Quarterly Code Update
The Centers for Medicare and Medicaid Services (CMS) publishes a quarterly code update, which include Healthcare Common Procedure Coding System (HCPCS©), Current Procedural Terminology (CPT©), and Current Dental Terminology (CDT©) code updates. In addition, CMS issues an annual international classification of diseases, tenth revision, clinical modification, and procedure coding system (ICD-10-CM, ICD-10-PCS) code updates.
Please see the most recent update below for Iowa Medicaid Fee-For-Service coverage and billing information.
Telehealth Approved List
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.
The payment methodology for a physician-administered drugs (e.g., J codes) that are listed as “by-report” is based on the Average Wholesale Price (AWP) for the National Drug Code (NDC) billed less 12%. The source of the AWP is Medi-Span. Then, based on legislative requirements there is a further 5% reduction then a 1% increase.
The payment methodology for Durable Medical Equipment (DME) that are listed as “by-report” is based on AWP less 10%. If AWP is not available, payment is based on Manufacturer’s Suggested Retail Price (MSRP) less 15%. If MSRP is not available, payment is based on invoice, cost plus 10%.
The payment methodology for other procedure codes that are listed as “by-report” is based on comparison of procedure codes of similar description and complexity. If there is no procedure code of similar description and complexity, then Provider Cost Audit (PCA) is contacted to assist with developing a fee.
Maternity Billing Guidelines
Maternity care includes antepartum care, delivery services, and postpartum care. The document referenced below contains billing guidance for obstetrical (OB) codes and maternity care services. In addition, the guidance indicates what services are and are not separately reimbursable to other maternity services.
Inpatient Only Codes
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.
Skilled Special Populations Nursing Facilities in Iowa
Hospital Based Swing Bed Facilities in Iowa
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:
Codes for "CC" Modifiers
Codes for "KR" Modifiers
Chiropractic Diagnosis Codes by Category
Medicaid recognizes Medicare's National Level II Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes. However, not all HCPCS and CPT are covered. The specific CPT codes that are covered for chiropractors under Iowa Medicaid are listed below. It is noted that Iowa Medicaid does not cover any HCPCS codes for chiropractors.
It is the provider's responsibility to select the procedure code that best describes the item of services that was dispensed. A claim submitted without a procedure code and a corresponding diagnosis code will be denied.
Covered procedures for chiropractic manipulative treatment are:
98940 Spinal, one or two regions
98941 Spinal, three or four regions
98942 Spinal, five regions
Generally, Medicaid limits chiropractic manipulative treatment to one code per day per patient. You are not required to bill excluded services. Please see the Chiropractic Provider Manual for additional information.
The utilization guideline for diagnostic combinations between categories is 28 manipulations per 12-month period. Any treatments beyond the utilization guidelines listed must be submitted with documentation to support the medical necessity. If documentation is not submitted, the claim will be denied for lack of information. The claim may be resubmitted with documentation for reconsideration.
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.
MS-DRG Version 38.1
MS-DRG Version 36.0
MS-DRG Version 33.0
MS-DRG Version 29.0
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 annually from 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.
Long-Term Care (LTC) Compilation Reports:
The annual LTC compilation reports of costs and other statistical data are prepared using data from the cost reports for nursing facilities, and intermediate care facilities for the intellectually disabled. These reports are used to establish statewide reimbursement limits, and to evaluate changes in cost that can be used to assist the legislature and the department in determining fiscal impacts to proposed changes and in developing budgets.
Nursing Facility (NF) Compilation Report
Intermediate Care Facility for Individuals with Intellectual Disability (ICF/ID) Compilation Report
Nursing Facilities Services for Iowa Health and Wellness Plan (IHAWP) and MAGI
Nursing facility services are a state plan benefit and can be a covered service for all members who have full Medicaid benefits. This includes Iowa Wellness Plan members who have a Medically Exempt (ME) status and members on MAGI Medicaid coverage groups. To be eligible for nursing facility services the member must reside in a skilled nursing facility (SNF), a nursing facility (NF), or receiving hospice benefits while residing in a SNF or NF, meet the required LOC, and are subject to Transfer of Assets (TOA) policies.
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.
Specialty Drug Administration - Alternative Site of Care
Site of care (SOC) for specialty drug administration refers to the physical location where the specialty drug is administered. Medically necessary services should be rendered in the least intensive setting appropriate for delivery of the services and supplies. The goal of the Iowa Medicaid Specialty Drug Administration - Alternative SOC program is to provide alternative SOC options for members on select chronic, provider-administered drugs (i.e., improve access and accessibility).
List of specialty drugs open for alternative site of care
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.
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.
Iowa Medicaid Preferred Drug List (PDL) Website
Iowa Medicaid Pharmacy Provider Portal
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.
Family Planning Program (FPP) Covered Services:
The FPP is for men and women between the ages of 12-54. The FPP helps with the cost of family planning related services. This program is a state-funded DHS program which replaced the Iowa Family Planning Network (IFPN) program. IFPN members were transitioned to the FPP July 1, 2017. The list of covered services is arranged by diagnosis and procedure codes. The codes as of June 1, 2022 are available below:
Follow this link* to the fee schedule* for reimbursement rates associated with Provider Type 22 (Family Planning).
*Please note: Not all of the procedure codes listed here are in the Provider Type 22 fee schedule. Some of the codes have special programming in the background to be associated with the FPP.