REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0074 03/15/2021 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, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Polici es. 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. Thi s Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred t o 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. Car eSource 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. Ac cording 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 Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Cov erage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 03/15/20212A. Subject COVID-19 Vaccine Reimbursement B. Background Reimbursement policies are designed to assist you 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 members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 /NDC 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. The 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) f or the following vaccines for the prevention of COVID-19: Pfizer-Bio NTech, Moderna, and Janssen as of February 2021. The Pfizer-BioNTech and Moderna vaccines are offered as a two-dose series. The Janssen vaccine is offered as a single-dose vaccine. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech, Moderna, and Janssen COVID-19 vaccines for the prevention of COV ID-19 in the U.S. The interim recommendations are derived from the EUA of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. The Centers of Medicare and Medicaid Services (CMS) and State Medicaid programs have released toolkits, guidance and bulletins on coverage and reimbursement. Additional considerations will be updated as additional information become available or if additional vaccine products are authorized. C. Policy This reimbursement policy outlines the reimbursement rates for COVID-19 vaccine and associated vaccine administration fees. Providers may bill CareSource through our standard claims processes. The following list(s) of codes is provided as a reference. This list may not be all inc lusive and is subject to updates. Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 03/15/20213HCPCS CodeDescription Reimbursement 91300 SARSCOV2 VAC 30MCG/0.3ML IM (Pfizer-Biontech Covid-19 Vaccine) $0.0 0* 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer-Biontech Covid-19 Vaccine Administration First Dose) $40.00 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer-Biontech Covid-19 Vaccine Administration Second Dose) $40.00 91301 SARSCOV2 VAC 100MCG/0.5ML IM (Moderna Covid-19 Vaccine) $0.0 0* 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose (Moderna Covid-19 Vaccine Administration First Dose) $40.00 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna Covid-19 Vaccine Administration Second Dose) $40.00 91303 SARSCOV2 VAC AD26 .5ML IM (Janssen Covid-19 Vaccine) $0.00* 0031A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5×10 10 viral particles/0.5mL dosage, single dose (Janssen Covid-19 Vaccine Administration) $40.00 Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 03/15/20214*Providers should note that the vaccine is available at no charge to providers at this time. Therefore, CareSour ce will pay at zero until further notice. Providers are still ask to bill the vaccine codes for data collection purposes. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts , utilizing appropriate NDC codes and POS National Council for Presription Drug Programs (NCPDP) codes for administration. Please visit the Express Scripts Pharmacist Resource Center for additional information. D. 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. E. Related Policies/Rules COVID-19 Vaccination Administrative Policy F. Review/Revision History DATE ACTIONDate Issued 12/18/2020 New policyDate Revised 03/03/2021 Policy revised to include information about Janssen COVID-19 vaccine. Reimbursement amoun ts updated. Date Effective 03/15/2021 Date Archived G. References 1. Centers for Medicare & Medicaid Services. Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans. 2. Centers for Medicare & Medicaid Services. Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Childrens Health Insurance Program, and Basic Health Program . 3. Georgia Department of Community Health. Medicaid-PeachCare Notification 01/11/2021: Oupatient Fee-For-Service Pharmacy Program Important Information. The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date COVID-19 Vaccine Reimbursement PY-PHARM-0074 12/18/2020 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, 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. Thi s 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. Car eSource 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. Ac cording 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 Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Cov erage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 12/18/20202A. Subject COVID-19 Vaccine Reimbursement B. Background Reimbursement policies are designed to assist you 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 members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 /NDC 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. The 2019 novel coronavirus, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease known as coronavirus disease 2019 (COVID-19). The Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) for two vaccines for the prevention of COVID-19: Pfizer-BioTech and Moderna as of December 2020. Both vaccines are offered as a two-dose series. The EUA allows the vaccines to be widely distributed in the United States. The Advisory Committee on Immunization Practices (ACIP) has issued interim recommendations for the use of Pfizer-BioNTech and Moderna COVID-19 vaccines for the prevention of COVID-19 in the U.S. The interim recommendations are derived from the EUA of the vaccines, other data sources, general best practice guidelines for immunization, and expert opinion. The Centers of Medicare and Medicaid Services (CMS) and State Medicaid programs have released toolkits, guidance and bulletins on coverage and reimbursement. Additional considerations will be updated as additional information become available or if additional vaccine products are authorized. C. Policy This reimbursement policy outlines the reimbursement rates for COVID-19 vaccine and associated vaccine administration fees. Providers may bill Ca reSource through our standard claims processes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 12/18/20203HCPCS CodeDescription Reimbursement 91300 SARSCOV2 VAC 30MCG/0.3ML IM (Pfizer-Biontech Covid-19 Vaccine) $0.0 0* 0001A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose (Pfizer-Biontech Covid-19 Vaccine Administration First Dose) $10.00 0002A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose (Pfizer-Biontech Covid-19 Vaccine Administration Second Dose) $10.00 91301 SARSCOV2 VAC 100MCG/0.5ML IM (Moderna Covid-19 Vaccine) $0.0 0* 0011A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage ; first dose (Moderna Covid-19 Vaccine Administration First Dose) $10.00 0012A Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spi ke protein, preservative free, 100 mcg/0.5mL dosage; second dose (Moderna Covid-19 Vaccine Administration Second Dose) $10.00 *Providers should note that the vaccine is available at no charge to providers at this time. Therefore, CareSource will pay at zero until further notice. Providers are still ask to bill the vaccine codes for data collection purposes. Pharmacies should submit claims through their pharmacy claims platform through our pharmacy benefits manager, Express Scripts , utilizing appropriate NDC codes and POS National Council for Presription Drug Programs (NCPDP) codes for administration. Please visit the Express Scripts Pharmacist Resource Center for additional information. Archived COVID-19 Vaccine Reimbursement GEORGIA MEDICAID PY-PHARM-0074 Effective Date: 12/18/20204D. 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. E. Related Policies/Rules COVID-19 Vaccination Administrative Policy F. Review/Revision History DATE ACTIONDate Issued 12/18/2020 New policyDate Revised Date Effective 12/18/2020 Date Archived G. References 1. Centers for Medicare & Medicaid Services. Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans. 2. Centers for Medicare & Medicaid Services. Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Childrens Health Insurance Program, and Basic Health Program . 3. Georgia Department of Community Health. Medi caid-PeachCare Notification 01/11/2021: Oupatient Fee-For-Service Pharmacy Program Important Information. The Reimbursement Policy Statement detai led above has r eceived due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Date Effective Drug Testing PY-0156 04/01/2021-11/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 6 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 6 Reimbursement Policy St at ement : 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, ben efits 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 dis ease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of go od 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, Ev idence 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 contr act (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 sub ject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. 2 A. SubjectDrug Testing Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy 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 verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) f or the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring,and recovery phase f or members with subst ance use disorder (SUD); for members who are at risk f or abuse/misuse of drugs; or f or other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Ur ine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualitative and conf irmatory/quantitative. Drug testing is sometimes also ref erred to as toxicology testing. C. Def initions Presumptive/Qualitative test – The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test – A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or def initive testing. Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) – This benefit provides comprehensive and preventive health care services f or children under age 21 who are enrolled in Medicaid. Rando m drug test – A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory – A laboratory certif ied to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating – Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Residential services – Psychiatric Residential Treatment Facilit y (PRTF) services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults 21 years of age or younger who, due to severe emotional disturbance, are in need of quality active treatment that can only be 3 Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 provided in an inpatient treatment setting and f or whom alternative, less restrictive f orms of treatment have been unsuccessf ul or are not medically indicated. PRTFs serve as the most intensive, inpatient treatment f or youth/young adults with severe behavioral health disorders. 1 NOTE: Clinical guidelines, definitions, standards, and scenarios f or drug testing are outlined in detail within the CareSource Drug Testing Medical Policy. Please ref er to this policy f or in-depth information on medical necessity f or drug testing, documentation requirements, and CareSource monitoring and review of drug testing claims. D. Poli cyI. General Criteria f or Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication f or UDT. C. The submitted CPT/HCPCS code must accurately describe the service perf ormed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims f orms. II. Prior Authorization (PA)A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they f all within the standards of care under EPDST guidelines. 1. PA is required f or UDT f or members when a conf irmatory test f or greater than 14 drug classes (Codes G0482 & G0483) are ordered . These higher number drug panels are rarely indicated f or routine urine drug testing as lower number panels are suf f icient for modifying treatment plans in the majority of cases. 2. PA is not required in an emergency room setting. UDT utilization will be monitored by CareSource. 3. PA needs to make a clear case f or medical necessity f or the level of testing being requested. B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. f reezing specimen. C. Must submit appropriate clinical documentation with PA request to determ ine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. III. Quantity LimitationsA. CareSource will reimburse up to 25 UDT in a calendar year f or each member. 1. Each CPT code is counted as one test toward the 25 total drug tests in a calendar year. 1 www.m m is.georgia .gov4 Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 2. UDT G0482 and G0483 (requiring a PA as noted above) will also count toward the 25 total UDT in a calendar year. B. Only one presumptive testing CPT code may be billed per member per day. C. Only one conf irmatory testing CPT code (drug class) may be billed per member per day. IV. LaboratoryA. Drug testing conducted f or CareSource members by non-participating labs or f acilities is not billable to and will not be reimbursed by CareSource, even if suc h tests were ordered by a participating provider. B. Non-participating providers are not covered for drug testing laboratory services. C. CareSource laboratories perf orming drug testing services must bill CareSource directly. CareSource does not allow pass-throu gh billing of services . Any claim submitted by a provider which includes services ordered by that provider, but are perf ormed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care service f or children under age 21. VI. Non-Urine TestingA. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples perf ormed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body f luid testing f or controlled substance monitoring has limited support in medical evidence and is not covered VII. Conf irmatory TestingA. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource. B. Conf irmatory testing must be individualized f or the member and medically necessary. Routine conf irmatory dru g tests with negative presumptive results are not covered by CareSource. C. Conf irmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modif ication of treatment plan, consultation with specialist and one of the f ollowing: a. Presumptive testing was negative f or prescription medications and provider was expecting the test to be positive f or prescribed medication and member reports taking medication as prescribed; b. Presumptive testing was positive f or prescription drug with abuse potential that was not prescribed by provider and the member disputes the presumptive testing results; c. Presumptive testing was positive f or illegal drug and the member disputes the presumpti ve testing results; or d. A substance or metabolite is needed to be identif ied that cannot be identif ied by presumptive testing. (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing5 A. Testing that is not individualized such as1. Ref lexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing required by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing f or pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery f or physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing f or athletics. 5. Testing required for military service. 6. Testing in residential f acility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or f ederal agency. 8. Testing f or marriage license. 9. Forensic. 10. Testing f or other admin purposes. 11. Routine physical/medical examination EXCEPT f or the EPSDT program. C. Testing f or validity of specimen It is included in the payment f or the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body f luid testing f or controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing f ollowing a negative presumptive expected result. I. Custom Prof iles, standing orders, drug screen panel, custom panel, blanket orders, ref lex testing or conduct additional testing as needed orders. K. A conf irmatory test p rior to discussing results of presumptive test with member. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. 6 F. RELATED POLIC IES/RULESCareSo urce Drug Testing Medical Policy G. REVIEW/REVISION HISTORY Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 DATE ACTIONDate Issued 11/29/2017Date Revised 09/01/2019 07/22/202009/02/2020Up d ated clinical indications, quantity limits, and prior autho rizatio ns requirements Up d ated IV Up d ated codes and removed PA for non-p articipating Date Effective 04/01/2021 Date Archived 11/30/2021 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. REFERENCES1. A. Jaf f e, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016, January). Review and recommendations f or drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . 2(1): 28-45. doi: 10.17756/jrdsas.2016-025 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of def initive drug testing results in their work with substance – use patients: A qualitative study. International Journal of Mental Health and Addiction. (14) 64-80. doi: 10.1007/s11469-015-9569-7 3. American Society of Addiction Medici ne. (2017, May/June). Appropriate use of drug testing in clinical addiction medicine. 11(3) 163-173. doi: 10.1097/ADM.0000000000000323 4. Andersson, H. W., Wenaas, M., & Nordf jrn, T. (2019). Relapse af ter inpatient substance use treatment: A prospective cohort study among users of illicit substances. Addictive Behaviors, (90)222-228. doi:10.1016/j.addbeh.2018.11.008 5. American Society of Addi ction Medicine (2010, October) . Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings . Retrieved August 12, 2020 from www.asam.org. 6. Dowel l, D., Haegerich, T. M., & Chou, R. (2016, March). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016 . Retrieved August 12, 2020 f rom www.cdc.gov 7. eCFR Code of Federal Regulations. 42 Code of Federal Regulations (CFR) Part 8. (n.d.). Retrieved August 12, 2020 f rom www.ecfr.gov 8. Gourlay, D. L., Heit, H. H., & Caplan, Y. H. (2015, August 31). Urine Drug Testing in Clinical Practice The Art and Science of Patient Care (Edition 6). PharmaCom Group Inc./Center for Independent Healthcare Education 9. Jarvis, M, Williams, J, Hurf ord, M, Li ndsay, D, Lincoln, P, Giles, L, Luongo, P,..Saf arian, T. (2017, April 5). Appropriate Use of Drug Testing in Clinical Addiction Medication. Journal of Addiction Medicine . Retrieved August 12, 2020 f rom www.dca.ca. gov 10. Medicare Learning Network. (2020, May). CLIA Program and Medicare Laboratory Services. Retrieved August 12, 2020 f rom www.cms.gov 7 Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 04/01/2021 11. National Academies of Sciences, Engineering, and Medicine. 2017. Pain Owen, G, Burton, A, Schade, C, Passik, S. (2012). Urine Drug Testing: Current management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription opioid use . Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24781 .Recommendations and Best Practices. Pain Physician Journal . 15, ES119-ES133. Retrieved August 12, 2020 from www.painphysicianjournal 12. Reisf ield, MD, G. M., Webb, PhD, F. J., Bertholf, PhD, R. L., Sloan, MD, P. A., & Wilson, MD, G. R. (2007). Family physicians prof iciency in urine drug test interpretation. Journal of Opioid Management , 3(6), 333. doi:10.5055/jom.2007.0022 13. Substance Abuse and Mental Health Services Administration. Clinical Drug Testing in Primary Care. Technical Assistance Publication (TAP) 32. HHS Publication No. (SMA) 12-4668. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. 14. Stanos, S. P. (2017, October 10). Presidents Message. National Academies of Sciences, Engineerin g, and Medicine (NASEM). Pain Medicine. 18(10). 1835-1836. doi:10.1093/pm/pnx224 15. U.S. Department of Veterans Af fairs. (2017, February). VA/DoD Clinical Practice Guideline f or Opioid Therapy for Chronic Pain. Retrieved August 12, 2020 from www.va.gov 16. Agency Medical Directors Group. (2010). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. Retrieved August 12, 2020 f rom www.agencymed directors.wa.gov 17. GAMMIS. Policies and Procedures for Ind ependent Laboratory Services (2020, July). Retrieved February 26, 2019 from www.mmis.georgia.gov 18. GAMMIS. Policies and Procedures for Physician Services (2020, July 1). Retrieved February 26, 2019 f ro m www.mmis.georgia.gov Th e Reimbursemen t Po licy Statemen t d etailed above h as received d ue co nsideratio n as d efined in th eReimbursemen t Po licy Statemen t Po licy an d is ap proved .GA-MED-P-383892 Issue d ate 11/29/2017 DCH Ap p ro ved 12/31/2020
Reimbursement Policy Statement: 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 serv ice(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 (MHP AEA), 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 Policy Number Effective Date Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center PY-0847 01/01/2021-07/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement ……………………………………………………………………………………. 1 A. Subject …………………………………………………………………………………………………………………. 2 B. Background …………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………… 4 E. Conditions of Coverage ………………………………………………………………………………………….. 5 F. Related Policies/Rules ……………………………………………………………………………………………. 8 G. Review/Revision History …………………………………………………………………………………………. 8 H. References …………………………………………………………………………………………………………… 8 2 A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center B. Background Reimbursement policies are designed to assist you 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 members eligibility. 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. Most dental care can be provided in a traditional dental office setting with local anesthesia and if medically nec essary, a continuum of behavior guidance strategies, ranging from simple communicative techniques to nitrous oxide, enteral or parenteral sedation. Monitored Anesthesia Care or Sedation (Minimal, Moderate or Deep) may be a requirement of some patients including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitations or other special needs. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologist s (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia in a healthcare facility such as an Ambulatory Surgical Center or Outpatient Hospital facility.C. D EFINITIONS Ambulatory Surgical Center (ASC) – Any freestanding institution, building, or facility or part thereof, devoted primarily to the provision of surgical treatment to patients not requiring hospitalization, as provided under provisions of Georgia Code Section 88-1901. Such facilities do not admit patients for treatment, which normally requires overnight stay, nor provide accommodations for treatment of patients for period of twenty-four (24) hours or longer. It is not under the operation or control of a hospit al. The term does not include individual or group practice offices of private physicians or dentists, unless the offices have a distinct part used solely for outpatient surgical treatment on a regular and organized basis, and has been regulated and certified by the state as such. Inpatient Hospital-A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Off Campus-Outpatient Hospital-A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.3 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 On Campus-Outpatient Hospital-A portion of a hospitals main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. SPU Short procedure unit-A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. Minimal Sedation (Anxiolysis ) – A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (Conscious Sedation) – A drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular func tion is usually maintained. Monitored Anesthesia Care (MAC) does not describe the continuum of depth of sedation; rather it describes a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. ** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Deep Sedation/Analgesia-A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia-A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (Conscious Sedation) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia. *** Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation.4 D. PolicyDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 