledgmenthysterectomy58150Total abdominal hysterectomy (corpus and cervix), with orwithout removal of tube(s), with or without removal of ovary(s)Hysterectomy informed consent andacknowledgement statementPublished: May 4, 20212
Indiana Health Coverage ProgramsProcedure Codes That Require AttachmentsProcedure Codes That Require AttachmentsReviewed/Updated: April 30, 2021ProcedureCodeDescriptionAttachment58152Total abdominal hysterectomy (corpus and cervix), with orwithout removal of tube(s), with or without removal ofovary(s); with colpo-urethrocystopexy (eg, Marshall-MarchettiKrantz, Burch)58180Supracervical abdominal hysterectomy (subtotal hysterectomy), Hysterectomy informed consent andwith or without removal of tube(s), with or without removal of acknowledgement statementovary(s)58200Total abdominal hysterectomy, including partial vaginectomy,with para-aortic and pelvic lymph node sampling, with orwithout removal of tube(s), with or without removal of ovary(s)Hysterectomy informed consent andacknowledgement statement58210Abdominal removal of uterus, cervix, and lymph nodes on bothsides of pelvis and aortic lymph node biopsyHysterectomy informed consent andacknowledgement statement58240Removal of malignant uterus, cervix, lymph nodes, bladder,with transplantation of urinary ducts (ureters), and bowelHysterectomy informed consent andacknowledgement statement58260Vaginal hysterectomy, for uterus 250 g or less;Hysterectomy informed consent andacknowledgement statement58262Vaginal removal of uterus (250 grams or less), tubes, and/orovaries58263Vaginal removal of uterus (250 grams or less), tubes, and/orovaries with repair of herniated bowelHysterectomy informed consent andacknowledgement statementHysterectomy informed consent andacknowledgement statement58267Vaginal hysterectomy, for uterus 250 g or less; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyratype) with or without endoscopic controlHysterectomy informed consent andacknowledgement statement58270Vaginal hysterectomy, for uterus 250 g or less; with repair ofenteroceleHysterectomy informed consent andacknowledgement statement58275Vaginal hysterectomy, with total or partial vaginectomy;58280Vaginal hysterectomy, with total or partial vaginectomy; withrepair of enteroceleHysterectomy informed consent andacknowledgement statementHysterectomy informed consent andacknowledgement statement58285Vaginal removal of uterus, vagina, and pelvic lymph nodes58290Vaginal hysterectomy, for uterus greater than 250 g;58291Vaginal removal of uterus (greater than 250 grams), tubes,and/or ovariesHysterectomy informed consent andacknowledgement statementHysterectomy informed consent andacknowledgement statementHysterectomy informed consent andacknowledgement statement58292Vaginal removal of uterus (greater than 250 grams), tubes,and/or ovaries with repair of herniated bowelHysterectomy informed consent andacknowledgement statement58294Vaginal hysterectomy, for uterus greater than 250 g; with repairof enteroceleHysterectomy informed consent andacknowledgement statement58541Laparoscopy, surgical, supracervical hysterectomy, for uterus250 g or less;Hysterectomy informed consent andacknowledgement statement58542Partial removal of uterus (250 grams or less), tubes and/orovaries with retention of cervix using an endoscopeHysterectomy informed consent andacknowledgement statement58543Laparoscopy, surgical, supracervical hysterectomy, for uterusgreater than 250 g;Hysterectomy informed consent andacknowledgement statementPublished: May 4, 2021Hysterectomy informed consent andacknowledgement statement3
Indiana Health Coverage ProgramsProcedure Codes That Require AttachmentsProcedure Codes That Require AttachmentsReviewed/Updated: April 30, ionAttachmentPartial removal of uterus (greater than 250 grams), tubes, and/or Hysterectomy informed consent andacknowledgement statementovaries using an endoscopeHysterectomy informed consent andRemoval of uterus, cervix, and lymph nodes on both sides ofacknowledgement statementpelvis and aortic lymph node biopsy using an endoscopeHysterectomy informed consent andLaparoscopy, surgical, with vaginal hysterectomy, for uterusacknowledgement statement250 g or less;Hysterectomy informed consent andVaginal removal of uterus (250 grams or less), tubes, and/oracknowledgement statementovaries using an endoscopeHysterectomy informed consent andLaparoscopy, surgical, with vaginal hysterectomy, for uterusacknowledgement statementgreater than 250 g;Hysterectomy informed consent andacknowledgement statement58554Vaginal removal of uterus (greater than 250 grams), tubes,and/or ovaries with assistance of endoscope58565Hysteroscopy, surgical; with bilateral fallopian tube cannulation Consent for Sterilization formto induce occlusion by placement of permanent implantsLaparoscopy, surgical, with total hysterectomy, for uterus 250 g Hysterectomy informed consent andacknowledgement statementor less;58570585715857258573Laparoscopy, surgical, with total hysterectomy, for uterus 250 g Hysterectomy informed consent andacknowledgement statementor less; with removal of tube(s) and/or ovary(s)Hysterectomy informed consent andLaparoscopy, surgical, with total hysterectomy, for uterusacknowledgement statementgreater than 250 g;Hysterectomy informed consent andAbdominal removal of uterus (greater than 250 grams), tubes,acknowledgement statementand/or ovaries using an endoscope58600Ligation or transection of fallopian tube(s), abdominal orvaginal approach, unilateral or bilateralConsent for Sterilization form58605Ligation or transection of fallopian tube(s), abdominal orvaginal approach, postpartum, unilateral or bilateral, duringsame hospitalization (separate procedure)Consent for Sterilization form58611Ligation or transection of fallopian tube(s) when done at thetime of cesarean delivery or intra-abdominal surgery (not aseparate procedure) (List separately in addition to code forprimary procedure)Consent for Sterilization form58615Occlusion of fallopian tube(s) by device (eg, band, clip, Falopering) vaginal or suprapubic approachConsent for Sterilization form58661Laparoscopy, surgical; with removal of adnexal structures(partial or total oophorectomy and/or salpingectomy)Consent for Sterilization form58670Laparoscopy, surgical; with fulguration of oviducts (with orwithout transection)Consent for Sterilization form58671Laparoscopy, surgical; with occlusion of oviducts by device(eg, band, clip, or Falope ring)Consent for Sterilization form58673Laparoscopy, surgical; with salpingostomy (salpingoneostomy)Consent for Sterilization form58700Salpingectomy, complete or partial, unilateral or bilateral(separate procedure)Consent for Sterilization form58720Salpingo-oophorectomy, complete or partial, unilateral orbilateral (separate procedure)Consent for Sterilization formPublished: May 4, 20214
Indiana Health Coverage ProgramsProcedure Codes That Require AttachmentsProcedure Codes That Require AttachmentsReviewed/Updated: April 30, ctomy, partial or total, unilateral or bilateral;Consent for Sterilization form58943Oophorectomy, partial or total, unilateral or bilateral; forovarian, tubal or primary peritoneal malignancy, with paraaortic and pelvic lymph node biopsies, peritoneal washings,peritoneal biopsies, diaphragmatic assessments, with or withoutsalpingectomy(s), with or without omentectomyConsent for Sterilization form58950Resection (initial) of ovarian, tubal or primary peritonealmalignancy with bilateral salpingo-oophorectomy andomentectomy;Consent for Sterilization form58951Removal of abdominal lining, uterus, both ovaries and fallopian Hysterectomy informed consent andtubes, and pelvic and aortic lymph nodesacknowledgement statement58952Resection (initial) of ovarian, tubal or primary peritonealmalignancy with bilateral salpingo-oophorectomy andomentectomy; with radical dissection for debulking (ie, radicalexcision or destruction, intra-abdominal or retroperitonealtumors)58953Removal of abdominal lining, uterus, both ovaries and fallopian Hysterectomy informed consent andtubes with tumor reductionacknowledgement statement58954Removal of abdominal lining, uterus, both ovaries and fallopian Hysterectomy informed consent andtubes, and pelvic and aortic lymph nodes with tumor reductionacknowledgement statement58956Removal of abdominal lining, uterus, and both ovaries andfallopian tubesHysterectomy informed consent andacknowledgement statement59135Surgical treatment of ectopic pregnancy; interstitial, uterinepregnancy requiring total