Anthem Medicaid s Medical Necessity Code List

Transcription

1 Serving Hoosier Healthwise, Healthy Indiana Plan And Hoosier Care Connect Anthem Medicaid s Medical Necessity Code List DX Codes DX Description 042 Human Immunodeficiency Virus [HIV] 277.0x Cystic Fibrosis 282.xx 283.xx 284.xx Hereditary Hemolytic Anemias Acquired Hemolytic Anemias Aplastic Anemias Sideroblastic Anemia Coagulation Defects Qualitative Platelet Defects Immune Thrombocytopenic Purpura (ITP) Evans' syndrome Congenital and hereditary thrombocytopenic purpura Congenital neutropenia Functional disorders of polymorphonuclear neutrophils Genetic anomalies of leukocytes Eosinophilia Hemophagocytic syndromes Hypersplenism Chronic congestive splenomegaly Splenic sequestration Neutropenic splenomegaly Familial polycythemia Methemoglobinemia Primary hypercoagulable state 416.xx Chronic Pulmonary Heart Disease Thrombotic Thrombocytopenic Purpura (TTP) 491.xx 492.xx 493.xx 494.xx 496.xx Chronic Bronchitis Emphysema Asthma Bronchiectasis Chronic airway obstruction, not elsewhere classified Postinflammatory pulmonary fibrosis Idiopathic pulmonary fibrosis Regional enteritis of small intestine 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 May 2014

2 Page 2 of Regional enteritis of large intestine Regional enteritis of small intestine with large intestine Regional enteritis of unspecified site Unspecified ulcerative colitis Gastroenteritis and colitis due to radiation Toxic gastroenteritis and colitis Hemorrhage of gastrointestinal tract, unspecified Placenta previa without hemorrhage, unspecified as to episode of care Placenta previa without hemorrhage, with delivery Hemorrhage from placenta previa, unspecified as to episode of care Hemorrhage from placenta previa, with delivery Premature separation of placenta, unspecified as to episode of care Premature separation of placenta, with delivery Antepartum hemorrhage associated with coagulation defects, unspecified as to episode of care Antepartum hemorrhage associated with coagulation defects, with delivery Other antepartum hemorrhage, unspecified as to episode of care Other antepartum hemorrhage, with delivery Unspecified antepartum hemorrhage, unspecified as to episode of care Unspecified antepartum hemorrhage, with delivery Benign essential hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care Benign essential hypertension with delivery Benign essential hypertension, with delivery, with current postpartum complication Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care Hypertension secondary to renal disease, with delivery Hypertension secondary to renal disease, with delivery, with current postpartum complication Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care Other pre-existing hypertension, with delivery Other pre-existing hypertension, with delivery, with current postpartum complication Transient hypertension of pregnancy, unspecified as to episode of care Transient hypertension of pregnancy, with delivery Transient hypertension of pregnancy, with delivery, with current postpartum complication Mild or unspecified pre-eclampsia, with delivery, with current postpartum complication Mild or unspecified pre-eclampsia, unspecified as to episode of care Mild or unspecified pre-eclampsia, with delivery Mild or unspecified pre-eclampsia, with delivery, with current postpartum complication Severe pre-eclampsia, unspecified as to episode of care Severe pre-eclampsia, with delivery Severe pre-eclampsia, with delivery, with current postpartum complication

3 Page 3 of Eclampsia complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care Eclampsia, with delivery Eclampsia, with delivery, with current postpartum complication Pre-eclampsia or eclampsia superimposed on preexisting hypertension, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery, with current postpartum complicatio Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care Unspecified hypertension, with delivery Unspecified hypertension, with delivery, with current postpartum complication Unspecified renal disease in pregnancy, with delivery Unspecified renal disease in pregnancy, with delivery, with current postpartum complication Liver and biliary tract disorders in pregnancy, delivered, with or without mention of antepartum condition Maternal diabetes mellitus with delivery Maternal congenital cardiovascular disorders, with delivery Maternal congenital cardiovascular disorders, with delivery, with current postpartum complication Other maternal cardiovascular diseases, with delivery Other maternal cardiovascular diseases, with delivery, with current postpartum complication Abnormal glucose tolerance of mother, unspecified as to episode of care or not Abnormal maternal glucose tolerance, with delivery Abnormal maternal glucose tolerance, with delivery, with current postpartum complication Coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepar Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complic Epilepsy complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication Twin pregnancy, unspecified as to episode of care Twin pregnancy, delivered Triplet pregnancy, unspecified as to episode of care Triplet pregnancy, delivered Quadruplet pregnancy, unspecified as to episode of care Quadruplet pregnancy, delivered Twin pregnancy with fetal loss and retention of one fetus, unspecified as to episode of care or not Twin pregnancy with fetal loss and retention of one fetus, delivered

4 Page 4 of Triplet pregnancy with fetal loss and retention of one or more, unspecified as to episode of care or not Triplet pregnancy with fetal loss and retention of one or more, delivered Quadruplet pregnancy with fetal loss and retention of one or more, unspecified as to episode of care or not Quadruplet pregnancy with fetal loss and retention of one or more, delivered Other multiple pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not Other multiple pregnancy with fetal loss and retention of one or more fetus(es), delivered Multiple gestation following (elective) fetal reduction, unspecified as to episode of care or not Multiple gestation following (elective) fetal reduction, delivered, with or without mention of antepartum condition Other specified multiple gestation, unspecified as to episode of care Other specified multiple gestation, delivered Unspecified multiple gestation, unspecified as to episode of care Unspecified multiple gestation, delivered Unstable lie of fetus, delivered Multiple gestation with malpresentation of one fetus or more, delivered Central nervous system malformation in fetus, with delivery Chromosomal abnormality in fetus, affecting management of mother, with delivery Suspected damage to fetus from viral disease in mother, affecting management of mother, with delivery Suspected damage to fetus from other disease in mother, affecting management of mother, with delivery Suspected damage to fetus from drugs, affecting management of mother, delivered Suspected damage to fetus from radiation, affecting management of mother, delivered Other known or suspected fetal abnormality, not elsewhere classified, affecting management of mother, delivery Fetal-maternal hemorrhage, unspecified as to episode of care or not Fetal-maternal hemorrhage, with delivery Rhesus isoimmunization affecting management of mother, delivered Isoimmunization from other and unspecified blood-group incompatibility, affecting management of mother, delivered Fetal distress, affecting management of mother, unspecified as to episode of care or not Fetal distress affecting management of mother, delivered Intrauterine death affecting management of mother, delivered Poor fetal growth, affecting management of mother, delivered Polyhydramnios, unspecified as to episode of care Polyhydramnios, with delivery Oligohydramnios, delivered Premature rupture of membranes, unspecified as to episode of care or not Premature rupture of membranes in pregnancy, delivered

5 Delayed delivery after spontaneous or unspecified rupture of membranes, delivered Infection of amniotic cavity, unspecified as to episode of care or not Infection of amniotic cavity, delivered Anthem Blue Cross and Blue Shield Page 5 of Abnormality in fetal heart rate or rhythm, delivered, with or without mention of antepartum condition Vasa previa complicating labor and delivery Vasa previa complicating labor and delivery, delivered Fetus or newborn affected by maternal death Chorioamnionitis V08 Asymptomatic Human Immunodeficiency Virus (HIV) infection status V23.5 Pregnancy with other poor reproductive history V27.1 Outcome of delivery, single stillborn