Most dental care and/or oral surgery is effectively provided in an office setting. However, some members may have a qualifying condition that requires the procedure be provided in a hospital setting or ambulatory surgical center under general anesthesia. The purpose of this document is to provide reimbursement and billing guidance for facility related services when dental procedures are rendered in a in a Hospital or Ambulatory Surgical Center (ASC) Place of Service (POS) under general anesthesia. Hospital Inpatient or Outpatient Facility services and ASC Facility services for the provision of dental care under general anesthesia are addressed in this policy, not dental care or oral surgery in an office setting. Professional dental services are covered only to the extent that the member has dental benefits and guidelines for dental services are provided in the applicable dental policy manual. CareSource policy notes the intent of Hospital, Outpatient, and ASC facility requests is the medical necessity of general anesthesia services to perform dental procedures on a member. Requests with the goal of no, minimal, moderate or deep sedation services, will only be considered in extenuating circumstances mandated by systemic disease for which the patient is under current medical management and which increases the probability of complications, such as respiratory illness, cardiac conditions or bleeding disorders. Medical Record and Physician attested letter would be required with authorization requests. I. Prior authorization A. A prior authorization is required for all Hospital Inpatient or Outpatient Facility or Ambulatory Surgery Center Facility procedures that require general anesthesia or anesthesia monitoring with sedation. 1. No prior authorization is required for CPT 00170. B. The review for dental services in a Hospital Inpatient or Outpatient Facility or Ambulatory Surgery Center Facility under anesthesia is a two-step process. 1. STEP ONE is completed by the Treating Dentist . An authorization for the requested dental services is sent to the Dental Utilization Management (UM-DM) team who will determine the medical necessity of the services being completed in a hospital or outpatient setting. a. For authorization requests for POS (19, 21, 22, or 24) medical necessity review, the Treating Dentist should submit at least one (1) unit of (D9420) hospital or ambulatory surgical center call. b. The pre-determination letter (PDL) or authorization is sent to the treating/submitting dentist and to the member. c. The treating/submitting dentist must provide the facility with the PDL. 2. STEP TWO is completed only after the first step has been approved. a. The Facility will submit a precertification/authorization to the medical management team and must include a copy of the PDL. b. The Medical Utilization Management (UM-MM) team will complete ALL of the following: 01. Verify that facility is in or out of network AND; 02. Review the pre-determination letter (PDL) or authorization AND; 03. Determine medical necessity for any other non-dental CPT/HCPCS codes submitted AND; 04. The Medical Management approval of D9420 is sent via a letter 5 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center GEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 to the facility, member, and Treating Dentist. This letter indicates approval of D9420 for (19) Off Campus-Outpatient Hospital, (21) Inpatient Hospital, (22) On Campus-Outpatient Hospital, or (24) Ambulatory Surgical Center setting and General Anesthesia Services if applicable. I I. Additional guidelines on the benefit limits/frequencies of D9420 can be found in theDental Health Partner Provider Manual. NOTE: Please remember that the provider who submits the authorization for the dental therapeutic services must be the provider that performs the services. If the authorized provider does not perform the service, claims will deny. In the event the authorized provider is unable to perform the services or the location changes, CareSource must be notified to update the authorization prior to the services being performed. E.Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.T he following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates.R evenue codes and additional information can be found in the Department ofCommunity Health and ASC Policy manuals as well as the Dental Health PartnerProvider Manual.Outpatient Hospital Facility (SPU) POS (19, 22) CPT Code Description D9420 D9420 for the technical component to the facility SPU/OR use is calculated in time units 1 unit = 30 minutes. The maximum units reimbursable per date of service is 6 units Operating Room-When a hospital outpatient, SPU or organized outpatient clinic operating room is used for patient dental services, a single HCPCS code for reporting the facility technical component of multiple dentoalveolar procedures is used. That code must be utilized rather than reporting the tests or procedures individually. (CPT/HCPCS code 41899, discontinued by State, should not be used). Facility should use D9420 with appropriate billed charges of OR time use for dental services performed. Any other Dcodes listed will be for procedural documentation only and not for reimbursement. 6 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 No HCPCS required Recovery Room – Recovery Room is intended for cases when a patient requires recovery from deep sedation or anesthesia. Recovery room use is reimbursable only when billed for the same date of service as a surgery that is not considered a common office procedure. No HCPCS required HCPCS required for revenue code 0636* Hospital Add-On (HAO) services only applicable if state or contract required. Separate reimbursement may not be applicable. Maximum allowances may be applicable0017000170 is calculated in CMS Base units. The Base unit =5 units. Reimbursement will be subject to maximum allowances. Anesthesia Services-Anesthesiology professional Services for intraoral procedures. Time units for physician and CRNA services-both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (i.e. 75 minutes) 75 = 6 units (of 15 min increments). CMS Base units =5. Maximum state allowances may be applicable.Inpatient Hospital Facility POS (21) All of the above facility codes as well as any additional Room and Board fees would have to be pre-certified and receive medical necessity review. Services are subject to benefit provisions Ambulatory Surgical Center POS (24)CPT Code DescriptionD9420 D9420 for the technical component to the facility or ASC use is calculated in time units 1 unit = 30 minutes. The maximum units reimbursable per date of service is 6 units. Operating Room-A single code for reporting the facility fee must be used for the ASC or Facility should use D9420. (CPT/HCPCS code 41899), discontinued by State, should not be used. CareSources policy is aligned with State policy is D9420 is used a global code for ASC facility services. 