Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect

July 2015 Published in the August Network Update

Healthy Indiana Plan Chiropractic Code Set Anthem Blue Cross and Blue Shield (Anthem) chiropractic code set covered within each of the four new Healthy Indiana Plan (HIP) programs – HIP Plus, HIP Basic, HIP State Plan Plus and HIP State Plan Basic – has been updated and became effective February 1, 2015. HIP Plus and HIP Basic In accordance with the revision to LSA Document #07-648 (F) of the Indiana Check-Up Plan, HEA 1678 (2007) clarifies that chiropractors may provide services that are covered by the plan and within their scope of practice. Chiropractic benefits for spinal manipulations are NOT included in the HIP Plus or HIP Basic plan benefits; however, CPT codes in Tables 3, 4 and 5 and ICD codes in Table 6 are covered services in the HIP Plus and HIP Basic plans. All chiropractic services are covered for pregnant members in HIP Plus or HIP Basic during their pregnancy period. As a reminder, the HIP Basic plan has a $4 outpatient/office visit copayment due at the time of service. Member copayments may be found using Anthem’s Availity. HIP State Plan Plus and HIP State Plan Basic Chiropractic benefits are included in HIP State Plan Plus and HIP State Plan Basic and mirror the Indiana Medicaid coverage. Chiropractic services are covered for members who are pregnant or medically frail as part of their HIP State Plan benefits. Anthem limits reimbursement to a total of 50 treatments per member per calendar year. The 50 treatments can be a combination of office visits, spinal manipulation, or physical medicine treatments. However, Anthem limits office visits to five per year; up to five of the 50 units can be office visits. CPT codes in Tables 1 through 5 and ICD codes in Table 6 are covered in the HIP State Plans. Members do not need prior authorization and may self-refer for services provided by Anthem-contracted chiropractors. The HIP State Plan Basic has a $4 outpatient/office visit copayment due at the time of service. All HIP Plans Chiropractic services are a self-referred service in HIP, which means members may self-refer to any Indiana Health Coverage Programs (IHCP) enrolled chiropractor. Some covered services may require a www.anthem.com Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc., independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. AINPEC-0454-15 July 2015

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medical necessity determination through prior authorization. Contact the Anthem Utilization Management Department at for prior authorization requests. Providers must verify eligibility at the time of service using Web interChange or Anthem’s Availity before rendering services. Failure to verify eligibility could result in claim denials. Anthem encourages chiropractors to contract with Anthem for HIP. Providers interested in contracting can complete the provider maintenance form at www.anthem.com to request becoming part of the Anthem Medicaid and HIP provider networks.

TABLE 1: Non-Covered Chiropractic Office Manipulative Treatment (OMT) Codes CPT Code

Description

98925 98926 98927 98928 98929

OMT, one to two body regions Three to four body regions Five to six body regions Seven to eight body regions Nine to ten body regions

TABLE 2: Non-Covered Chiropractic Codes for Spinal Manipulations CPT Code

Description

98940 98941 98942 98943

Chiropractic manipulative treatment (CMT); spinal, one to two regions Chiropractic manipulative treatment (CMT); spinal, three to four regions Chiropractic manipulative treatment (CMT); spinal, five regions Chiropractic manipulative treatment (CMT); extraspinal, one or more regions

TABLE 3: Covered Chiropractic Codes for Office Visits CPT Code 99201

99202

Description Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

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99203

99211

99212

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

TABLE 4: Covered Chiropractic Codes for Physical Medicine CPT Code 99213

97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110

Description Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. Application of a modality to one or more areas; traction, mechanical Application of a modality to one or more areas; electrical stimulation (unattended) Application of a modality to one or more areas; vasopneumatic devices Application of a modality to one or more areas; paraffin bath Application of a modality to one or more areas; whirlpool Application of a modality to one or more areas; diathermy (e.g., microwave) Application of a modality to one or more areas; infrared Application of a modality to one or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to one or more areas; iontophoresis, each 15 minutes Application of a modality to one or more areas; contrast baths, each 15 minutes Application of a modality to one or more areas; ultrasound, each 15 minutes Application of a modality to one or more areas; Hubbard tank, each 15 minutes Unlisted modality (specify type and time if constant attendance) Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

