Anthem Central Region Clinical Claims Edit

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1 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Generation or Automated Data, Testing and Supplies with Ambulance Services Edit #: 533 Effective Date: 10/22/ /31/2099 Status: Current Last Review Date: 9/15/2005 Edit or (Generation of automated data; interactive process involving nuclear physician and/or allied health professional personnel; simple or complex manipulations and interpretations, 30 or more minutes); (Vital capacity, total); 94760, or (Noninvasive ear or pulse oximetry for oxygen saturation; single, multiple determinations or by continuous overnight monitoring); A0382 (BLS routine disposable supplies); A0384 (BLS specialized service disposable supplies; defibrillation {used by ALS ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulance}); A0392 (ALS specialized service disposable supplies; defibrillation {to be used only in jurisdictions where defibrillation cannot be performed by BLS}), A0394 (ALS specialized service disposable supplies; IV drug therapy); A0396 (ALS specialized service disposable supplies; esophageal intubation); A0398 (ALS routine disposable supplies); A0420 (Ambulance waiting time {ALS or BLS}, one half hour increments); A0422 (Ambulance {ALS or BLS} oxygen and oxygen supplies, life sustaining situation); A4206 (Syringe with needle, sterile 1 cc, each); A4207 (Syringe with needle, sterile 2 cc, each); A4208 (Syringe with needle, sterile 3 cc, each); A4209 (Syringe with needle, sterile 5 cc or greater, each); A4213 (Syringe, sterile, 20 cc or greater, each); A4215 (Needles only, sterile, any size, each); A4222 (Infusion supplies for external drug infusion pump, per cassette or bag); A4322 (Irrigation syringe, bulb or piston, each); A4554 (Disposable underpads, all sizes {e.g., chux s}); A4556 (Electrodes {e.g., apnea monitor}, per pair); A4558 (Conductive paste or gel); A4565 (Slings); A4570 (Splint); A4615 (Cannula, nasal); A4616 (Tubing {oxygen}, per foot); A4617 (Mouthpiece); A4620 (Variable concentration mask); A4623 (Tracheostomy, inner cannula); A4624 (Tracheal suction catheter, any type other than closed system, each); A4628 (Oropharyngeal suction catheter, each); A4649 (Surgical supply; miscellaneous); A4860 (Disposable catheter tips for peritoneal dialysis); A4927 (Gloves, non-sterile, per 100); A6216 (Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each); A6219 (Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing); A6257 (Transparent film, 16 sq. in. or less, each); A7000 (Canister, disposable, used with suction pump); A9901 (DME delivery, set up, and/or dispensing service component of another HCPCS code); J0210 (Injection, methyldopate HCL, up to 250 mg); J0280 (Injection, aminophylline, up to 250 mg); J0300 (Injection, amobarbital, up to 125 mg); J0360 (Injection, hydralazine HCL, up to 20 mg); Page 1 of 5

2 J0460 (Injection, atropine sulfate, up to 0.3 mg); J0475 (Injection, baclofen, 10 mg); J0610 (Injection, calcium gluconate, per 10 ml); J1160 (Injection, digoxin, up to 0.5 mg); J1165 (Injection, phenytoin sodium, per 50 mg); J1170 (Injection, hydromorphone, up to 4 mg); J1200 (Injection, diphenhydramine HCL, up to 50 mg); J 1240 (Injection, dimenhydrinate, up to 50 mg); J1245 (Injection, dipyridamole, per 10 mg); J1250 (Injection, dobutamine HCL. Per 250 mg); J1700 (Injection, hydrocortisone acetate, up to 25 mg); J1710 (Injection, hydrocortisone sodium phosphate, up to 50 mg); J1720 (Injection, hydrocortisone sodium succinate, up to 100 mg); J1730 (Injection, diazoxide, up to 300 mg); J1800 (Injection, propranolol HCL, up 1 mg); J1885 (Injection, ketorolac tromethamine, per 15 mg); J1940 (Injection, furosemide, up to 20 mg); J2060 (Injection, lorazepam, 2 mg); J2150 (Injection, mannitol, 25% in 50 ml); J2175 (Injection, meperidine HCL, per 100 mg); J2270 (Injection, morphine sulfate, up to 10 mg); J2271 (Injection, morphine sulfate, 100 mg); J2300 (Injection, nalbuphine HCL, per 10 mg); J2515 (Injection, pentobarbital sodium, per 50 mg); J2560 (Injection, Phenobarbital sodium, up to 120 mg); J2690 (Injection, procainamide HCL, up to 1 g); J2765 (Injection, metoclopramide HCL, up to 10 mg); J2780 (Injection, ranitidine HCL, 25 mg); J2810 (Injection, theophylline, per 40 mg); J3070 (Injection, pentazocine, 30 mg); J3230 (Injection, chlorpromazine HCL, up to 50 mg); J3280 (Injection, thiethylperazine maleate, up to 10 mg); J3360 (Injection, diazepam, up to 5 mg); J3410 (Injection, hydroxyzine HCL, up to 25 mg); J3480 (Injection, potassium chloride, per 2 mg); J7030 (Infusion, normal saline solution, 1,000 cc) bundles with A0225 (Ambulance service, neonatal transport, base rate, emergency transport, one way); A0426 (Ambulance service, advanced life support, non-emergency); A0427 (Ambulance service advanced life support, emergency transport, level 1 {ALS 1-emergency}); A0428 (Ambulance service, basic life support, non-emergency transport {BLS}); A0429 (Ambulance service, basic life support, emergency transport {BLS-emergency}); A0430 (Ambulance service, conventional air services, transport, one way {fixed wing}); A0431 (Ambulance service, conventional air services, transport, one way {rotary wing}); A0432 (Paramedic intercept {PI}, rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers); A0433 (Advanced life support, level 2 {ALS 2}), A0434 (Specialty care transport {SCT}), Q3019 (ALS vehicle used, emergency transport, no ALS level services furnished) and Q3020 (ALS vehicle used, non-emergency transport, no ALS level service furnished). CODE RULE CODE A0382 A0384 A0392 Incidental A0225 A0426 A0427 A0428 A0429 A0430 A0431 A0432 A0433 Page 2 of 5