7 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 00170 00170 is calculated in CMS Base units. The Base unit =5 units. Reimbursement will be subject to maximum allowances. General Anesthesia for intraoral procedures, including biopsy; not otherwise specified-Anesthesiology professional Services for intraoral procedures. Time units for physician and CRNA services-both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal plac e. Total minutes are listed as the units (i.e. 75 minutes) 75 = 6 units (of 15 min increments). CMS Base units =5. Maximum state allowances may be applicable. Dental/Oral Surgery Professional Services The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. The professional dental procedure codes listed are for reference only and do not imply coverage of dental procedures. Information on dental benefits, please consult Dental Health Partner manual for clinical guidelines, policies and procedures CPT Code Description(D0000 – D9999) Reimbursed according to provider contractual rate Dental Services using the CDT codes-Follow applicable clinical policy guidelines in Dental Health Partner Provider Manual Dental service charges will be paid directly to the TREATING DENTIST PAYEE GORUP All dental services that require authorization must receive prior authorization via Dental Management. ICD-10 and CPT code for Oral or Maxillofacial region Other Services Oral or Macillofacial Services using CPT codes – Follow applicable benefit guidelines in Health Partner manual for CPT code All medical services of th e oral, maxillofacial, head and neck regions performed in the hospital/ASC must receive prior authorization from the Medical Management team 8 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center GEORGIA MEDICAID PY-0847 Effective Date: 01/01/2021 F.Related Policies/RulesG. Review/Revision History DATE ACTION Date Issued 10/01/2019 New Policy Date Revised 08/19/2020 Removed PA for CPT 00170. Date Effective 01/01/2021 Date Archived 07/31/2022This 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. Part II Policies and Procedures for Ambulatory Surgical and Birthing Center Services(2020, July). Retrieved on July 3, 2020 from www.mmis.georgia.gov2. P art II Policies and Procedures for Dental Services (2020, July). Retrieved on July30, 2020 from www.mmis.georgia.gov3. P art II Policies and Procedure for Hospital Services (2020, July). Retrieved on July30, 2020 from www.mmis.georgia.gov4. C ontinuum of Depth of Sedation: Definition of General Anesthesia and Levels ofSedation/Analgesia. (2018, October 23). Retrieved July 30, 2020, from www.asahq.org5. A merican Academy of Pediatric Dentistry. Oral Health Policies andRecommendations. (2019). Retrieved July 20, 2020 from www.aapd.org6. A merican Association of Oral and Maxillofacial Surgeons, Ambulatory SurgicalCenter Coding and Billing. Retrieved April 5, 2019 from www.aaoms.orgThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1075 01/01/2021-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard 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 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 func tion, 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 p rovider. 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 make the determination. CSMG Co. 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. 2 A. SubjectImplantable Spinal Cord Stimulator Imp lan table Sp in al Co rd Stimulato rGEORGIA MEDICAID PY-1075 Effective Date: 01/01/2021 B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy 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 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/HCPCS 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. Nearly 84% of adults experience back pain during their lif etime. Long term outcomes are largely f avorable f or most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is def ined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures f or management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multi disciplinary treatments include promoting patient self – management and aim to reduce the impact of pain on a patient’s daily lif e, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conserva tive treatment should be provided only by physicians qualif ied to deliver these health services. C. Def initions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrica l current to the spinal cord to block the sensation of pain . D. Policy I. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required f or all implantable spinal cord stimulators, including short-term trial placement, permanent placement and removal and revision of the implanted device. 1. Prior authorizations f or implantable spinal cord stimulator services are not required f or the following: a. Implantable device and device components are considered part of the procedure and does not require a sepa rate PA. 3 b. Electronic analysis/studies post implantation Imp lan table Sp in al Co rd Stimulato rGEORGIA MEDICAID PY-1075 Effective Date: 01/01/2021 B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria f ound in the Implantable Spinal Cord Stimulator Medical policy MM-0812. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Implantable S pinal Cord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy f or implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including f luoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including f luoroscopy, when perf ormed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including f luoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including f luoroscopy, when performed 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording f rom the central nervous system; in upper limbs 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording f rom the central nervous system; in the trunk or head 95928 Central motor evoked potential study (transcranial motor stimulation); upper limbs 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs 4 Imp lan table Sp in al Co rd Stimulato rGEORGIA MEDICAID PY-1075 Effective Date: 01/01/2021 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording f rom the central nervous system; in upper and lower limbs 95939 Central motor evoked potential study (transcranial motor stimulation); in upper and lower 95970 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, f requency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, a nd passive parameters) by physician or other qualif ied health care prof essional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/transmitter, without programming 95971 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, f requency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualif ied health care prof essional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or oth er qualif ied health care professional 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, f requency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualif ied health care prof essional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimul ator pulse generator/transmitter programming by physician or other qualif ied health care professional F. Related Policies/RulesImplantable Spinal Cord Stimulator MM-0812 G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020Date Revised 08/26/2020 PA is now required for removal/revision of implanted device. Date Effective 01/01/2021 Date Archived 05/31/2021 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy 5 H. Ref erencesImp lan table Sp in al Co rd Stimulato rGEORGIA MEDICAID PY-1075 Effective Date: 01/01/2021 1. Georgia Department of Community Health Fee Schedules. Retrieved on April 22, 2020 f rom www.mmis.georgia.com The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Pain Pump PY-1069 01/01/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Polici es. 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. CSMG Co. 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.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Implantable Pain PumpGEORGIA MEDICAIDPY-1069 Effective Date: 01/01/2021 2 A. SubjectImplantable Pain Pump B. Background Reimbursement policies are designed to assist you 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 act ual 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 members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate andappropriate 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.Nearly 84% of adults experience back pain during their lifetime. Long term outcomes arelargely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Stud y of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conserva tive treatment ina multimodality approach. Multidisciplinary treatments include promoting patient self-management and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Implantable Pain Pump – Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for continuous or variable rates of infusion . D. Policy I. Prior authorization (PA) is required for all implantable pain pumps, including trial administration, permanent placement and single shot intrathecal injections for the treatment of severe chronic intractable pain of malignant or non-malignant origin. Prior authorization is also required for the removal or revision of the implanted device. Implantable Pain PumpGEORGIA MEDICAIDPY-1069 Effective Date: 01/01/2021 3 A. Prior Authorizations are not required for the following services:1. Implantable device is considered part of the procedure and does not require a separate PA; and 2. Electronic analysis /studies post transplantation . B. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump Medical policy MM-0802 . E. Conditions of Coverage Reimburs ement 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 all inclusive and is subject to updates . Implantable Pain PumpDescription 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62355 Removal of previously implanted intrathecal or epidural catheter 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming 623 65 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming 62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill Implantable Pain PumpGEORGIA MEDICAIDPY-1069 Effective Date: 01/01/2021 4 (requiring skill of a physician or other qualifie d health care professional) F. Related Policies/Rules Implantable Pain Pump MM-0802 G. Review/Revision History DATE ACTIONDate Issued 12/11/2019Date Revised 08/26 /2020 PA is now required for removal/revision of the implanted device. Date Effective 01/01/20 21 Date Archived H. References1. Georgia Department of Community Health Fee Schedules. Retrieved on April 15, 2020 from mmis.georgia.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in the Reimbursement Policy Statement Policy and is app roved.
Reimbursement Policy Statement: 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, indust ry-stand ard 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 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, dysfun ction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in th e local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medicall y 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 ens ure 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 contr act (i.e., Evidence of C overage), 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 les s favorable than the limitations that apply to medical conditions as covered under this policy . REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Date Effective Drug Testing PY-0156 12/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT C ontents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2 D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 6 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………… 7 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 7 2 A. Subject Drug Testing Drug TestingGEORGIA MEDICAID PY-0156 Effective Date: 12/01/2020 B. BackgroundReimbursement policies are designed to assist you 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 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 code(s) for the product or service that is being provided. The inclusio n of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medi care Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug tes t guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive/qualit ative and confirmatory/quantitative. Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive/Qualitative test – The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory/Quantitative test – A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Early and Periodic Screening, Diagnostic and Treatment (EPSDT ) – This benefit provi des comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test – A laboratory drug test administered at an irregular interval that is not known in advance by the member. Independent laboratory – A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a providers office. Participating/non-participating – Participating means in-network and contracted with CareSource. Non-particip ating, means out-of-network, not contracted with CareSourc e. Residential services – Psychiatric Residential Treatment Facility (PRTF) services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults 21 years of age or younger who, due to severe emotional disturbance, are in need of quality active treatment that can only be 3 Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 12/01/2020 provided in an inpatient treatment setting and for whom alternative, less restrictive forms of treatment have been unsuccessful or are not medically indicated. PRTFs serve as the most intensive, inpatient treatment for youth/young adults with severe behavi oral health disorders. 1 NOTE: Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0127. Please refer to this policy for in-depth information on medical necessity for drug testing, documentation requirements, and CareSource monitoring and review of drug testing claims. D. PolicyI. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the ICD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of t he claims forms. II. Prior Authorization (PA)A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. 1. PA is required for UDT for members when a confirmatory test for greater than 14 drug classes (Codes G0482 & G0483) are ordered . These higher number drug panels are rarely indicated for routine urine drug testing as lower number panels are sufficient for mo difying treatment plans in the majority of cases. 2. PA is required for any non-participating provider with CareSource for non – emergency room setting. 3. PA is not required in an emergency room setting. UDT utilization will be monitored by CareSource. 4. PA needs to make a clear case for medical necessity for the level of testing being requested. B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process is complete i.e. freezi ng specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authorization. 1 https:// www.mmis.georgia.gov/portal/portals/0/staticcontent/public/all/handbooks/psychiatric%20residential%20trea tment%20facility%20 20190108214956.pdf 4 III. Quantity Limitations Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 12/01/2020 A. CareSource will reimburse up to 25 UDT in a calendar year for each member. 1. Each CPT code is counted as one test toward the 25 total drug tests in a calendar year. 2. UDT G0482 and G0483 (requiring a PA as noted above) will also count toward the 25 total UDT in a calendar year. B. Only one presumptive testing CPT code may be billed per member per day. 1. 80305 2. 80306 3. 80307 C. Only one confirmatory testing CPT code (drug class) may be billed per member per day. 1. G0480 2. G0481 3. G0482 4. G0483 IV. LaboratoryA. Drug testing conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. Non-participating providers are not covered for drug testing laboratory services. C. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services . Any claim submitted by a provider which includes services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive he alth care service for children under age 21. VI. Non-Urine TestingA. CareSource will reimburse blood testing in emergency room settings. B. Drug testing with blood samples performed in any other setting outside of an emergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VII. Confirmatory TestingA. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource. B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test r esults will guide plan of care i.e. modification of treatment plan, consultation with specialist and one of the following: 5 Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 12/01/2020 a. Presumptive testing was negative for prescription medications and provider was expecting the test to be positive for prescribed medication and member reports taking medication as prescribed; b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider and the member disputes the presumptive testing results; c. Presumptive testing was positive for illegal drug and the member disputes the presumptive testing results; or d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing. (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testing that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing required by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc .). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Forensic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result. 