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97112

97113 97116 97124 97139 97140

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; aquatic therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; gait training (includes stair climbing) Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility; massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) Unlisted therapeutic procedure (specify) therapeutic procedure, one or more areas, each 15 minutes; Manual therapy techniques (mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

TABLE 5: Covered Chiropractic Codes for Radiology CPT Code

Description

72010 72020 72040 72050 72052 72069 72070 72072 72074 72080 72090 72100 72110 72114

Radiologic examination, spine, entire, survey study, anteroposterior and lateral Radiologic examination, spine, single view, specify level Radiologic examination, spine, cervical; three views or less Radiologic examination, spine, cervical; four or five views Radiologic examination, spine, cervical; six or more views Radiologic examination, spine, thoracolumbar, standing (scoliosis) Radiologic examination, spine; thoracic, two views Radiologic examination, spine; thoracic, three views Radiologic examination, spine; thoracic, minimum of 4 four views Radiologic examination, spine; thoracolumbar, two views Radiologic examination, spine; scoliosis study, including supine and erect studies Radiologic examination, spine, lumbosacral; two or three views Radiologic examination, spine, lumbosacral; minimum of four views Radiologic examination, spine, lumbosacral; complete, including bending view, minimum of six views Radiologic examination, spine, lumbosacral; bending views only, two or three views Radiologic examination, pelvis; one or two views Radiologic examination, pelvis; complete, minimum of three views Radiologic examination, sacroiliac joints; less than three views Radiologic examination, sacroiliac joints; three or more views Radiologic examination, sacrum and coccyx, minimum of two views Radiologic examination; clavicle, complete Radiologic examination; scapula, complete Radiologic examination, shoulder; one view Radiologic examination, shoulder; complete, minimum of two views Radiologic examination; acromioclavicular joints, bilateral, with or without weighted

72120 72170 72190 72200 72202 72220 73000 73010 73020 73030 73050

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73060 73070 73080 73090 73100 73110 73120 73130 73140 73500 73510 73520 73550 73560 73562 73564 73565 73590 73600 73610 73620 73630 73650 73660

distraction Radiologic examination; humerus, minimum of two views Radiologic examination, elbow, two views Radiologic examination, elbow, complete, minimum of three views Radiologic examination; forearm, two views Radiologic examination, wrist; two views Radiologic examination, wrist; complete, minimum of three views Radiologic examination, hand; two views Radiologic examination, hand; minimum of three views Radiologic examination, finger(s), minimum of two views Radiologic examination, hip, unilateral; one view Radiologic examination, hip, complete, minimum of two views Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis Radiologic examination, femur, two views Radiologic examination, knee; one or two views Radiologic examination, knee; three views Radiologic examination, knee; complete, four or more views Radiologic examination, knee; both knees, standing, anteroposterior Radiologic examination; tibia and fibula, two views Radiologic examination, ankle; two views Radiologic examination, ankle; complete, minimum of three views Radiologic examination, foot; two views Radiologic examination, foot; complete, minimum of three views Radiologic examination; calcaneus, minimum of two views Radiologic examination, toe(s), minimum of two views

TABLE 6: ICD Covered Codes for Chiropractic Services Diagnosis Code 307.81 333.83 339.00 339.01 339.02 339.03 339.04 339.05 339.09 339.10 339.11 339.12 339.20 339.21 339.22

Description Tension headache Spasmodic torticollis Cluster headache syndrome, unspecified Episodic cluster headache Chronic cluster headache Episodic paroxysmal hemicrania Chronic paroxysmal hemicrania Short lasting unilateral neuralgiform headache with conjunctival injection and tearing Other trigeminal autonomic cephalgias Tension type headache, unspecified Episodic tension type headache Chronic tension type headache Post-traumatic headache, unspecified Acute post-traumatic headache Chronic post-traumatic headache

