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 285.0 Sideroblastic Anemia 286.0-286.7 Coagulation Defects 287.1 Qualitative Platelet Defects 287.31 Immune Thrombocytopenic Purpura (ITP) 287.32 Evans' syndrome 287.33 Congenital and hereditary thrombocytopenic purpura 288.01 Congenital neutropenia 288.1 Functional disorders of polymorphonuclear neutrophils 288.2 Genetic anomalies of leukocytes 288.3 Eosinophilia 288.4 Hemophagocytic syndromes 289.4 Hypersplenism 289.51 Chronic congestive splenomegaly 289.52 Splenic sequestration 289.53 Neutropenic splenomegaly 289.6 Familial polycythemia 289.7 Methemoglobinemia 289.81 Primary hypercoagulable state 416.xx Chronic Pulmonary Heart Disease 446.6 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 515.00 Postinflammatory pulmonary fibrosis 516.31 Idiopathic pulmonary fibrosis 555.00 Regional enteritis of small intestine 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-0047-14 May 2014
Page 2 of 5 555.10 Regional enteritis of large intestine 555.20 Regional enteritis of small intestine with large intestine 555.90 Regional enteritis of unspecified site 556.90 Unspecified ulcerative colitis 558.10 Gastroenteritis and colitis due to radiation 558.20 Toxic gastroenteritis and colitis 578.90 Hemorrhage of gastrointestinal tract, unspecified 641.00 Placenta previa without hemorrhage, unspecified as to episode of care 641.01 Placenta previa without hemorrhage, with delivery 641.10 Hemorrhage from placenta previa, unspecified as to episode of care 641.11 Hemorrhage from placenta previa, with delivery 641.20 Premature separation of placenta, unspecified as to episode of care 641.21 Premature separation of placenta, with delivery 641.30 Antepartum hemorrhage associated with coagulation defects, unspecified as to episode of care 641.31 Antepartum hemorrhage associated with coagulation defects, with delivery 641.80 Other antepartum hemorrhage, unspecified as to episode of care 641.81 Other antepartum hemorrhage, with delivery 641.90 Unspecified antepartum hemorrhage, unspecified as to episode of care 641.91 Unspecified antepartum hemorrhage, with delivery 642.00 Benign essential hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care 642.01 Benign essential hypertension with delivery 642.02 Benign essential hypertension, with delivery, with current postpartum complication 642.10 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care 642.11 Hypertension secondary to renal disease, with delivery 642.12 Hypertension secondary to renal disease, with delivery, with current postpartum complication 642.20 Other pre-existing hypertension complicating pregnancy, childbirth, and the puerperium, unspecified as to episode of care 642.21 Other pre-existing hypertension, with delivery 642.22 Other pre-existing hypertension, with delivery, with current postpartum complication 642.30 Transient hypertension of pregnancy, unspecified as to episode of care 642.31 Transient hypertension of pregnancy, with delivery 642.32 Transient hypertension of pregnancy, with delivery, with current postpartum complication 642.34 Mild or unspecified pre-eclampsia, with delivery, with current postpartum complication 642.40 Mild or unspecified pre-eclampsia, unspecified as to episode of care 642.41 Mild or unspecified pre-eclampsia, with delivery 642.42 Mild or unspecified pre-eclampsia, with delivery, with current postpartum complication 642.50 Severe pre-eclampsia, unspecified as to episode of care 642.51 Severe pre-eclampsia, with delivery 642.52 Severe pre-eclampsia, with delivery, with current postpartum complication
Page 3 of 5 642.60 Eclampsia complicating pregnancy, childbirth or the puerperium, unspecified as to episode of care 642.61 Eclampsia, with delivery 642.62 Eclampsia, with delivery, with current postpartum complication 642.70 Pre-eclampsia or eclampsia superimposed on preexisting hypertension, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care 642.71 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery 642.72 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension, with delivery, with current postpartum complicatio 642.90 Unspecified hypertension complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care 642.91 Unspecified hypertension, with delivery 642.92 Unspecified hypertension, with delivery, with current postpartum complication 646.21 Unspecified renal disease in pregnancy, with delivery 646.22 Unspecified renal disease in pregnancy, with delivery, with current postpartum complication 646.71 Liver and biliary tract disorders in pregnancy, delivered, with or without mention of antepartum condition 648.01 Maternal diabetes mellitus with delivery 648.51 Maternal congenital cardiovascular disorders, with delivery 648.52 Maternal congenital cardiovascular disorders, with