405 Ind. Admin. Code 5-1-5

Current through October 31, 2024

Section 405 IAC 5-1-5 - Global fee billing; codes

Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2

Affected: IC 12-13-7-3; IC 12-15

Sec. 5.

(a) Providers must submit one (1) billing for a related group of procedures and services provided to a member.

(b) The Centers for Medicare and Medicaid Service's Common Procedure Coding System (HCPCS) and International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) codes shall be used by providers when submitting medical claims to the contractor for adjudication. American Dental Association codes from the Current Dental Terminology Users Manual shall be used by providers when submitting dental claims to the contractor for adjudication. Providers must use the most up-to-date versions of these coding classifications.

(c) Medicaid claims filed by pharmacy providers on the drug claim form/format must utilize an appropriately configured National Drug Code (NDC), Universal Package Code (UPC), Health Related Item Code (HRI), or state-assigned code. When services are billed that have been prior authorized, the procedure code from the prior authorization form shall be utilized. On UB-04 forms, use the appropriate UB-04 Revenue Codes, as well as the narrative descriptions of services, and the appropriate diagnostic and procedure code contained in ICD-10-CM.

(d) Documentation in the medical records maintained by the provider must substantiate that the procedure or service is medically necessary and the code selected or description given by the provider. This is subject to postpayment audit and review.

405 IAC 5-1-5

Office of the Secretary of Family and Social Services; 405 IAC 5-1-5; filed Jul 25, 1997, 4:00p.m.: 20 IR 3300; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Feb 14, 2005, 10:25 a.m.: 28 IR 2131; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA

Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA

Errata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACA

Readopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFA

Errata filed 5/11/2023, 1:06 p.m.: 20230517-IR-405230393ACA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA