Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Influenza Testing-GA MCD-PY-1543 01/01/2025-09/30/2025 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 3 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 Influenza Testing-GA MCD-PY-1543 Effective Date: 01/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectInfluenza TestingB. Background Influenza (flu) is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs. Rapid influenza diagnostic tests (RIDTs) are immunoassays that can identify the presence of influenza A and Bviral nucleoprotein antigens in respiratory specimens and display the result in a qualitative way (positive vs. negative). Influenza can cause mild to severe illness, and at times can lead to death. Flu symptoms usually come on suddenly. The best way to reduce the risk of flu and its potentially serious complications is by getting vaccinated each year. Having clinical signs and symptoms consistent with influenza increases the reliability of a positive RIDT result. A positive result is most likely a true positive result if the respiratory specimen was collected within 3-4 days of illness during periods of high influenza activity (eg, winter). A negative result does not exclude influenza virus infection, and influenza should still be considered in a patient if clinical suspicion is high based upon history, signs, symptoms, and clinical examination. C. Definitions Influenza (Flu) Season Typically, flu activity begins to increase in October and peaks between December and February, although significant activity can last as late as May and begins to increase in October. Rapid Influenza Diagnostic Tests (RIDTs) Immunoassays which detect the parts of the virus (antigens) that stimulate an immune response, resulting in a positive or negative result. These tests can provide results within approximately 10-15 minutes. D. Policy I. CareSource considers conventional testing, such as rapid influenza diagnostic tests (RIDTs), as lowest cost and should be utilized before any further testing or higher cost tests are performed. II. RIDTs is medically necessary for members who present with signs and symptoms of influenza which may include the following: fever of 100.4 or higher feeling feverish/chills cough sore throat runny or stuffy nose muscle or body aches headaches fatigue (tiredness) some people may have vomiting and diarrhea, though this is more common in children than adults. Influenza Testing-GA MCD-PY-1543 Effective Date: 01/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 II I.The lowest cost CPT code for testing must be utilized first to confirm influenza in a pat ient presenting symptoms:A. 87804-Infectious agent antigen detection by immunoassay with direct optical observation; influenza I V.CareSource considers influenza testing medically necessary between October 1 st May 31 st for symptomatic individuals. VI . If conventional testing isA. Positive no further testing is medically necessary.B. Negative if the members presenting symptoms support the diagnosis, th en m olecular diagnostic test (MDT) by polymerase chain reaction (PCR) testing ma y be m edically necessary to confirm the diagnosis. V II. Limitations/ExclusionsA. Only 1 test per member per day is reimbursable.B. Duplicate tests will not be reimbursed.C. Influenza testing from June 1st September 30th is not medically necessary and i s not covered during this time. E. Conditions of Coverage NA F. Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 09/25/2024 New policy Date Revised Date Effective 01/01/2025 Date Archived 09/30/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1. Diagnosing flu. Centers for Disease Control and Prevention. October 3, 2022. Accessed August 26, 2024. www.cdc.gov2. F lu season. Centers for Disease Control and Prevention. September 20, 2022. Accessed August 26, 2024. www.cdc.gov3. Ra pid influenza diagnostic tests. Centers for Disease Control and Prevention.October 25, 2016. Accessed August 26, 2024. www.cdc.gov Influenza Testing-GA MCD-PY-1543 Effective Date: 01/01/2025 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 GA-M ED-P-3284391 Issue date 9/25/2024 DCH Approved 10/04/2024
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 12/01/2024-12/03/2024 Policy Type REIMBURSEMENT Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 8 G. Review/Revision History …………………………………………………………………………………………. 8 H. References …………………………………………………………………………………………………………… 9 CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectCLIA-Waived Testing in Office Setting B. Background During the course of an office visit with a physician or other qualified healthcare provider, the provider may determine that diagnostic laboratory testing is necessary to establish a diagnosis and/or determine treatment options to manage the members current health issues. While most laboratory tests are best performed by an independent laboratory, in some instances, results from these laboratory tests are needed immediately to manage urgent medical conditions or medical emergencies and may be performed appropriately in the physicians office. Due to the complexity of laboratory tests and regulations around facilities that perform these tests, only laboratory procedures on the short turnaround time (STAT) code list may be performed in the office, while all other tests should be referred to an independent, contracted laboratory provider. C. Definitions Clinical Laboratory Improvement Amendments (CLIA) The Centers for Medicare & Medicaid Services (CMS) regulates programs that test human specimens to ensure accurate, reliable, and timely patient test results, regardless of where a test is performed and including physician offices. Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Laboratory-A facility for the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the purpose of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings. These examinations also include procedures to determine, measure, or otherwise describe the presence or absence of various substances or organisms in the body. Facilities only collecting or preparing specimens (or both) or only serving as a mailing service and not performing testing are not considered laboratories. Laboratory Procedures Defined in the Current Procedural Terminology (CPT) in the ranges 80300 through 89398 and panels 80047 through 80076. D. Policy I. CareSource will reimburse for laboratory procedures performed in the physicians office when ALL the following apply: A. The test results are needed immediately in order to manage urgent or emergent medical situations. B. The CPT code for the test is on the short turnaround time (STAT) code list. If a test has been developed and approved by the FDA as a CLIA-waived test since publication of this policy, the FDA list of CLIA-waived tests will rule. C. The physician billing for laboratory testing is in compliance with the final rules of CLIA of 1988, which includes, at a minimum, a certificate of waiver for tests as CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 defined by the Centers for Medicare and Medicaid Services (CMS). For tests performed of moderate or higher complexity, the physician must meet the CLIA requirements for certification. D. The place of service (POS) 11 is used. E. Modifier QW is used to indicate the test is CLIA-waived. II. All other laboratory procedures may not be performed in the office and should be referred to an independent, contracted laboratory provider. Claims submitted for all other laboratory procedures may not be reimbursed.E. Conditions of Coverage It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Please refer to the individual fee schedule for appropriate codes. Place of Service(POS) Code Description 11 – Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis CPT Modifier DescriptionQW CLIA waived test STAT Code ListCPT / HCPCSDescription 0202U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0223U Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected 0224U Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), includes titer(s), when performed 0225U Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected 0226U Surrogate viral neutralization test (sVNT), severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (eg, utilizing CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation whenperformed, per date of service80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 80324 Amphetamines; 1 or 2 80325 Amphetamines; 3 or 4 80326 Amphetamines; 5 or more 80327 Anabolic steroids; 1 or 2 80328 Anabolic steroids; 3 or more 80329 Analgesics, non-opioid; 1 or 2 80330 Analgesics, non-opioid; 3-5 80331 Analgesics, non-opioid; 6 or more 80332 Antidepressants, serotonergic class; 1 or 2 80333 Antidepressants, serotonergic class; 3-5 80334 Antidepressants, serotonergic class; 6 or more 80335 Antidepressants, tricyclic and other cyclicals; 1 or 2 80336 Antidepressants, tricyclic and other cyclicals; 3-5 80337 Antidepressants, tricyclic and other cyclicals; 6 or more 80338 Antidepressants, not otherwise specified 80339 Antiepileptics, not otherwise specified; 1-3 80340 Antiepileptics, not otherwise specified; 4-6 80341 Antiepileptics, not otherwise specified; 7 or more 80342 Antipsychotics, not otherwise specified; 1-3 80343 Antipsychotics, not otherwise specified; 4-6 80344 Antipsychotics, not otherwise specified; 7 or more 80345 Barbiturates 80346 Benzodiazepines; 1-12 80347 Benzodiazepines; 13 or more 80348 Buprenorphine 80349 Cannabinoids, natural 80350 Cannabinoids, synthetic; 1-3 80351 Cannabinoids, synthetic; 4-6 80352 Cannabinoids, synthetic; 7 or more 80353 Cocaine 80354 Fentanyl 80355 Gabapentin, non-blood 80356 Heroin metabolite 80357 Ketamine and norketamine 80358 Methadone 80359 Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Methylphenidate 80361 Opiates, 1 or more 80362 Opioids and opiate analogs; 1 or 2 CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 80363 Opioids and opiate analogs; 3 or 480364 Opioids and opiate analogs; 5 or more 80365 Oxycodone 80366 Pregabalin 80367 Propoxyphene 80368 Sedative hypnotics (non-benzodiazepines) 80369 Skeletal muscle relaxants; 1 or 2 80370 Skeletal muscle relaxants; 3 or more 80371 Stimulants, synthetic 80372 Tapentadol 80373 Tramadol 80374 Stereoisomer (enantiomer) analysis, single drug class 80375 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 80376 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more 83992 Phencyclidine (PCP) 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81015 Urinalysis; microscopic only 81025 Urine pregnancy test, by visual color comparison methods 82043 Albumin; urine (eg, microalbumin), quantitative 82044 Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) 82247 Bilirubin; total 82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) 82271 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82465 Cholesterol, serum or whole blood, total 82565 Creatinine; blood 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82947 Glucose; quantitative, blood (except reagent strip) 82948 Glucose; blood, reagent strip 82950 Glucose; post glucose dose (includes glucose) 82951 