GA Med Reimbursement Archived Policy

Neonatal Intensive Care Unit (NICU) Level of Care

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 10/01/2025 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 service, m edical 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 no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of care that a newborn with specified diagnoses and symptoms require. All four levels of care are represented by a uniquerevenue code . Any inpatient revenue codes not billed as levels 2-4 will be recognized as level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy are not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms require s. Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well Baby Care Services A basic level of care to neonates who are low risk. D. PolicyI. Per federal mandate, newborn members are covered at an inpatient facility for a 2 – day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with revenue codes 0170/0171 and a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to submit documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn require s a NICU admission or a higher IOC service, anauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, an authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed during transitional time.VI. Clinical review will determine appropriate IOC utilizing MCG standards. Care Source will adjust IOC reimbursement if clinical documentation does not support the IOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria , as well as CareSource policy.VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to reference MCG guidelines as well as the clarifications and specific details below . Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 NICU LevelRevenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care ( LOC-010 ) Neonatal care may be indicated for the p hysiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn care Evaluation and care of neonates with conditions that require inpatient services available at Level I Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues (eg , sustained weight gain, poor PO feeding ), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medications Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level IIIntensity of Care Criteria 2 Continuing Care (LOC-011 )Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation ( 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation ( NIPPV ) o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min of IV treatment or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W ) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermia Surgical conditions requiring general anesthesia up to 2 days post-op , if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation , or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013 ) Includes Level 3 requirements and 1 or more of the following: Perioperative care following surgical repair of severe neonatal conditions, for example: o bowel resection for necrotizing enterocolitis (NEC) o tracheoesophageal fistula or esophageal atresia repair o cardiac surgery excluding PDA ligation o myelomeningocele closure (up to 48 hours post-op) o organ transplant Medically necessary inhaled nitric oxide (iNO) Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange transfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing IV fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusion CPR in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation (eg, hemolytic anemia, disseminated intravascular coagulation, hemorrhage) E. Conditions of CoverageI. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align with authorized levels of care and/or clinically validate diagnoses, procedures , and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care Issue a base DRG payment Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping, A request for complete medical records and/or itemized statements to support the services on the claim may be made II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 03/12/2025 New policy. Approved at Committee.Date Revised Date Effective 10/01/2025 Date Archived H. References1. About preterm labor and birth. National Institutes of Health (NIH). Reviewed May 9, 2023. Accessed January 30, 2025 . www.nichd.nih.gov Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 2. Admission to NICU. Specification Manual for Joint Commission National QualityMeasures . The Joint Commission; 2024. Version 2024B1. www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care. LOC-010 (ISC GRG). MCG Health. 2 8th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care. LOC-011 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care. LOC-012 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care. LOC-013 (ISC GRG). MCG Health. 2 8th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III, and IV. Pediatrics . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 GA-MED-P-3769851 Issue Date 03/12/2025 Approved DCH 07/02/2025

Influenza Testing

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Influenza Testing-GA MCD-PY-1543 10/01/2025 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, benefi ts 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, m edical 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 llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (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.Table of ContentsA. 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-1543Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectInfluenza Testing B. BackgroundInfluenza (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 identify the presence of influenza A and Bviral nucleoprotein antigens in respiratory specimens and display the result in a qualitative way (positive vs. negative) . The best way to reduce the risk of flu and potentially serious complications is by getting vaccinated each year. Having clinical signs and symptoms consistent with influenza increases, which 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 n egative result of RIDTs do 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 The time in which influenza spikes in the population, typically starting in October and peaking between December and February, although significant activity can last as late as May. Rapid Influenza Diagnostic Tests (RIDTs) Testing that detect s the parts of the virus (antigens) that stimulate an immune response. These tests can provide results within approximately 10-15 minutes. D. PolicyI. CareSource considers conventional testing, such as rapid influenza diagnostic tests (RIDTs) , as lowe st cost and should be utilized before any further testing or higher cost tests are performed . II. Influenza can cause mild to severe illness and , at times , can lead to death. Flu symptoms usually come on suddenly. P atients who have flu often feel some or all of these signs and symptoms: fever of 100.4 or higher feeling feverish/chills cough sore throat runny or stuffy nose muscle or body aches headaches fatigue (tiredness) vomiting and diarrhea (more common in children ) Influenza Testing-GA MCD-PY-1543Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. RIDT CPT code must be billed first when testing for influenza : 87804 – Infectious agent antigen detection by immunoassay with direct optical observation; influenza VI. If conventional testing is:A. Positive no further testing is medically necessary. B. Negative if the members presenting symptoms support the diagnosis, then molecular diagnostic test (MDT) may be medically necessary to confirm the diagnosis. VII. CareSource may request documentation to support medical necessity .B. Only 1 RIDT per member per day is reimbursable. C. Only 1 MDT per member per day is reimbursable if medically necessary. C. Duplicate tests will not be reimbursed. VIII. Documentation must support medical necessity, and testing during or outside of the defined influenza season may result in recoupment if documentation does not support medical necessity.E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/25/2024 New policyDate Revised 03 /12 /2025 Revision. Removed flu season timeframe. VII. Clarified duplicate testing. Added documentation language and updated references. Approved at Committee. Date Effective 10/ 01/2025 Date Archived H. References1. Diagnosis for flu. Centers for Disease Control. October 3, 2022. Accessed January 24, 2025. www.cdc.gov 2. Flu season. Centers for Disease Control. Updated October 28,2024. Accessed January 24, 2025. www.cdc.gov 3. Rapid influenza diagnostic tests. Centers for Disease Control. Updated September 17, 2024. Accessed January 24, 2025. www.cdc.gov GA-MED-P-3769851 Issue Date 09/2 5/202 4 Approved DCH 07/02/2025

