405 Ind. Admin. Code 5-26-9

Current through October 31, 2024

Section 405 IAC 5-26-9 - Surgical procedures; reimbursement

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3

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

Sec. 9.

(a) All surgical procedures on one (1) foot or both feet performed on the same date will be paid at one hundred percent (100%) of the Medicaid allowance for the major procedure and fifty percent (50%) of the Medicaid allowance for subsequent procedures.

(b) If the surgery is performed on both feet, and if the surgery on the second foot is performed at least five (5) days following surgery on the first foot, one hundred percent (100%) allowance is payable for the second surgery.

(c) If the major surgical procedure is performed on one (1) foot, a time period of five (5) days must elapse before subsequent surgery on the same foot would again be paid at one hundred percent (100%) of Medicaid allowable reimbursement. Surgery performed sooner than five (5) days will be paid at fifty percent (50%) of Medicaid allowable reimbursement.

(d) If the major surgical procedure is performed on one (1) toe, a time period of thirty (30) days must elapse before subsequent surgery on the same toe would again be paid at one hundred percent (100%) of Medicaid allowable reimbursement. Surgery performed sooner than thirty (30) days will be reimbursed at fifty percent (50%) of Medicaid allowable reimbursement.

(e) Podiatric surgical procedures, including diagnostic surgical procedures, cannot be fragmented and billed separately. Such procedures generally are included in the major procedure. Such procedures may include, but are not limited to, the following:

(1) Scope procedures used for the surgical procedure approach.

(2) Arthroscopy or arthrotomy procedures in the same area as a major joint procedure unless claim documents a second incision was made.

(3) Local anesthesia administered to perform the surgical or diagnostic procedure.

405 IAC 5-26-9

Office ofthe Secretary of Family and Social Services; 405 IAC 5-26-9; filed Jul 25, 1997, 4:00p. m.: 20 IR 3350; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA

Readopted filed 11/13/2019, 11:54 a.m.: 20191211-IR-405190487RFA

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