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 82952 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 83036 Hemoglobin; glycosylated (A1C) 83037 Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use 83655 Lead 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83986 pH; body fluid, not otherwise specified 84132 Potassium; serum, plasma or whole blood 84703 Gonadotropin, chorionic (hCG); qualitative 85013 Blood count; spun microhematocrit 85014 Blood count; hematocrit (Hct) 85018 Blood count; hemoglobin (Hgb) 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) 85049 Blood count; platelet, automated 85610 Prothrombin time; 85651 Sedimentation rate, erythrocyte; non-automated 86308 Heterophile antibodies; screening 86318 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip); 86328 Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 86408 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen 86409 Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); titer 86580 Skin test; tuberculosis, intradermal 86756 Antibody; respiratory syncytial virus 86769 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87070 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 87172 Pinworm exam (eg, cellophane tape prep) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87301 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; adenovirus enteric types 40/41 87400 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 7 87426 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay[EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 87428 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 87430 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus, group A 87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87635 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group B 87803 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Clostridium difficile toxin A 87804 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 87806 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies 87807 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 87808 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Trichomonas vaginalis 87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) 87880 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) C9803 Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), any specimen source G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 8 mass spectral drift); qualitative or quantitative, all sources, includes specimen validitytesting, per day; 1-7 drug class(es), including metabolite(s) if performedG0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes G2023 Specimen collection for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source G2024 Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) from an individual in a SNF or by a laboratory on behalf of a HHA, any specimen source Q0111 Wet mounts, including preparations of vaginal, cervical or skin specimens Q0112 All potassium hydroxide (KOH) preparations U0001 CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel U0002 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R U0004 2019-nCoV coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R F. Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 08/28/2024 New policy. Approved at Committee. Date Revised Date Effective 12/01/2024 Date Archived 12/03/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. CLIA-Waived Testing in Office Setting-GA MCD-PY-1462 Effective Date: 12/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 9 H. References1. CLIA Clinical Laboratory Improvement Amendments Currently Waived Analytes. U.S. Food and Drug Administration. Updated August 12, 2024. Accessed August 13, 2024. www.accessdata.fda.gov 2. CPT Code Detail. Optum Encoder Pro; 2024. Accessed August 9, 2024. www.encoderprofp.com 3. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions, 42 U.S.C. 410.32 (2023). 4. HCPCS Code Detail. Optum Encoder Pro; 2024. Accessed August 9, 2024. www.encoderprofp.com 5. Laboratory Requirements, 42 U.S.C. 493 (2023). 6. Laboratory Services, 42 U.S.C. 441.17 (2023). 7. Other Laboratory and X-Ray Services, 42 U.S.C. 440.30 (2023). 8. Place of Service Code Set. Centers for Medicare and Medicaid Services; 2024. Accessed August 9, 2024. www.cms.gov 9. Policies and Procedures, II: Physician Services. Georgia Department of Community Health, Division of Medicaid; 2024. Revised July 1, 2024. Accessed August 9, 2024. www.mmis.georgia.gov 10. Policies and Procedures, II: Diagnostic Screening and Preventive Services. Georgia Department of Community Health, Division of Medicaid; 2024. Revised July 1, 2024. Accessed August 9, 2024. www.mmis.georgia.govGA-MED-P -3256801 Issue date 08/28/2024 Approved DCH 09/20/2024