delivery, with current postpartum complication 648.61 Other maternal cardiovascular diseases, with delivery 648.62 Other maternal cardiovascular diseases, with delivery, with current postpartum complication 648.80 Abnormal glucose tolerance of mother, unspecified as to episode of care or not 648.81 Abnormal maternal glucose tolerance, with delivery 648.82 Abnormal maternal glucose tolerance, with delivery, with current postpartum complication 649.30 Coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not 649.31 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepar 649.32 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complic 649.40 Epilepsy complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not 649.41 Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 649.42 Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 651.00 Twin pregnancy, unspecified as to episode of care 651.01 Twin pregnancy, delivered 651.10 Triplet pregnancy, unspecified as to episode of care 651.11 Triplet pregnancy, delivered 651.20 Quadruplet pregnancy, unspecified as to episode of care 651.21 Quadruplet pregnancy, delivered 651.30 Twin pregnancy with fetal loss and retention of one fetus, unspecified as to episode of care or not 651.31 Twin pregnancy with fetal loss and retention of one fetus, delivered
Page 4 of 5 651.40 Triplet pregnancy with fetal loss and retention of one or more, unspecified as to episode of care or not 651.41 Triplet pregnancy with fetal loss and retention of one or more, delivered 651.50 Quadruplet pregnancy with fetal loss and retention of one or more, unspecified as to episode of care or not 651.51 Quadruplet pregnancy with fetal loss and retention of one or more, delivered 651.60 Other multiple pregnancy with fetal loss and retention of one or more fetus(es), unspecified as to episode of care or not 651.61 Other multiple pregnancy with fetal loss and retention of one or more fetus(es), delivered 651.70 Multiple gestation following (elective) fetal reduction, unspecified as to episode of care or not 651.71 Multiple gestation following (elective) fetal reduction, delivered, with or without mention of antepartum condition 651.80 Other specified multiple gestation, unspecified as to episode of care 651.81 Other specified multiple gestation, delivered 651.90 Unspecified multiple gestation, unspecified as to episode of care 651.91 Unspecified multiple gestation, delivered 652.01 Unstable lie of fetus, delivered 652.61 Multiple gestation with malpresentation of one fetus or more, delivered 655.01 Central nervous system malformation in fetus, with delivery 655.11 Chromosomal abnormality in fetus, affecting management of mother, with delivery 655.31 Suspected damage to fetus from viral disease in mother, affecting management of mother, with delivery 655.41 Suspected damage to fetus from other disease in mother, affecting management of mother, with delivery 655.51 Suspected damage to fetus from drugs, affecting management of mother, delivered 655.61 Suspected damage to fetus from radiation, affecting management of mother, delivered 655.81 Other known or suspected fetal abnormality, not elsewhere classified, affecting management of mother, delivery 656.00 Fetal-maternal hemorrhage, unspecified as to episode of care or not 656.01 Fetal-maternal hemorrhage, with delivery 656.11 Rhesus isoimmunization affecting management of mother, delivered 656.21 Isoimmunization from other and unspecified blood-group incompatibility, affecting management of mother, delivered 656.30 Fetal distress, affecting management of mother, unspecified as to episode of care or not 656.31 Fetal distress affecting management of mother, delivered 656.41 Intrauterine death affecting management of mother, delivered 656.51 Poor fetal growth, affecting management of mother, delivered 657.00 Polyhydramnios, unspecified as to episode of care 657.01 Polyhydramnios, with delivery 658.01 Oligohydramnios, delivered 658.10 Premature rupture of membranes, unspecified as to episode of care or not 658.11 Premature rupture of membranes in pregnancy, delivered
658.21 Delayed delivery after spontaneous or unspecified rupture of membranes, delivered 658.40 Infection of amniotic cavity, unspecified as to episode of care or not 658.41 Infection of amniotic cavity, delivered Anthem Blue Cross and Blue Shield Page 5 of 5 659.71 Abnormality in fetal heart rate or rhythm, delivered, with or without mention of antepartum condition 663.50 Vasa previa complicating labor and delivery 663.51 Vasa previa complicating labor and delivery, delivered 761.60 Fetus or newborn affected by maternal death 762.70 Chorioamnionitis V08 Asymptomatic Human Immunodeficiency Virus (HIV) infection status V23.5 Pregnancy with other poor reproductive history V27.1 Outcome of delivery, single stillborn