405 IAC 5-28-1 - Reimbursement limitations

Current through March 30, 2022

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. 1.

(a) All levels of medical care, prior to surgical procedures, will be reimbursed on an individual basis based on documentation of the member's medical condition. All levels of preoperative and postoperative care will be based on criteria set out in this rule.
(b) If the surgeon is doing the surgery only, and not the routine preoperative and postoperative care, this information must be indicated on the surgeon's claim form.
(c) If the primary care physician is rendering the preoperative or postoperative care only, this information must be indicated on the claim form and the name and address of the operating surgeon.
(d) If the member's condition requires additional medical or surgical care outside the scope of the operating surgeon, then reimbursement for medical components will be considered on an individual basis.
(e) Medical visits made for surgical complications may be reimbursed only if medically indicated and no other physician has billed for the same or related diagnosis. The claim must indicate the specific complications. These medical visits are billed separately from the surgical fee.
(f) If visits are made for treatment of a condition other than the surgery related diagnosis and no other physician has billed for the same or related diagnosis, then these visits are billed separately from the surgical fee. Associated medical care for denied surgical procedures will also be denied.
(g) When two (2) or more covered surgical procedures are done during the same operative session, multiple surgery reductions shall apply to the procedures based on the following adjustments:
(1) One hundred percent (100%) of the global fee for the most expensive procedure.
(2) Fifty percent (50%) of the global fee for the second most expensive procedure.
(3) Twenty-five percent (25%) of the global fee for the remaining procedures.
(h) Surgical procedures, including diagnostic surgical procedures, may not be fragmented and billed separately. Such procedures are generally included in the major procedure. Such procedures may include, but are not limited to, the following:
(1) Exploratory laparotomy when done with an intra-abdominal procedure.
(2) Scope procedures used for the surgical procedure approach.
(3) Arthroscopy/arthrotomy procedures in the same area as a major joint procedure unless claim documents a second incision was made.
(4) Local anesthesia administered to perform the surgical/diagnostic procedure.
(5) Pelvic exam under anesthesia when performed during the same operative session as vaginal procedure, dilation and curettage (D&C), and laparoscopy procedures.
(i) A surgical procedure generally includes the preoperative visits performed on the same day or the day prior to the surgery for major surgical procedures, and the day of the surgical procedure for minor surgical procedures. Separate reimbursement is available for preoperative care when the member has never been seen by the provider performing the surgery, or the decision to perform surgery was made during the preoperative visit. The postoperative care days for a surgical procedure include ninety (90) days following a major surgical procedure and ten (10) days following a minor surgical procedure. Separate reimbursement is available for care provided during the global postoperative period that is unrelated to the surgical procedure, or for care rendered that is not considered routine postoperative care for the surgical condition, such as complications.
(j) Prior authorization is required for all procedures as listed in 405 IAC 5-17-2.


405 IAC 5-28-1
Office ofthe Secretary of Family and Social Services; 405 IAC 5-28-1; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3352; 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 Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA

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