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339.89 346.00 346.01 346.02 346.03 346.10 346.11 346.12 346.13 346.20 346.21 346.22 346.23 346.30 346.31 346.32 346.33 346.40 346.41 346.42 346.43 346.50 346.51 346.52 346.53 346.70 346.71 346.72 346.73

Other specified headache syndromes Migraine with aura without mention of intractable migraine without mention of status migrainosus Migraine with aura with intractable migraine, so stated, without mention of status migrainosus Migraine with aura, without mention of intractable migraine, with status migrainosus Migraine with aura, with intractable migraine, so stated, with status migrainosus Migraine without aura without mention of intractable migraine without mention of status migrainosus Migraine without aura with intractable migraine, so stated, without mention of status migrainosus Migraine without aura, without mention of intractable migraine with status migrainosus Migraine without aura, with intractable migraine, so stated, with status migrainosus Variants of migraine, not elsewhere classified without mention of intractable migraine without mention of status migrainosus Variants of migraine, not elsewhere classified with intractable migraine, so stated, without mention of status migrainosus Variants of migraine, not elsewhere classified, without mention of intractable migraine with status migrainosus Variants of migraine, not elsewhere classified, with intractable migraine, so stated, with status migrainosus Hemiplegic migraine, without mention of intractable migraine without mention of status migrainosus Hemiplegic migraine, with intractable migraine, so stated, without mention of status migrainosus Hemiplegic migraine, without mention of intractable migraine with status migrainosus Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus Menstrual migraine, without mention of intractable migraine without mention of status migrainosus Menstrual migraine, with intractable migraine, so stated, without mention of status migrainosus Menstrual migraine, without mention of intractable migraine with status migrainosus Menstrual migraine, with intractable migraine, so stated, with status migrainosus Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status migrainosus Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus Persistent migraine aura without cerebral infarction, without mention of intractable migraine with status migrainosus Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, with status migrainosus Chronic migraine without aura, without mention of intractable migraine without mention of status migrainosus Chronic migraine without aura, with intractable migraine, so stated, without mention of status migrainosus Chronic migraine without aura, without mention of intractable migraine with status migrainosus Chronic migraine without aura, with intractable migraine, so stated, with status migrainosus

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346.80 346.81 346.82 346.83 346.90 346.91 346.92 346.93 353.0 353.1 353.2 353.3 353.4 353.6 353.8 353.9 354.4 354.8 354.9 355.71 355.79 355.8 646.93 648.73 648.93 719.40 719.41 719.42 719.43 719.44 719.45 719.46 719.47 719.48 719.49 720.0 720.1 721.0 721.1 721.2 721.3 721.41

Other forms of migraine without mention of intractable migraine without mention of status migrainosus Other forms of migraine with intractable migraine, so stated, without mention of status migrainosus Other forms of migraine, without mention of intractable migraine with status migrainosus Other forms of migraine, with intractable migraine, so stated, with status migrainosus Migraine, unspecified without mention of intractable migraine without mention of status migrainosus Migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus Migraine, unspecified, without mention of intractable migraine with status migrainosus Migraine, unspecified, with intractable migraine, so stated, with status migrainosus Brachial plexus lesions Lumbosacral plexus lesions Cervical root lesions, not elsewhere classified Thoracic root lesions, not elsewhere classified Lumbosacral root lesions, not elsewhere classified Phantom limb (syndrome) Other nerve root and plexus disorders Unspecified nerve root and plexus disorder Causalgia of upper limb Other mononeuritis of upper limb Mononeuritis of upper limb, unspecified Causalgia of lower limb Other mononeuritis of lower limb Mononeuritis of lower limb, unspecified Unspecified complication of pregnancy, antepartum Bone and joint disorders of maternal back, pelvis, and lower limbs, antepartum Other current maternal conditions classifiable elsewhere, antepartum Pain in joint, site unspecified Pain in joint, shoulder region Pain in joint, upper arm Pain in joint, forearm Pain in joint, hand Pain in joint, pelvic region and thigh Pain in joint, lower leg Pain in joint, ankle and foot Pain in joint, other specified site Pain in joint, multiple site Ankylosing spondylitis Spinal enthesopathy Cervical spondylosis without myelopathy Cervical spondylosis with myelopathy Thoracic spondylosis without myelopathy Lumbosacral spondylosis without myelopathy Thoracic or lumbar spondylosis with myelopathy; thoracic region

