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Medical Policy Manual - Indiana Medicaid Provider Home

Medical Policy Manual Version January 2018 List of Policy Modules Anesthesia Services Cardiac Rehabilitation Chiropractic Services Clinical Trials Dental Services Diabetes Self-Management Training Services Durable and Home Medical Equipment and Supplies Early and Periodic Screening Services Emergency Services Evaluation and Management Services Family Planning Services Federally Qualified Health Centers and Rural Health Clinics Genetic Testing Services Hearing Services Home Health Services Hospice Services Hospital Inpatient Services Hospital Outpatient Services Injections, Vaccines, and Other Physician Administered Drugs Laboratory Services Lead Services Mental Health and Addiction Services Obstetrical and Gynecological Services Oncology Services Out-of-State Services Podiatry Services Radiology Services Surgical Services Telehealth and Telemedicine Services Therapy Services Transplant Services Transportation Services Traumatic Brai

Anesthesia is defined as the loss of sensation resulting from pharmacologic depression of nerve function or from neurologic dysfunction. Additionally, anesthesia is a broad term for

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Transcription of Medical Policy Manual - Indiana Medicaid Provider Home

1 Medical Policy Manual Version January 2018 List of Policy Modules Anesthesia Services Cardiac Rehabilitation Chiropractic Services Clinical Trials Dental Services Diabetes Self-Management Training Services Durable and Home Medical Equipment and Supplies Early and Periodic Screening Services Emergency Services Evaluation and Management Services Family Planning Services Federally Qualified Health Centers and Rural Health Clinics Genetic Testing Services Hearing Services Home Health Services Hospice Services Hospital Inpatient Services Hospital Outpatient Services Injections, Vaccines, and Other Physician Administered Drugs Laboratory Services Lead Services Mental Health and Addiction Services Obstetrical and Gynecological Services Oncology Services Out-of-State Services Podiatry Services Radiology Services Surgical Services Telehealth and Telemedicine Services Therapy Services Transplant Services Transportation Services Traumatic Brain Injury Program Vision Services Anesthesia Services Last Update: January 1, 2017 Anesthesia Services Description of Service Anesthesia is defined as the loss of sensation resulting from pharmacologic depression of nerve function or from neurologic dysfunction.

2 Additionally, anesthesia is a broad term for anesthesiology as a clinical specialty. Anesthesia services may include, but are not limited to, general anesthesia, regional anesthesia, supplementation of local anesthesia, or other supportive services to give a patient the anesthesia care deemed optimal by the anesthesiologist to reduce or mitigate pain during a procedure. The services include the usual preoperative and postoperative visits, anesthesia care during the procedure, the administration of fluids and/or blood, and the usual monitoring services. For example, electrocardiogram (ECG), temperature, blood pressure, oximetry, capnography, and mass spectrometry.

3 Other monitoring services such as intra-arterial, central venous, and Swan-Ganz are not included. Medical Policy Regional or Selective Nerve Block Medical Direction IHCP reimbursement is available for Medical direction of a procedure involving an anesthetist only when the direction is by an anesthesiologist, and only when the anesthesiologist medically directs two, three, or four concurrent procedures involving qualified anesthetists. An anesthesiologist involved in medically directing more than one and up to four procedures may not be personally performing procedures at the same time. Criteria for Medical direction include the following: Ensure that only qualified people administer anesthesia.

4 Monitor anesthesia at frequent intervals. Participate in the most demanding portions of the procedures, including induction and emergence, if applicable. Perform the preoperative evaluation. Perform the postoperative evaluation. Prescribe an anesthesia plan. Remain immediately available and not perform other services. Anesthesia Services Last Update: January 1, 2017 Regional Anesthesia (Epidural, Nerve Block, Spinal) IHCP reimbursement is available for regional anesthesia or nerve blocks involving blocking nerve impulses with a local anesthetic, steroid, narcotic, or other agent. It is administered by a physician and requires special techniques and attention, especially during the initial phase of instituting the block.

5 Monitored Anesthesia IHCP reimbursement is available for monitored anesthesia when the service has been determined to be medically reasonable and necessary. Monitored anesthesia care (MAC) involves the intraoperative monitoring of a patient s vital signs in anticipation of the need to administer general anesthesia; or the development of adverse physiological patient reaction to the surgical procedure or anesthesia. MAC also includes the performance of a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessary oral or parenteral medications such as; Atropine, Demerol, or Valium, and the provision of indicated postoperative anesthesia care.

6 Postoperative Pain Management Services IHCP reimbursement is available for postoperative epidural catheter management services. Anesthesia for Obstetrical Services IHCP reimbursement is available for anesthesia during obstetrical services under the following conditions: General, regional, or epidural anesthesia administered by the same Provider who performs the surgical or obstetrical delivery procedure is not reimbursable, as it is included in the surgical delivery fee. Providers billing anesthesia services for vaginal or cesarean deliveries must use the appropriate anesthesia CPT codes. Anesthesia for Dental Services For information on anesthesia for dental services, please refer to the Dental Services Policy Module.

7 Prior Authorization Prior authorization is not required for anesthesia services. For information on anesthesia for dental services, please refer to the Dental Services Policy module. Anesthesia Services Last Update: January 1, 2017 Billing and Coding For further billing information, see the Anesthesia Services Provider reference module. For a list of billing codes, see the Anesthesia Services Codes on the Code Sets/Tables webpage. Rules and Citations 405 IAC 5 IHCP Provider Bulletins IHCP Provider Banners Note: For the most updated information regarding the Provider Reference Materials, Bulletins, and Banners, please visit Update History January 1, 2017 Initial Publication Cardiac Rehabilitation Last Updated: January 1, 2017 Cardiac Rehabilitation Description of Service Progressive exercise programs have demonstrated benefit in the management and rehabilitation of individuals with cardiac disease, especially following certain cardiac events.

8 Cardiac rehabilitation programs are typically divided into three stages. The initial stage (Phase I) involves the most intensive supervision and occurs in an inpatient setting. A Phase I program is typically initiated during the acute convalescent period following a cardiac event. The second stage (Phase II) begins with an overall treatment plan, including a physician s prescription for progressive exercise based on the individual s clinical status and physical capacity. Phase II programs incorporate close monitoring and individualized progressive increases in the intensity of physical activity, as well as lifestyle changes, such as dietary modifications and smoking cessation.

9 Phase II exercise programs for cardiac patients may be conducted in specialized, freestanding, cardiac rehabilitation clinics, as well as in outpatient hospital departments. The third stage (Phase III) is an ongoing maintenance period consisting of continued lifestyle changes and aerobic exercise. All phases of cardiac rehabilitation programs include individualized exercises and behavior-change therapy with the intention of returning the patient to an active life with minimized symptoms. Medical Policy Required Components The IHCP provides reimbursement for comprehensive cardiac rehabilitation programs. Cardiac rehabilitation requires that specific components be included in the rehabilitation program.

10 Required components include: Medical evaluation A program to modify cardiac risk factors ( , nutritional counseling, assessing smoking status, history and control of diabetes or hypertension, lipid management, weight management, and any psychosocial interventions such as depression screening) Prescribed exercise Education Counseling Under the direct supervision of a physician Phase I Phase I reimbursement is included in the inpatient diagnosis related group (DRG); therefore, IHCP does not provide separate reimbursement for Phase I. Cardiac Rehabilitation Last Updated: January 1, 2017 Phase II IHCP reimbursement is available for cardiac rehabilitation services for Phase II when considered medically reasonable and necessary.


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