hysterectomyHysterectomy informed consent andacknowledgement statement59525Subtotal or total hysterectomy after cesarean delivery (Listseparately in addition to code for primary procedure)Hysterectomy informed consent andacknowledgement statement63199Removal of spine bone with incision of middle spinal cord, 2stages within 14 daysPhysician/practitioner notes oroperative report88399Unlisted surgical pathology procedurePhysician/practitioner notes oroperative report98960Education and training for patient self-management, each 30minutesClaim note with name of communityhealth worker (CHW)98961Education and training for patient self-management, 2–4patients, each 30 minutesClaim note with name of CHW98962Education and training for patient self-management, 5–8patients, each 30 minuteClaim note with name of CHW0042TCerebral perfusion analysis using computed tomography withPhysician/practitioner notes orcontrast administration, including post-processing of parametric operative reportmaps with determination of cerebral blood flow, cerebral bloodvolume, and mean transit time0072TFocused ultrasound ablation of uterine leiomyomata, includingMR guidance; total leiomyomata volume greater or equal to200 cc of tissuePhysician/practitioner notes oroperative report0567TBlockage of fallopian tubes with implants inserted throughcervixConsent for Sterilization formPublished: May 4, 2021Consent for Sterilization form5
Indiana Health Coverage ProgramsProcedure Codes That Require AttachmentsProcedure Codes That Require AttachmentsReviewed/Updated: April 30, gency transportation and bus, intra- or interstatecarrierTicket/proof of purchase priceA0140Nonemergency transportation and air travel (private orcommercial) intra- or interstateTicket/proof of purchase priceA0999Unlisted ambulance serviceItemized cost invoiceA4223Infusion supplies not used with external infusion pump, percassette or bag (list drugs separately)Manufacturer’s suggested retail price(MSRP) documentation (or costinvoice if no MSRP is available for theitem)A4226Supplies for maintenance of insulin infusion pump with dosagerate adjustment using therapeutic continuous glucose sensing,per weekMSRP documentation (or cost invoiceif no MSRP is available for the item)A4261Cervical cap for contraceptive useMSRP documentation (or cost invoiceif no MSRP is available for the item)A4264Permanent implantable contraceptive intratubal occlusiondevice(s) and delivery systemConsent for Sterilization form anditemized cost invoiceA4266Diaphragm for contraceptive useMSRP documentation (or cost invoiceif no MSRP is available for the item)A4269Contraceptive supply, spermicide (e.g., foam, gel), eachMSRP documentation (or cost invoiceif no MSRP is available for the item)A4281Tubing for breast pump, replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4282Adapter for breast pump, replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4283Cap for breast pump bottle, replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4284Breast shield and splash protector for use with breast pump,replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4285Polycarbonate bottle for use with breast pump, replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4286Locking ring for breast pump, replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4301Implantable access total catheter, port/reservoir (e.g., venous,arterial, epidural, subarachnoid, peritoneal, etc.)MSRP documentation (or cost invoiceif no MSRP is available for the item)A4321*Therapeutic agent for urinary catheter irrigationMSRP documentation (or cost invoiceif no MSRP is available for the item)A4420*Ostomy pouch, closed; for use on barrier with locking flange (2piece), eachMSRP documentation (or cost invoiceif no MSRP is available for the item)A4458*Enema bag with tubing, reusableMSRP documentation (or cost invoiceif no MSRP is available for the item)A4459Manual pump-operated enema system, includes balloon,catheter and all accessories, reusable, any typeMSRP documentation (or cost invoiceif no MSRP is available for the item)*Attachment not required if item is obtained from one of the IHCP-contracted incontinence vendors.Published: May 4, 20216
