ICD -10 Elective C-Section Coverage Table
Iowa Legislature mandated that the Iowa Medicaid program no longer provide coverage of, or payment for, elective, non-medically necessary Cesarean section (C-section) deliveries. This change was effective July 1, 2013, and aligns with initiatives being undertaken by the Iowa HealthCare Collaborative, as well as by various individual hospitals and hospital systems. This diagnosis code list is split into three parts. The first is diagnosis codes that will always be payable (i.e., Group 1), the second is diagnosis codes that will require documentation to determine medical necessity and payment (i.e., Group 2), and the third list is diagnosis codes that will not be payable (i.e., Group 3). A table with these different diagnosis groups is on the following page.
This link will take you to a list of the Ambulatory Patient Classification (APC) status indicator “C” codes for 2015. The status indicator of the codes is determined by the Centers for Medicare and Medicaid Services (CMS) and can be changed on a quarterly basis. A code that is listed as a status “C” code by CMS will not be paid under the Outpatient Prospective Payment System (OPPS). The member should be admitted, and the claim billed appropriately to reflect the inpatient status. Providers should check the CMS website on a quarterly basis for any updates or status changes for these codes. Please note that any claims submitted to the Iowa Medicaid Enterprise (IME) with a status “C” (inpatient only code) on an outpatient claim will be denied for Medically Unlikely CCI Edit. This claim denial edit cannot be altered by the IME.
Skilled Nursing Services
Skilled nursing services with Iowa Medicaid are covered in hospital based-facilities and hospital swing-beds that provide round-the-clock care. Skilled nursing services include; necessary therapy, medications, wound care, stoma care, ventilator, tracheostomy care or tube feedings. The list of hospital based skilled nursing facilities and swing bed facilities in the state of Iowa are available here.
Codes that accept CC and KR Modifiers
All Level II A, B, E, K, and L Healthcare Common Procedure Coding System (HCPCS) codes may be submitted with the CC or KR modifiers for Medical Supply Dealers and Pharmacy Providers effective February 1, 2013. The codes for the CC and KR modifiers may be accessed below:
This section outlines a complete listing of all the technical and instructional manuals used by recognized provider types as specified by the Iowa Medicaid Enterprise (IME). Each of the provider manual is specific to a service offered by the IME and is designed to guide an IME Provider with clear and concise outlines of what services are covered or not covered under that service. Additionally, the manuals also provide instructions on how to read and complete the various forms required by the IME for each offered service. These manuals serve as very important tools for providers in helping them ensure a more seamless administrative process involving IME guidelines, billings, and documentations.
The Iowa Medicaid Enterprise (IME) fee schedule is a list of the payment amounts, by provider type, associated with the health care procedures and services covered by the IME. Providers are contractually obligated to submit their usual and customary charges but accept the IME fee schedule reimbursement as payment in full. Provider charges are routinely reviewed by Policy staff to determine the cost for service and the fee schedule can be increased or decreased based upon comparable charges throughout the community.
Diagnosis-Related Group (DRG) Weights:
Acute Care Hospital inpatient claims are reimbursed using prospective payment system diagnosis-related groups (DRG). Hospital base rates and capital cost rates are developed using a blend of hospital-specific and statewide average costs taken from hospital cost reports. In addition, there are weights assigned to more than 500 diagnosis-related groups, which represent the relative resource consumption, as measured by the relative charges by hospitals for cases associated with each DRG. Iowa Medicaid Enterprise (IME) uses the Medicare DRG system with IME-specific weights calculated for each DRG to determine the payment for all hospitals. There are also provisions within the DRG payment methodology for additional payments for treating patients with a long-length stay (day outlier) or a large amount of economic resources (cost outlier). Payments are reduced or limited for certain treatment cases with a short-length stay (short-stay day outlier) or where a patient transfer has occurred.
Nursing Facilities Rates:
This link will bring you a listing of current and archived Nursing Facility rates which are further broken down into quarterly sections. These rates are determined by a cost report, which is based on a case mix of current residents in the facility. New Cost Reports are due every two years for the Nursing Facilities to determine the per diem (daily rate) that is assigned by Provider Cost Audit and Rate Setting. The listing of the current rates is a tool that Hospice providers can use to determine the Per Diem that is due per patient per day based on the location of the facility.
The Iowa Medicaid Enterprise (IME) implemented the ambulatory payment classification (APC) methodology for outpatient services in acute care hospitals on October 1, 2008. The outpatient hospital payments are based on Medicare's Outpatient Prospective Payment System (OPPS) APC's and relative weights and are updated annually effective January 1st using the most current calendar update as published by Centers for Medicare & Medicaid Services (CMS). To assist hospitals with claims processing, an IME- specific listing of Outpatient Coding Editor (OCE) edits were posted on the IME website at the above link.
Preferred Drug List:
The Iowa Medicaid Enterprise (IME) and the State of Iowa implemented the Preferred Drug List (PDL) on January 15th, 2005 as cost saving measure for the Medicaid Budget. The PDL lists all pharmaceuticals allowed by the IME and is a reference point for all pharmaceutical coverage. This site will assist Pharmacists and other providers to determine if a drug is covered with or without prior authorization. This will also provide information on the quantity and frequency of dispensation for any given drug that members may receive.
State Maximum Allowable Cost:
State Maximum Allowable Cost (SMAC) rate schedules are based on the premise that chemically equivalent drug products in the same strength, dosage, and package size available from multiple sources should be reimbursed similarly. SMAC rates are designed to maximize the cost-effectiveness of pharmacy services by setting reimbursement amounts for brand name and therapeutically equivalent drug products at the same price, based on the cost of the products. The SMAC rate applies to both the brand and generic drug products unless if the prescription specifically states, "brand medically necessary" and prior authorization is obtained as required. Additionally, if the brand drug product is listed as preferred on the Preferred Drug List, the SMAC rate only applies to generic drug products. The Centers for Medicare & Medicaid Services (CMS) uses this same premise to establish federal upper limits (FULs) for drug products. SMAC rates are essentially the state Medicaid program version of CMS FULs.
Pharmacy Point of Sale:
The Point of Sale (POS) website provides information regarding claim submission for providers. The website contains the Iowa DHS Point of Sale Agreement as well as the most recent payer sheet. Current informational letters notify providers regarding recent changes to the claim submission process. The website also provides information regarding quantity limits for medications, reimbursement for specialty drug products, and the preferred listing of diabetic supplies.
Smoking Cessation Program:
The Iowa Medicaid Smoking Cessation Program is comprised of two components; "Quitline Iowa" and pharmacy services. "Quitline Iowa" provides counseling services for tobacco users who want to quit. A toll-free helpline is available at 1-800-784-8669. Pharmacy services include various nicotine replacement products such as the patch, gum or other products. Medicaid members need to work with their physicians to receive a diagnosis and prior authorization for access to the products.
Iowa Family Planning Network (IFPN):
IFPN is a federally approved waiver for men and women ages 12 through 54 with limited coverage of Family Planning related services such as, birth control exams and supplies, and voluntary sterilization. The list of covered services is arranged with effective date by calendar year. The codes as of October 1, 2015 are available at this link.
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