IHA & IHEBA Applicable Visit Codes ADMINISTRATIVE HYBRID >1 comprehensive visit with a PCP during the 120 day At least one (1) comprehensive visit during period after the enrollment date. the 120 day period after the enrollment date CPT = 99203-99205, 99213-99215 by administrative data or medical record 99382-99387, 99392-99397 review. ICD-10 Medical record documentation requirements: Note = Z0000 indicating visit with PCP, date visit occurred and at least the following: a comprehensive history & physical exam, including a developmental history for members under 1 21 years of age, counseling/anticipatory guidance/risk factor reduction interventions in accordance with recommendations of the 9 Z005 AAP and the USPSTF, and the ordering of Z006 any medically necessary or required laboratory/diagnostic procedures; Z0070 for pregnant members, documentation of Z008 an initial prenatal care visit, with the Z020 provider who will oversee the member’s care during her pregnancy, which meets Z021 contractual requirements for the first Z022 comprehensive prenatal visit; for members with chronic and/or Z024 complex conditions, a plan for the Z025 continuation of all services necessary to treat the condition, including Z026 continuation of specialty care. Z0289 CPT (pregnant members on enrollment) = OR 59400, 59510, 59610, 59618, Z1032 OR CPT (hospitalized member) in hospital = 99221- 99223 with subsequent office visit with PCP having a CPT = 99201-99205, 99211-99215 OR CPT for home visit = 99342-99345, 99348-99350 OR CPT (for members in SNF) = 99304-99306 or home visit CPTs = 99342-99345, 99348-99350
IHA & IHEBA Applicable Visit Codes ADMINISTRATIVE HYBRID >1 comprehensive visit with a PCP during the 120 day period after the enrollment date. CPT = 99203-99205, 99213-99215 99382-99387, 99392-99397 At least one (1) comprehensive visit during the 120 day period after the enrollment date by administrative data or medical record review. ICD-10 = Z0000 Z005 Z006 Z0070 Z008 Z020 Z021 Z022 Z024 Z025 Z026 Z0289 OR Medical record documentation requirements: Note indicating visit with PCP, date visit occurred and at least the following: a comprehensive history & physical exam, including a developmental history for members under 21 years of age, counseling/anticipatory guidance/risk factor reduction interventions in accordance with recommendations of the AAP and the USPSTF, and the ordering of any medically necessary or required laboratory/diagnostic procedures; for pregnant members, documentation of an initial prenatal care visit, with the provider who will oversee the member’s care during her pregnancy, which meets contractual requirements for the first comprehensive prenatal visit; for members with chronic and/or complex conditions, a plan for the continuation of all services necessary to treat the condition, including continuation of specialty care. CPT (pregnant members on enrollment) = 59400, 59510, 59610, 59618, Z1032 OR CPT (hospitalized member) in hospital = 99221- 99223 with subsequent office visit with PCP having a CPT = 99201-99205, 99211-99215 OR CPT for home visit = 99342-99345, 99348-99350 OR CPT (for members in SNF) = 99304-99306 or home visit CPTs = 99342-99345, 99348-99350 1 9