Obstetrical Care-Total Cost

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Obstetrical Care-Total Cost-GA MCD-PY-0231 04/01/ 2025 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, benefi ts 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, m edical 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 llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care Total Cost B. BackgroundObstetrical care is health care treatment provided in relation to pregnancy and delivery of a newborn child , including care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members receive in a hospital or birthing center , as well all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification ofmedical necessity for these services. Proper billing and submission guidelines must be followed , including the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating providers and facilities. C. Definitions Prenatal Profile Initial laboratory services. Initial and Prenatal Visit Practitioner visit to determine if member is pregnant. Total Obstetrical Care Antepartum care, delivery, and postpartum care. High Risk Delivery Labor management and delivery for an unstable or critically ill pregnant patient. Premature Birth Delivery before 37 weeks of pregnancy. Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. D. PolicyI. Obstetrical Care A. Initial visit and prenatal profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and Management (E/M) codes are utilized when services are provided to diagnose the pregnancy. These are not part of antepartum care. B. Total obstetrical care for uncomplicated care provided to the member including antepartum, delivery, and postpartum care includes 1. If a member meets all the following criteria, the practitioner designated in the member s medical record must bill for total obstetrical care under th e practitioners number : Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 a. Member i s eligible for Medicaid for the duration of pregnancy b. Member i s cared for by one practitioner or group practice for the antepartum care, delivery, and postpartum care , and c. The a ttending physician is designated in the medical record with services billed under that practitioner tax identification number. 2. Billing for total obstetrical care cannot be submitted until the date of delivery. 3. Total obstetrical care cannot be billed for a delivery of less than 20 week s gestation. 4. Total obstetrical care codes are as follows: a. A corresponding obstetrical diagnosis with outcome of birth must be listed on the claim. An ICD-10 code from category Z34 should be listed as the first diagnosis for routine obstetric care. b. Reimbursement is provided for 1 of the following codes per pregnancy: 5. Modifiers a. A modifier UB, UC, and UD appended to the billed delivery procedure code is required , or the delivery claim will be denied. b. Deliveries with modifiers UB or UD must show medical necessity , and medical documentation may be requested. c. Use appropriate modifiers (not all-inclusive): Modifier Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. UB Medically-necessary delivery prior to 39 weeks of gestation . UC Delivery at 39 weeks of gestation or later . UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 Code s Description 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 weeks gestation)6. Services (not all-inclusive):Services included that may NOTbe billed separatelyServices excluded and therefore may be billed separately Admission history Greater than 13 antepartum visits due to high-risk condition Admission to hospital Complications of pregnancy Artificial rupture of membranes Surgical complications or other problems related to pregnancy Care provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum Cephalic version Cesarean delivery Ultrasonography Cesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Fetal nonstress test Classic cesarean section Maternal or fetal echography Each month up to 28 weeks gestation Fetal echocardiography procedures Every other week from 29 to 36 weeks gestation Fetal biophysical profile Fetal heart tones Amniocentesis, any method Hospital/office visits following cesarean section or vaginal delivery Chorionic villus sampling, any method Initial/subsequent history Fetal contraction stress test Low cervical cesarean section Hospital and observation care visits for premature labor prior to 36 weeks of gestation Management of uncomplicated labor High risk pregnancies requiring more visits or more laboratory data Physical Exams Conditions unrelated to pregnancy i.e., hypertension, glucose intolerance Recording of weight/blood pressures Treatment and management of complications during the postpartum period that require additional services Routine chemical urinalysis Laboratory tests outside of routine chemical urinalysis Routine prenatal visits Cordocentesis Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Successful vaginal delivery after previous cesarean deliveryOB ultrasounds Patients with previous cesarean delivery who present with the expectation of a vaginal delivery RH immune globulin administration Vaginal delivery with or without episiotomy or forceps Weekly from 36 weeks until deliveryII. Multiple gestations A. Diagnosis code (s) for multiple gestations must be included . B. Total obstetrical care billing for multiple gestations should include 1 procedure code and a delivery only code for each subsequent delivery with the appropriate diagnosis code and modifier for the multiple gestations. C. When all deliveries are performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 may be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. III. High risk deliveriesA. High risk pregnancy with appropriate trimester should be the first listed diagnosis for prenatal outpatient visits and from the ICD-10 category O09 supervision of high-risk pregnancy. B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be allinclusive and is subject to updates.Codes Description59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy.Date Revised 04/01/2020 10/26/202211/06 /2024New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed unbundled information, updated most content, included modifiers and updated codes. Periodic review. Editorial changes and reference updates only. Periodic review. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. Policies and Procedures for Physician Services . Georgia Dept of Community 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct procedural services UB Medically necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) Obstetrical Care-Total Cost-GA MCD-PY-0231Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 Health, Division of Medicaid; 2024. Accessed October 1 5, 202 4. www.mmis.georgia.gov 2. ACOG Committee Opinion: optimizing postpartum care. Obstet Gynecol . Opinion No. 736. 2018;131(5):e140-e150. doi:10.1097/AOG.0000000000002633 GA-MED-P-3459100 Issue Date 07/01/2017 Approved DCH 12/30/202 4