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721.42 721.5 721.6 721.7 721.90 721.91 722.0 722.10 722.11 722.2 722.30 722.31 722.32 722.4 722.51 722.52 722.6 722.80 722.81 722.82 722.83 722.90 722.91 722.92 722.93 723.0 723.1 723.2 723.3 723.4 723.5 723.8 723.9 724.00 724.01 724.02 724.09 724.1 724.2 724.3 724.4 724.5 724.6 724.70 724.79 724.8

Thoracic or lumbar spondylosis with myelopathy; lumbar region Kissing spine Ankylosing vertebral hyperostosis Traumatic spondylopathy Spondylosis of unspecified site; without mention of myelopathy Spondylosis of unspecified site; with myelopathy Displacement of cervical intervertebral disc without myelopathy Displacement of lumbar intervertebral disc without myelopathy Displacement of thoracic intervertebral disc without myelopathy Displacement of intervertebral disc, site unspecified, without myelopathy Schmorl’s nodes; unspecified region Schmorl’s nodes; thoracic region Schmorl’s nodes; lumbar region Degeneration of cervical intervertebral disc Degeneration of thoracic or thoracolumbar intervertebral disc Degeneration of lumbar or lumbosacral intervertebral disc Degeneration if intervertebral disc, site unspecified Postlaminectomy syndrome; unspecified region Postlaminectomy syndrome; cervical region Postlaminectomy syndrome; thoracic region Postlaminectomy syndrome; lumbar region Other and unspecified disc disorder; unspecified region Other and unspecified disc disorder; cervical region Other and unspecified disc disorder; thoracic region Other and unspecified disc disorder; lumbar region Spinal stenosis in cervical region Cervicalgia Cervicocranial syndrome Cervicobrachial syndrome (diffuse) Brachia neuritis or radiculitis, NOS Torticollis, unspecified Other syndromes affecting cervical region Unspecified musculoskeletal disorders and symptoms referable to neck Spinal stenosis, unspecified region Spinal stenosis, thoracic region Spinal stenosis, lumbar region, without neurogenic claudication Spinal stenosis, other Pain in thoracic spine Lumbago Sciatica Thoracic or lumbosacral neuritis or radiculitis, unspecified Backache, unspecified Disorders of sacrum Unspecified disorder of coccyx Disorders of coccyx, other Other symptoms referable to back, facet syndrome

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724.9 728.71 728.85 729.1 729.4 729.5 732.0 737.0 737.10 737.12 737.19 737.20 737.21 737.22 737.29 737.30 737.31 737.32 737.34 737.39 737.40 737.41 737.42 737.43 737.8 737.9 738.4 739.0 739.1 739.2 739.3 739.4 739.5 739.6 739.7 739.8 754.1 754.2 756.11 756.12 784.0 839.00 839.01 839.02 839.03 839.04