3 A0394 A0396 A0398 A0420 A0422 A4206 A4207 A4208 A4209 A4213 A4215 A4222 A4322 A4554 A4556 A4558 A4565 A4570 A4615 A4616 A4617 A4620 A4623 A4624 A4628 A4649 A4860 A4927 A6216 A6219 A6257 A7000 A9901 J0210 J0280 J0300 J0360 J0460 J0475 J0610 J1160 A0434 Q3019 Q3020 Page 3 of 5

4 J1165 J1170 J1200 J1240 J1245 J1250 J1700 J1710 J1720 J1730 J1800 J1885 J1940 J2060 J2150 J2175 J2270 J2271 J2300 J2515 J2560 J2690 J2765 J2780 J2810 J3070 J3230 J3280 J3360 J3410 J3480 J7030 Rationale for Edit: Anthem Central Region bundles , 94150, , A0382-A0384, A0392-A0422, A4206- A4209, A4213-A4215, A4222, A4322, A4554-A4556, A4558, A4565-A4570, A4615-A4617, A4620- A4624, A4628, A4649, A4860, A4927, A6216, A6219, A6257, A7000, J0210, J0280, J0300, J0360, J0460, J0475, J0610, J1160, J1165, J1170, J1200, J1240, J1245, J1250, J1700, J1710, J1720, J1730, J1800, J1885, J1940, J2060, J2150, J2175, J2270, J2271, J2300, J2515, J2560, J2690, J2765, J2780, Page 4 of 5

5 J2810, J3070, J3230, J3280, J3360, J3410, J3480 OR J7030 with A0225, A0425-A0434 or Q3019- Q3020. Anthem follows Medicare Claims Processing Manual, Chapter 15-Ambulance, General following Method #2: Payment for items and services is included in the fee scheduled payment. Such items and services include but are not limited to oxygen, drugs, extra attendants, and EKG testing- Therefore if bundles , 94150, , A0382-A0384, A0392-A0422, A4206-A4209, A4213-A4215, A4222, A4322, A4554-A4556, A4558, A4565-A4570, A4615-A4617, A4620-A4624, A4628, A4649, A4860, A4927, A6216, A6219, A6257, A7000, J0210, J0280, J0300, J0360, J0460, J0475, J0610, J1160, J1165, J1170, J1200, J1240, J1245, J1250, J1700, J1710, J1720, J1730, J1800, J1885, J1940, J2060, J2150, J2175, J2270, J2271, J2300, J2515, J2560, J2690, J2765, J2780, J2810, J3070, J3230, J3280, J3360, J3410, J3480 or J7030 with A0225, A0425-A0434 or Q3019-Q3020 only the ambulance service reimburses (A0225, A0425-A0434 or Q3019-Q3020). Reference Information: 1. Medicare Claims Processing Manual-Chapter 15-Ambulance, 10.2-Billing Methods (Rev ) 2. Medicare Claims Processing Manual-Chapter 15-Ambulance, General (Rev ) Page 5 of 5

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