Indiana Health Coverage ProgramsProcedure Codes That Require AttachmentsProcedure Codes That Require AttachmentsReviewed/Updated: April 30, 2021ProcedureCodeDescriptionAttachmentA4467Belt, strap, sleeve, garment, or covering, any typeMSRP documentation (or cost invoiceif no MSRP is available for the item)A4555Electrode/transducer for use with electrical stimulation deviceused for cancer treatment, replacement onlyMSRP documentation (or cost invoiceif no MSRP is available for the item)A4566Shoulder sling or vest design, abduction restrainer, with orwithout swathe control, prefabricated, includes fitting andadjustmentMSRP documentation (or cost invoiceif no MSRP is available for the item)A4606Oxygen probe for use with oximeter device, replacementMSRP documentation (or cost invoiceif no MSRP is available for the item)A4634Replacement bulb for therapeutic light box, tabletop modelMSRP documentation (or cost invoiceif no MSRP is available for the item)A4638Replacement battery for patient-owned ear pulse generator,eachMSRP documentation (or cost invoiceif no MSRP is available for the item)A5510For diabetics only, direct formed, compression molded topatient's foot without external heat source, multiple-densityinsert(s) prefabricated, per shoeMSRP documentation (or cost invoiceif no MSRP is available for the item)A6000Noncontact wound-warming wound cover for use with thenoncontact wound-warming device and warming cardMSRP documentation (or cost invoiceif no MSRP is available for the item)A6228Gauze, impregnated, water or normal saline, sterile, pad size 16sq in or less, without adhesive border, each dressingMSRP documentation (or cost invoiceif no MSRP is available for the item)A6239Hydrocolloid dressing, wound cover, sterile, pad size more than MSRP documentation (or cost invoice48 sq in, with any size adhesive border, each dressingif no MSRP is available for the item)A6411Eye pad, nonsterile, eachMSRP documentation (or cost inv
Feb 12, 2021 · analgesia/anesthesia care Hysterectomy informed consent and acknowledgement statement 01966 Anesthesia for induced abortion procedures Physician/practitioner notes or operative report 01969 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition
IAS 36 – LỖ TỔN THẤT TÀI SẢN. xxx KHÔNG áp dụngcho Ápdụngcho x Hàng tồnkho (IAS 2) x . Tài sản tài chính (IFRS 9) x . Quyền lợi người lao động (IAS 19) x . Tài sản thuế hoãn lại (IAS 12) x . Hợp đồng xây dựng (IAS 11) x . Bất động s
DENTAL FEE SCHEDULE AND PROCEDURE CODES CDT 2016* REVISION February 2016 EFFECTIVE DATE January 1, 2016 *The CDT 2016 codes and nomenclature that follow have been obtained, or appears verbatim from the Current Dental Terminology (CDT) 2016 Dental Procedure Codes (including procedure codes, definitions, and other data contained therein .
PROCEDURE CODES CDT 2014 - 2015* REVISION July 2014 *The CDT 2014 - 2015 codes and nomenclature that follow have been obtained, or appears verbatim from the Current Dental Terminology (CDT) 2014 Dental Procedure Codes (including procedure codes, definitions, and other data contained therein); copyrighted by the American Dental Association .
Oct 01, 2015 · Conformed to FSC New Codes Added No new codes. Added a definition for R&D Stage 7, Commercialization, to the manual (the related codes are already in use in FPDS). 30 new codes to capture missing services. 1 code added to match FSC list. Codes End Dated None 12 ended codes (combined with existing codes). 39 codes which have been in use in FPDS but
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Telemental health services are considered face-to-face given that the client is visually present. Roll-Up Procedure Codes: DHCS only accepts a limited set of Procedure Codes. Los Angeles County Department of Mental Health “rolls-up” the Procedure Codes submitted by Providers
Nov 21, 2005 · 1.3 mak field codes for nonmilitary u.s. government weapons 1.4 mak field for foreign military weapons 1.5 mak field codes alphabetically by manufacturer 1.6 mak field codes alphabetically by code 2--caliber (cal) field codes 2.1 cal field codes 2.2 cal field codes for shotguns 3--type (typ)
4.1 rules for the consolidation of source codes from 2023 year of assessment 4 4.2 normal income codes 7 4.3 allowance codes 11 4.4 fringe benefit codes 17 4.5 lump sum codes 21 4.6 gross remuneration codes 25