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 11/01/2024-10/31/2025 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XUB. Background Reimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are two-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59.C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review. A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day, and 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. are performed at separate anatomic sites 2. are performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.)Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 E.C onditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of stat e s pecific instructions, the CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.P roviders must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to bot h par ticipating and nonparticipating providers and facilities.In t he event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document. F. Related Policies/Rules Modifier 2 5 M odifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised 08/02/2023 07/17/2024 Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee Date Effective 11/01/2024 Date Archived 10/31/2025 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1.General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 2024. Accessed July 1, 2024. www.cms.gov2.M edicare Claims Processing Manual Chapter 12 Physicians/Nonphysici an P ractitioners . US Centers for Medicare and Medicaid Services; 2024. Accessed Jul y 1, 2024. www.cms.gov3.Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicar e and M edicaid Services. Updated September 6, 2023. Accessed July 1, 2024. www.cms.gov4. M LN1783722-Proper Use of Modifiers 59 & – X{EPSU}. US Centers for Medicare & M edicaid Services; 2024. July 1, 2024. www.cms.gov5.Tr ansmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers forDistinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed July 1, 2024. www.cms.gov Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 GA-MED-P -3118500 Issue Date 08/17/2022 Approved DCH 08/13/2024
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Modifier 25-GA MCD-PY-1361 11/01/2024-08/31/2025 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 5 Modifier 25-GA MCD-PY-1361 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 25B. Background Reimbursement policies are designed to assist physicians when submitting claims to CareSource and are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-digit code that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier 25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CPT) book defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a medically necessary, significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57 for a surgical decision. For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. CareSource uses published guidelines from Modifier 25-GA MCD-PY-1361 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. DefinitionsAmerican Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment clinical validation or prepayment medical record coding review. a. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. b. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. VI. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances: Modifier 25-GA MCD-PY-1361 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 A.The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period.B. The E/M service is reported by a qualified professional provider other than t he qual ified professional provider who performed the procedure.C. The E/M service is performed on a different day than the procedure.D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure.E. The modifier is reported with a non-E/M service.F. The reason for the office visit was strictly for the minor procedure sinc e r eimbursement for the procedure includes the related pre-operative and post-operative service.G. The professional provider performs ventilation management in addition to an E/ M se rvice.H. The preventative E/M service is performed at the same time as a preventativ e c are visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Sinc e bot h services are preventative, only one should be reported.I. The routine use of the modifier is reported without supporting clinica l doc umentation. E.Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of stat e s pecific instructions, CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.P roviders must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to bot h par ticipating and nonparticipating providers and facilities.In t he event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document. F. Related Policies/Rules Modifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 New Policy Date Revised 08/02/2023 07/17/2024 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Date Effective 11/01/2024 Modifier 25-GA MCD-PY-1361 Effective Date: 11/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date Archived 08/31/2025This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy.H.References 1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online).2023;33(11):1-12. Accessed July 8, 2024. www.ama.assn.org2. A ppropriate use of Modifier 25. American College of Cardiology. Accessed July 8,2024. www.acc.org3. C haplain S. Are you using Modifier 25 correctly. American Academy of ProfessionalCoders. Published March 25, 2022. Accessed July 8, 2024. www.aapc.com4. C hapter 1 General Correct Coding Policies for National Correct Coding Initiativ e P olicy Manual for Medicare Services. Centers for Medicare and Medicaid Services;2024. Accessed July 8, 2024. www.cms.gov5. Fel ger TA, Felger M. Understanding when to use modifier-25. Fam Pract Manag.2004;11(9):21-22. Accessed July 8, 2024. www.aafp.org6. M edicare Claims Processing Manual Chapter 12 Physicians/Nonphysici an P ractitioners . Centers for Medicare and Medicaid Services; 2024. Accessed July 8 , 2024. www.cms.govGA-MED-P-3118500 Issue Date 08/17/2022 Approved DCH 08/13/2024