Obstetrical Care-Unbundled Cost

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Obstetrical Care-Unbundled Cost-GA MCD-PY-0924 04/01/2025 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, benefi ts 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, m edical 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 llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (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.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 8 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 8 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 8 H. References ………………………….. ………………………….. ………………………….. …………………….. 9 Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectObstetrical Care Unbundled CostB. 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 office staff are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS)/International Classification of Disease-10 (ICD-10) code(s) for the product orservice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.Obstetrical care refers to the health care treatment given in relation to pregnancy anddelivery of a newborn child. This include s care during the prenatal period, labor, birthing,and the postpartum period. CareSource covers obstetrical services members r e c e iv e in a h o s p it a l o r b ir t h in g c e n t e r a s w e l l as all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of themedical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using CPT codes, HCPCS codes , and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record.. Unless otherwise noted, this policy is applicable to obstetricians-gynecologists (OB/GYNs),obstetricians (OBs), gynecologists (GYNs), and nurse-midwives.C. Definitions High risk delivery Labor management and delivery for an unstable or critically ill pregnant patient. Initial and Prenatal Visit Practitioner visit to determine whether member is pregnant . Pregnancy For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days. Premature Birth Delivery before 3 7 weeks of pr egnancy. Prenatal Profile Initial laboratory services. Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Unbundled ( Partial) Obstetrical Care The practitioner bill s delivery, antepartum care, and postpartum care independently of one another. o Antepartum Care (Prenatal) The initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and then weekly visits until delivery. o Delivery Services Admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery. o Postpartum Care Hospital and office visits following vaginal or cesarean section delivery . The American College of Obstetricians and Gynecologists (ACOG ) recommends contact within the first 3 weeks postpartum and ongoing care a re needed , concluding with a postpartum visit no later than 12 weeks after birth. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care . B. Unbundled Obstetric Care – Report the services performed using the most accurate, most comprehensive procedure code s available based on what services the practitioner performed. The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 1. Unbundled o bstetric care s hould be billed when any of the following occur : a. The member has a change of insurer during pregnancy b. The member has received part of the obstetrical care ( antenatal care , deliver, or postpartum care) elsewhere (eg , from another group practice ) c. The member leaves the pratitioners group practice before the global obstetrical care is complete d. The member must be referred to a provider from another group practice or a different licensure (eg , midwife to MD) for a cesarean delivery e. The member has an unattended precipitous delivery f. Termination of pregnancy without delivery (eg , miscarriage, ectopic pregnancy) 2. Antepartum care only Antepartum care only does not include delivery or postpartum care : a. Use the appropriate CPT and trimester code (s) : CPT Code DescriptionE/M For antepartum care for 1-3 visits 59425 Antepartum care only; 4-6 visits Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 59426 Antepartum care only; 7 or more visits b. For E/M codes, bill with a diagnosis code O09.00 O09.93 , Z33.3; Z34.00-Z34.93 . c. E/M codes for antepartum care are limited to 3. d. Use the appropriate modifier (This list may not be all inclusive): NOTE: For Federally Qualified Health Centers/Rural Health Clinics(FQHC/RHC) members antepartum E/M visit limits do not apply. Modifier Description24 To indicate that the E/M visit was not related to typical postpartum care during the global period e. Only one code, either 59425 or 59426 can be billed per pregnancy.f. Antepartum care only code includes the following (This list may not be all inclusive ): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly from 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent history 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualified health care professional providing all or a portion of antepartum/postpartum care, but no delivery 09. Routine chemical urinalysis 10. Termination of pregnancy by abortion 11. Referral to another physician for delivery . 3. Delivery only – Use i f only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code (s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive) Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 Services included that may NOT bebibilled separatelyServices excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal delivery Successful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Inducing labor using pitocin or oxytocin Injecting anesthesia Artificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as delivery Delivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of deliveryd. Modifiers 1. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 2. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be request ed . e. Use the appropriate modifier (This list may not be all inclusive): Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 CPT Code DescriptionUB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) 4. Delivery and postpartum care only – If only delivery and postpartum care were provided a. Use the appropriate CPT and outcome code: CPT Code Description59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care b. Modifiers1. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 2. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be requested. c. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately (This list may not be all inclusive): 1. Admission history 2. Admission to hospital 3. Artificial rupture of membranes 4. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 5. Hospital/office visits following cesarean section or vaginal delivery 6. Management of uncomplicated labor 7. Physical exam 8. Vaginal delivery with or without episiotomy or forceps 9. Caesarean delivery 10. Classic cesarean section 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery 13. Previous cesarean delivery who present with the expectation of a vaginal delivery Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 14. Caesarean delivery following unsuccessful vaginal delivery attempt after previous cesarean delivery d. Postpartum care only – If postpartum care only was provided: 1. Use code 59430 postpartum care only. 2. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. 3. There is no specified number of visits included in the postpartum code. This includes h ospital and office visits following vaginal or cesarean section delivery. ACOG recommends contact within the first 3 weeks postpartum. 4. Postpartum care may include; and therefore are NOT allowed to be billed separately (This list may not be all inclusive) : a. Hospital, office and outpatient visits following cesarean section or vaginal delivery b. Qualified health care professional providing all or portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion 5. The following are billable separately during the postpartum period (This list may not be all inclusive): a. Conditions unrelated t o pregnancy i.e. respiratory tract infection b. Treatment and management of complications during the postpartum period that require additional services II. Member EligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner MUST use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical or normal hospital ev aluation and management services are not reimbursable. B. If a member becomes eligible for Medicaid due to a live birth, no prenatal services including laboratory services are reimbursable . III. Multiple Gestations.A. Include diagnosis code for multiple gestations . B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed . C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . IV . High Risk DeliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.8 B. Modifier 22 may be added to the delivery code to support substantial additional work.Documentation must be submitted with the claim demonstrating the reason and the additional work provided . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. For antepartum care only (e.g. 59425, 59426) please bill only the final date of service rather than the full date span; failure to do so may result in a timely filing denial . The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code DescriptionE/M For antepartum care for 1-3 visits 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care 59430 Postpartum care only. F. Related Policies/RulesObs tetrical Care – Hospital Admissions Obstetrical Care – Total Cost G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy. Date Revised 04/01/2020 New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed total care information, updated most content, included modifiers and updated codes. Added Section E. For antepartum care only (e.g. Obstetrical Care-Unbundled Cost-GA MCD-PY-0924Effective Dat e: 04/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.9 09/15/202110/12/202211/06/202359425, 59426) please bill only the final date of service rather than the full date span; failure to do so may result in a timely filing denial. Added reimbursement policy language. Removed duplicate modifiers. Update References. Approved at PGC. Added that E/M antepartum visit limitations do not apply to FQHC/RHC Periodic review. Updated references. Approved at Committee. Date Effective 04/01/2025 Date Archived H. References1. American Academy of Professional Coders. Code Obstetrical Care with Confidence. December 1, 2011. Accesssed October 14, 202 4. www.aapc.com 2. American College of Obstetricians and Gynecologists. Billing for care after the initial outpatient postpartum visit: the fourth trimester. Accessed October 14, 2024. www.acog.org 3. American College of Obstetricians and Gynecologists. Optimizing postpartum care. Obstet Gynecol . ACOG Committee Opinion No. 736. 2018;131(5):e140-e150. Accessed October 14, 2024. www.acog.org 4. American College of Obstetricians and Gynecologists. Preterm Labor and Birth. Updated April 2023. Accessed October 14, 2024. www.acog.org 5. Policies and Procedures for Physician Services . Georgia Dept of Community Health, Division of Medical Assistance Plans; 2024. Accessed October 14, 2024. www.mmis.georgia.gov GA-MED-P-3459100 Issue Date 07/01/2017 Approved DCH 1 2/30 /202 4

Influenza Testing

CLIA-Waived Testing in Office Setting

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

Modifier 59, XE, XP, XS, XU

Modifier 25

Dental Services Rendered in a Hospital or Ambulatory Surgery Center

Overpayment Recovery