Other unspecified back disorders Plantar fascial fibromatosis Spasm of muscle Myalgia and myositis Fascilitis, unspecified Pain in limb Juvenile osteochondrosis of spine Adolescent postural kyphosis Kyphosis (acquired) (postural) Kyphosis, postlaminectomy Kyphosis, other Lordosis, (acquired) (postural) Lordosis, postlaminectomy Other postsurgical lordosis Lordosis (acquired) – Other Scoliosis (and kyphoscoliosis), idiopathic Resolving infantile idiopathic scoliosis Progressive infantile idiopathic scoliosis Thoracongenic scoliosis Kyphoscoliosis and scoliosis, other Curvature of spine associated with other conditions – Curvature of spine, unspecified Curvature of spine associated with other conditions – Kyphosis Curvature of spine associated with other conditions – Lordosis Curvature of spine associated with other conditions – Scoliosis Other curvatures of spine Unspecified curvature of spine Acquired spondylolisthesis Nonallopath lesion – Head Nonallopath lesion – Cervical Nonallopath lesion – Thoracic Nonallopath lesion – Lumbar Nonallopath lesion – Saral Nonallopath lesion – Pelvic Nonallopath lesion – Lower extremity Nonallopath lesion – Upper extremity Nonallopath lesion – Rib cage Certain congenital musculoskeletal deformities of sternocleidomastoid muscle Certain congenital musculoskeletal deformities of spine Spondylolysis, lumbrosacral region Spondylolisthesis Headache Cervical vertebra dislocation, closed – Cervical vertebra, unspecified Cervical vertebra dislocation, closed – First cervical vertebra Cervical vertebra dislocation, closed – Second cervical vertebra Cervical vertebra dislocation, closed – Third cervical vertebra Cervical vertebra dislocation, closed – Fourth cervical vertebra

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839.05 839.06 839.07 839.08 839.20 839.21 846.0 846.1 846.2 846.3 846.8 846.9 847.0 847.1 847.2 847.3 847.4 847.9 907.3 953.0 953.1 953.2 953.3 953.4 953.5 956.0 956.1 956.2 956.3 956.4 956.5 956.8 956.9

Cervical vertebra dislocation, closed – Fifth cervical vertebra Cervical vertebra dislocation, closed – Sixth cervical vertebra Cervical vertebra dislocation, closed – Seventh cervical vertebra Cervical vertebra dislocation, closed – Multiple cervical vertebra Lumbar vertebra dislocation, closed Thoracic vertebra dislocation, closed Sprains and strains of sacroiliac region, lumbosacral (joint) (ligament) Sprains and strains of sacroiliac region, sacroiliac ligament Sprains and strains of sacroiliac region, sacrospinatus (ligament) Sprains and strains of sacroiliac region, sacrotuberous (ligament) Sprains and strains of sacroiliac region, other specified sites of sacroiliac region Sprains and strains of sacroiliac region, unspecified site of sacroiliac region Sprains and strains of other and unspecified parts of back – Neck Sprains and strains of other and unspecified parts of back – Thoracic Sprains and strains of other and unspecified parts of back – Lumbar Sprains and strains of other and unspecified parts of back – Sacrum Sprains and strains of other and unspecified parts of back – Coccyx Sprains and strains of other and unspecified parts of back – Unspecified site of back Late effect of injury to nerve root(s), spinal plexus(es), and other nerves of trunk Injury to nerve roots and spinal plexus, cervical root Injury to nerve roots and spinal plexus, dorsal root Injury to nerve roots and spinal plexus, lumbar root Injury to nerve roots and spinal plexus, sacral root Injury to nerve roots and spinal plexus, brachial plexus Injury to nerve roots and spinal plexus, lumbrosacral plexus Injury to peripheral nerve(s) of pelvic girdle and lower limb, sciatic nerve Injury to peripheral nerve(s) of pelvic girdle and lower limb, femoral nerve Injury to peripheral nerve(s) of pelvic girdle and lower limb, posterior tibial nerve Injury to peripheral nerve(s) of pelvic girdle and lower limb, peroneal nerve Injury to peripheral nerve(s) of pelvic girdle and lower limb, cutaneous sensory nerve, lower limb Injury to peripheral nerve(s) of pelvic girdle and lower limb, other specified nerve(s) of pelvic girdle and lower limb Injury to peripheral nerve(s) of pelvic girdle and lower limb, multiple nerves of pelvic girdle and lower limb Injury to peripheral nerve(s) of pelvic girdle and lower limb, unspecified nerve of pelvic girdle and lower limb