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Interest Payments-GA MCD-PY-1326 06/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of serv ice, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures . This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Poli cy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/R ules ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Interest Payments-GA MCD-PY-1326 Effective Date: 06/01/2024 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d.2A. Subject Interest Pay ments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/H CPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions 0078 Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. 0078 Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentati on that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements , of which the provider has knowledge. 0078 Original Claim The initial complete claim for one or more benefits on an application form. 0078 Prompt Payment Prompt payment is defined by state and/or f ederal regulation defining timeliness and interest requirements. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. ( O.C.G.A. 33-24-59.5, O.C.G.A. 33-21A-7 (Second Pass)) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims starts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name Policy Number Effective Date Single Dose Vial Claims Modif ier s PY-PHARM-0092 07-01-2023 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims edi ting logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify thi s Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitatio ns that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 3 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sin g le Do se Vial Claims Mo d ifiersGeo rg ia Med icaidPY-PHARM-0092 Effective Date: 07-01-2023 2 A. SubjectThis policy provides guid ance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and polic y clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encouraged to use self-service channels to verif y members eligibility. It is the responsibility of the submitting provider to submit the most a ccurate andappropriate CPT/HCPCS /ICD-10 code(s) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. This policy describes documentation require ments and reimbursement guidelines f orbilling of the administered and discarded portion (s) of drugs and biologicals . Providers shall bill and receive reimbursement f or both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manuf actured and supplied only in single dose or single use f ormat. The JW modif ier is required to be reported on a claim to report the amount of drug that is discarded and e ligible f or payment and should be used only f or claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identif ied with the JW Modif ier as a separate line item f rom the dose or administered portion. Pr oviders may be reimbursed f or the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers a re required to report the JZ modif ier on allclaims that bill f or drugs f rom single-dose containers when there are no discarded amounts. The JZ modif ier is reported on a claim to attest that no amount of drug was discarded and should only be used f or claim s that bill f or single-dose container drugs. Claims containing drug administered f rom multi-dose vials are not subject to this requirement. Under this policy, a ll claims for separately payable single dose format injectabledrugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Sin g le Do se Vial Claims Mo d ifiersGeo rg ia Med icaidPY-PHARM-0092 Effective Date: 07-01-2023 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discard ed p o rtio n o f d rug no t ad ministered Drug amo unt d iscard ed /no t ad ministered to any p atient JZ All d rug ad ministered no ne d iscard ed Zero d rug amount d iscarded/not administered to any p atient C. Def initionsModif ie r JW ref ers to the drug amount discarded (wasted)/not administered to any patient . Modif er JZ ref ers to zero drug amount discarded/not administered to any patient. Discarded Wastage or Unused Portion is def ined as the amount of a single use/dose vial or other single use/dose package that remains af ter administering a dose/quantity of a drug or biological. Single Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that is meant f or use in a single patient f or a sing le procedure. These vials are labeled as single-dose or single-vial by the manuf acturer and typically do not contain a preservative. Multi-Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that contains more than one dose of medication. These vials are labeled as multi-dose by the manuf acturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. D. PolicyModif ier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modif ier JW. Both details are reimbursable. CareSource will consider reimbursement f or: I. A single-dose or single-use vial drug that is wasted, when Modif ier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimburse ment f or:I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modif ier is required when there are no discarded amounts of a single – dose container drug f or which the JW modif ier would be required if there were discarded Sin g le Do se Vial Claims Mo d ifiersGeo rg ia Med icaidPY-PHARM-0092 Effective Date: 07-01-2023 4 amounts. The JZ modif ier is required to attest that there were no discarded amounts,and no JW modif ier amount is reported. E. Conditions of Coverage Providers must not use the JW modif ier f or medications manuf actured in a multi – dose vial f ormat. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered f or reimbursement must not exceed the package size of the vial used f or preparation of the dose. Providers must not bill f or vial contents overf ill. Providers must not use the JW modif ier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modif er is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modif ier. 1. Claim Line #1 HCPCS code f or drug administered and the amount admistered to the patien t. 2. Claim Line #2 HCPCS code f or drug discarded (wasted) with JW modif ier appended to indicate waste and the amount discarded (wasted). The JZ Modif ier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapt er 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original ef f ective dateDate Revised 08-25-2023 Updated policy to include JZ modif ier. Updated policy name and ref erences. Date Effective 07-01-2023 Date Archived H. Ref erences 1. Billin g an d Co d ing : JW an d JZ Mo d ifier Billin g Guid elines Article – Billin g an d Co d in g : JW an d JZ Mo d ifier Billin g Guid elin es (A55932) (cms.g o v) 2. New JZ Claims Mo d ifer fo r Certain Med icare Part BDru gs h ttp s://www.cms.g o v/files/d ocumen t/mm13056-n ew-jz-claims-modifier-certain-med icare-part-b- d rug s.p d f 3. Discard ed Drug s an d Bio lo g icals JW Mo d ifier an d JZ Mo d ifier Po licy FAQs. jw-mo d ifier – faq s.p d f (cms.g o v) The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in theReimbursement Policy Statement Policy and is app roved.
REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modifiers-GA MCD-PY-1353 02/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and do cumentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is su bject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization manage ment guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative , and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Man uals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced here in. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and t reatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 3 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …………………. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 3 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 4 Modifiers-GA MCD-PY-1353Effective Date: 02/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement modifiers are two-digit codes that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of bothCPT and HCPCS manuals. Use of a modifier does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claim s for the same procedure. To indicate that a procedure was performed on the left side, right side, or bilaterally. To report multiple procedures performed during the same session by the same health care provider. To indicate multiple health care profession als participated in the procedure. To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbu rsement rate, whileothers do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or s ervice. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) – Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – Codes that are issued, updated and maintained by the American Medical Association (AMA) that prov ide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier – Two-character codes , used along with a CPT or HCPCS code , to provide additional information about the service or supply rendered. Modifiers-GA MCD-PY-1353Effective Date: 02/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CP T/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive): National Correct Coding Initiative (NCCI) editing guidelines American Medical Association (AMA) guideline s American Hospital Association (AHA) billing rules Current Procedural Terminology (CPT) Healthcare Common Procedure Coding System (HCPCS) ICD-10 CM and PCS National Drug Codes (NDC) Diagnosis Related Group (DRG) guidelines CCI table edits. The inclusio n of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved CPT/HCPCS codes along with appropriate modifiers , if applicable. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies applyto both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 01/20/2022 New PolicyDate Revised 10/12/2022 09/27/2023 No changes. Update references. Updated references. Approved at Committee. Date Effective 02/01/2024 Date Archived Modifiers-GA MCD-PY-1353Effective Date: 02/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 H. References 1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS) . US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed September 11, 2023. www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed September 11, 2023. www.ama-assn.org 3. Medicare Claims Processing Manual, XII: Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 2003. Revised February 9, 2023. Accessed September 11, 2023. www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers . US Centers for Medicare and Medicaid Services; 2003. Revised March 24, 2023. Accessed September 11, 2023. www.cms.gov 5. Optum Encoder Pro. 2023. Accessed September 11, 2023. www.encoderprofp.com GA-MED-P-2484807 Issue Date 01/20/2022 Approved DCH 11/06/2023
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in an y federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 12/01/2023-10/31/2024 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 5 G. Review/Revision History …………………………………………………………………………………………. 5 H. References …………………………………………………………………………………………………………… 5 Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XUB. Background Reimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Reimbursement modifiers are two-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiat ive (NCCI) includes Procedure-to-Procedure edits that define when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modif iers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances . Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59.C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review. A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply fo r both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation s hould support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that 1. Are performed at different anatomic sites, and 2. Are not ordinarily performed or encountered on the same day, and 3. Cannot be described by one of the more specific anatomic NCCI Procedure to Procedure (PTP)-associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI). B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that 1. Are performed during different patient encounters, and 2. Cannot be described by one of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two timed procedures are performed during the same encounter but occur one after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that 1. Are performed at separate anatomic sites, or 2. Are performed at separate patient encounters on the same date of service. E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when 1. The diagnostic procedure is the basis for performing the therapeutic procedure, and 2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires, and3. Provides clearly the information needed to decide whether to proceed with the therapeutic procedure, and 4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately. F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure, and 2. It occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires, and 3. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (e.g., not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 E.C onditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and C PT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual f ee s chedule for appropriate codes.P roviders must follow proper billing, industry standards, and state compliant codes on a ll c laims submissions. The use of modifiers must be fully supported in the medical recor d and/ or office notes. Unless otherwise noted within the policy, this policy applies to bot h par ticipating and nonparticipating providers and facilities.In t he event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document. F. Related Policies/Rules Modifier 2 5 M odifiers G. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised 08/02/2023 Annual review: updated references. Approved at Committee. Date Effective 12/01/2023 Date Archived 10/31/2024This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSourcereserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy.H.R eferences 1.General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 2023.2. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysici an P ractitioners . US Centers for Medicare a nd Medicaid Services; 2022. Updat ed Febr uary 9, 2023.3. MLN1783722-Proper Use of Modifiers 59 & – X{EPSU}. US Centers for Medicare & M edicaid Services; 2023.4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicar e and M edicaid Services. Updated July 18, 2023.5. Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers forDistinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. GA-MED-P-2295952 Issue Date 08/17/2022 Approved DCH 08/29/2023
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In additi on to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contr act (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Modifier 25-GA MCD-PY-1361 12/01/2023-10/31/2024 Policy Type REIMBURSEMENT Tabl e of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 5 Modifier 25-GA MCD-PY-1361 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 25B. Background Reimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. CareSource may verify the us e of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a two-digit code that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by s ome specific circumstance. Modifier-25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Associati on (AMA) Current Procedural Terminology (CPT) book defines modifier-25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier-25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a medically necessary, significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separ ately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This cir cumstance may be reported by adding modifier-25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier-57 for a surgical decision. For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. CareSource uses published guidelines from CPT Modifier 25-GA MCD-PY-1361 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. DefinitionsAmerican Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier-25 may be flagged for either a prepayment clinical validation or prepayment medical record coding review. a. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. b. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier-25 may only be used t o indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier-25, the code may be denied. VI. Appending modifier-25 to an E/M service is considered inappropriate in the following circumstances: Modifier 25-GA MCD-PY-1361 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 A.The i nitial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period.B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure.C. The E/M service is performed on a different day than the procedure.D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure.E. The modifier is reported with a non-E/M service.F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post-operative service.G. The professional provider performs ventilation management in addition to an E/Mservice.H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported.I. The routine use of the modifier is reported without supporting clinical documentation. E. Conditions of Coverage Reimbursement is dependent upon, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes.Pr oviders must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/Rule s Modifiers G.Review/Revision History DATE ACTION Date Issued 08/17/2022 New Policy Date Revised 08/02/2023 Annual Review: updated references. Approved at Committee Date Effective 12/01/2023 Modifier 25-GA MCD-PY-1361 Effective Date: 12/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date Archived 10/31/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. H.R eferences 1. Appropriate use of Modifier 25. American College of Cardiology. Accessed July 24,2023. www.acc.org2.C hapter 1 General Correct Coding Policies for National Correct Coding Initiativ e Po licy Manual for Medicare Services. Centers for Medicare and Medicaid Services;2022. Accessed July 24, 2023. www.cms.gov3. CP TModifier 25. Palmetto GBA. Accessed July 24, 2023. www.palmettogba.com4. M edicare Claims Processing Manual Chapter 12 Physicians/Nonphysici an P ractitioners . Centers for Medicare and Medicaid Services; 2023. Accessed July 24,2023. www.cms.gov5. C haplain S. Are you using Modifier 25 correctly. American Academy of ProfessionalCoders. Published March 25, 2022. Accessed July 24, 2023. www.aapc.com GA-MED-P-2295952 Issue Date 08/17/2022 Approved DCH 08/29/2023
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical p ractice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contr act (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Interest Payments-GA MCD-PY-1326 08/01/2023-05/31/2024 Policy Type REIMBURSEMENT T able of Contents A.Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. Conditions of Coverage ………………………………………………………………………………………….. 3 F. Related Policies/Rules ……………………………………………………………………………………………. 3 G. Review/Revision History …………………………………………………………………………………………. 3 H. References …………………………………………………………………………………………………………… 3 Interest Payments-GA MCD-PY-1326 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. A. SubjectInterest Payments B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulat ion defining timeliness and interest requirements. D. Policy I. CareSource strictly adheres to all regulatory guidelines relating to interest and follows the guidelines outlined in Prompt Payment regulations. (O.C.G.A. 33-24-59.5, O.C.G.A. 33-21A-7 (Second Pass)) II. Payment of interest on original claims is made when CareSource fails to adjudicate original claims within the applicable state and federal prompt pay timeframes on clean claims. III. Payment of interest on adjusted claims starts on the date the provider disputes the original payment with CareSource. IV. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim Interest Payments-GA MCD-PY-1326 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. V. CareSource only pays interest on claim payment that is occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and federal regulations for interest payment.VI. CareSource performs regular reviews of our paid claims to correct claim payment.A. Reviews can include items, such as retroactive eligibility updates,authorization updates, coordination of benefits (COB) updates, and f ee s chedule updates.B. Reviews include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly.C. Claims are not subject to interest payment when CareSource takes proactiv e m easures to pay claims correctly. E.Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CP Tcodes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. F. Related Policies/Rules NA G. Review/Revision History DATE ACTION Date Issued 03/31/2021 New Policy Date Revised 04/27/2022 04/12/2023 No changes; Updated references No changes; Updated references. Approved by committee. Date Effective 08/01/2023 Date Archived 05/31/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Polic y. H.R eferences 1. Bureau of the Fiscal Service. (2013, January-2021, June). Interest Rates.Retrieved March 21, 2023 from www.fiscal.treasury.gov.2. C enters for Medicare & Medicaid Services. (2019, January). Notice of Ne w I nterest Rate for Medicare Overpayments and Underpayments-2nd Qtr.Retrieved March 21, 2023 from www.cms.gov.3. Feder al Register. Prompt Payment Interest Rate; Contract Disputes Act. Interest Payments-GA MCD-PY-1326 Effective Date: 08/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. Retrieved March 21, 2023 from www.fiscal.treasury.gov. 4. Justia US Law. (2020). 2020 Georgia Code Title 33 Insurance Chapter 21A-Medicaid Care Management Organization 33-21A-7 – Bundling of provider complaints and appeals. Retrieved March 21, 2023 from www.justia.com/codes/georgia. 5. Legal Information Institute. 42 CFR 422.520-Prompt payment by MA organization. Retrieved March 21, 2023 from www.law.cornell.edu. 6. Social Security Association. Sec 1816(c)(2)(B). Retrieved March 21, 2023 from www.ssa.gov. 7. Social Security Association. Sec 1842(c)(2)(B). Retrieved March 21, 2023 from www.ssa.gov. 8. United States Government Publishing Office. Title 31, Section 3902. Retrieved March 21, 2023 from www.govinfo.gov. 9. United States Government Publishing Office. Title 42, Section 7109. Retrieved March 21, 2023 from www.govinfo.gov.GA-MED-P -2027601 Issue Date 03/31/2021 Approved DCH 05/11/2023
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