6 Drug Testing GEORGIA MEDICA ID PY-0156 Effective Date: 12/01/2020 I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. K. A confirmatory test prior to discussing results of presumptive test w ith member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review.E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the Georgia Medicaid fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Codes Qualitative/Presumptive Tests-Description80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, p er date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, pe r date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometr y either with or without chromatography, (e.g., DART, DESI, GC-MS, GC – MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative/Confirmatory Tests-Description G0480 Drug Test definitive/Quantitative 1-7 drug classes 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 limi ted 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 s pectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug Test definitive/Quantitative 8-14 drug classes 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/M S (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) 7 Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 12/01/2020 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 G0482 Drug testing definitive/Quantitative 15-21 classes 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 limi ted 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 s pectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed G0483 Drug testing definitive/Quantitative 22+ classes 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/M S (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 mat rix 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 so urces, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed F. RELATED POLICIES/RULESCareSource Drug Testing Medical Policy MM-0127 G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 11/29/2017Date Revised 09/01/2019 07/22/2020Updated clinical indications, quantity limits, and prior authorizations requirementsUpdated IV Date Effective 12/01/2020 H. REFERENCES1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved December 11, 2018 from www.blumsrewarddeficiencysyndrome.com 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 8 Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 12/01/2020 3. American Society of Addiction Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved December 11, 2018 from www.asam.org 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved December 13, 2018 from www.journals.lww.com 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendations and Reports Retrieved December 11, 2018 from www.dx.doi.org 6. eCFR Code of Federal Regulations. (n.d.). Retrieved December 11, 2018 from www.ecfr.gov 7. GAMMIS. Policies and Procedures for Independent Laboratory Services (2019). Retrieved February 26, 2019 from www.mmis.georgia.gov 8. GAMMIS. Policies and Procedures for Physician Services (2019). Retrieved February 26, 2019 from www.mmis.georgia.gov 9. GAMMIS. Policies and Procedures for Psychiat ric Residential Treatment Facilities (2019). Retrieved February 26, 2019 from www.mmis.georgia.gov 10. Medicaid. Early and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved December 11, 2018 from www.medicaid.gov 11. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal . Retrieved December 13, 2018 from www.painphysicianjournal.com 12. U.S. Department of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved December 11, 2018 from www.va. gov 13. Washington State Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain. (2017) Retrieved December 11, 2018 from www.kbml.ky.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in theReimbursement Policy Statement Policy and is approved. GA-MED-P-235116 Issue Date 11/29/2017 DCH Approved 09/21/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Facet Joint Interventions PY-116 2 12/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirement s, 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 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 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 Pari ty 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 Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Facet Joint InterventionsGEORGIA MEDICAIDPY-1162 Effective Date: 12/01/2020 2 A. SubjectFacet Joint Interventions B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies a re 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 actu al 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 members eligibility. It is the responsibility of the sub mitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or s ervice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Interventiona l procedures for management of acute and chronic pain are part of acomprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-management and ai m to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Zygapophyseal (aka facet) Joint Level – refers to the zygapophyseal joint or the two medial branch (MB) nerves that innervate that zygapophyseal joint. Diagnostic Medial Branch Nerve Block Injection – refers to the diagnosis of facet – mediated pain requiring the establishment of pain relief following medial branch blocks (MBB) or intra-articular injections (IA). Neither physical exam nor imaging has adequate diagnostic power to confidently distinguish t he facet joint as the pain source. Radiofrequency Facet Ablation (RFA) – is performed using percutaneous introduction of an electrode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves . D. PolicyI. Facet Joint Interventions A. A p rior authorization (PA) is required for each facet joint intervention for pain management. Documentation, including dates of service, for conservative therapies are not required for PA, but must be available upon request. Facet Joint InterventionsGEORGIA MEDICAIDPY-1162 Effective Date: 12/01/2020 3 II. Medial Branch Nerve Block InjectionsA. Up to two medial branch nerve block injections in the cervical/thoracic or lumbar regions are considered medically necessary. 1. Only three (3) spinal levels (unilateral or bilateral) may be treated at the same time (maximum amount of six injections per rolling 12 months); 2. A response of at least 50% pain relief must be achieved before the second injection is performed; and 3. Injectio ns should be at least two (2) weeks apart. 4. Maximum number of benefit limits in this policy are based on medial necessity. 5. The member must meet the medically necessary criteria in the corresponding Facet Join t Interventions medical policy, before a diagno stic injection is performed. III. Per CPT guidelines, imaging guidance and any injec tion of contrast are inclusive components of all facet medial branch nerve blocks and are not reimbursed separately. IV. Radiofrequency Facet AblationA. Radiofrequency Facet Ablations are considered medically necessary when the member meets ALL of the medically necessary criteria in the corresponding Facet Joint Interventions medical policy . B. A maximum of four (4 ) radiofrequency facet ablation s per rolling twelve (12) months (two left and two right per spinal region: cervical, thoracic or lumbar). C. Repeat Radiofrequency Facet Ablation in the same spin al region and side is considered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy has been met. V. Sedation A. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necessary for intra-articular facet joint injections or medial branch blocks and are not routinely reimbursable. 1. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. 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. The following list(s) of c od es is provided as a reference. This list may not be all inclusive and is subject to updates. Facet Joint InterventionsGEORGIA MEDICAIDPY-1162 Effective Date: 12/01/2020 4 F. Related Policies/RulesFacet Joint Interventions Medical Policy G. Review/Revision History DATE ACTIONDate Issued 05/13/2020 This policy replaces the Facet Medial BranchNerve Block and Radiofrequency Facet Ablation policies. Date Revised 07/22/2020 11/11/2020Revisions: Medial Branch Nerve Block injection clinical criteria; requirement of one successful RFA session.Revision: RFA language revised around benefitlimit for clarity. (This revision does not require a network notification or a change of the Effective Date). Date Effective 12/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedules. Retrieved on April 15, 2020 from mmis.georgia.gov The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.
Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, 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 not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illne ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n 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 C overage 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 make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to servic es provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Pain Pump PY-1069 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. …………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 H. References ………………………….. ………………………….. ………………………….. …………………….. 4 2 A. Subject Implantable Pain Pump Implantable Pain Pump GEORGIA MEDICAIDPY-1069 Effective Date: 06/01/2020 B. BackgroundReimbursement policies are designed to assist you 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 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 code(s) for the product or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patien ts symptoms are categorized as chronic. Chronic pain is defined by the International Association for the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self-manag ement and aim to reduce the impact of pain on a patient’s daily life, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualifie d to deliver these health services. C. Definitions Implantable Pain Pump: Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery dir ectly to specific sites and can be programmed for continuous or variable rates of infusion. D. PolicyI. Implantable Pain Pump A. Prior authorization (PA) is required for all implantable pain pumps, including trial administration, permanent placement and single sh ot intrathecal injections for the treatment of severe chronic intractable pain of malignant or non-malignant origin. 1. Prior Authorizations for implantable pain pump services are not required for the following: a. Implantable device is considered part of the pr ocedure and does not require a separate PA. b. Removal/revision of implanted device c. Electronic analysis post transplantation B. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump Medical policy MM-0802. 3 Implantable Pain Pump GEORGIA MEDICAID PY-1069 Effective Date: 06/01/2020 E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Implantable Pain PumpDescription 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication adminis tration via an external pump or implantable reservoir/infusion pump; with laminectomy 62355 Removal of previously implanted intrathecal or epidural catheter 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidura l infusion 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming 62369 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill 62370 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill (requiring skill of a physician or other qualifie d health care professional) 4 F. Related Policies/Rules Implantable Pain Pump MM-0802 G. Review/Revision HistoryImplantable Pain Pump GEORGIA MEDICAIDPY-1069 Effective Date: 06/01/2020 DATE ACTIONDate Issued 12/11/2019Date Revised N/A Date Effective 06/01/2020 Date Archived 01 /01/2021 H. References1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0881 12/11/2019 DCH Approved 03/02/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Epidural Steroid Injections PY-1054 12/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 5 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-stand ard 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 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 func tion, 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 p rovider. 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 make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying thi s Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectEpidural Steroid Injections Ep id ural Stero id In jectionsGEORGIA MEDICAID PY-1054 Effective Date: 11/01/202 B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guaran tee 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 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/HCPCS 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. Nearly 84% of adults experience back pain during their lif etime. Long term outcomes are largely f avora ble f or most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is def ined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures f or management of acute and chronic pain are part of a comprehensive pain management care plan that incorporates conservative treatment in a multimodality approach. Multidisciplinary treatments include promoting patient self – management and aim to reduce the impact of pain on a patient’s daily lif e, even if the pain cannot be relieved completely. Interventional procedures for the management of pain unresponsive to conservative treatment should be provide d only by physicians qualif ied to deliver these health services. C. Def initions Epidural Steroid Injections – f or persistent or chronic radicular pain involve injection of corticosteroid, local anesthetic, opioid, or combination medication into the epidural space, requiring f luoroscopic imaging and injection of an appropriate agent to achieve a selective reproducible blockage of a specif ic nerve root. Anatomic locations f or epidural injections may involve the interlaminar space at the midline between vertebral bodies, caudal epidural injections or transf oraminal epidural injections. Epidural injections may be diagnostic f or localizing and determining the cause of radiating pain and providing short term pain relief . D. PolicyI. Epidural Steroid Injections A. A prior authorization (PA) is required f or each epidural injection f or pain management by the same or any physician, excluding labor and delivery in 3 Ep id ural Stero id In jectionsGEORGIA MEDICAID PY-1054 Effective Date: 11/01/2020 childbirth and f or post surgical pain. Documentation, including dates of service, f or conservative therapies are not required f or PA, but must be available upon request. B. The maximum epidurals of all types of epidural injections a member can receive in a rolling twelve (12) months is a total of six (6), regardless of the number of levels involved. 1. Repeat injections sooner than three (3) weeks may not reach pharmacodynamic ef f ect of the corticosteroid and will not be covered. 2. Requests f or repea t injections beyond three (3) weeks without documentation of suitable pain score reduction and f unctional improvements, or other documented rationale as described in this policy will not be covered. C. For Interlaminar or Caudal Epidural Injections 1. More than one (1) epidural injection per treatment date will not be authorized. 2. Bilateral injections and modif iers will not be recognized and coverage will be denied. D. For Transf oraminal Epidurals or Selective Nerve Root Blocks (SNRBs) 1. Transf oraminal Epidurals provided to more than two (2) vertebral levels per treatment date, whether unilateral or bilateral, will not be authorized and will not be covered. 2. Prior authorization is required f or treatment sessions per each spine region. E. Repeat Therapeutic Injections 1. Epidural injections may be repeated only when considered medically necessary and the f ollowing criteria is met: a. There must be at least 21 days between injections; b. No more than three (3) procedures in a twelve (12) -week period of time per region; c. Prior injection had a positive response by significantly decreasing pain; d. The patient continues to have ongoing pain or documented functional disability ( 6 on a scale of 0 to 10); and e. The patient is actively engaged in other f orms of conservative non – operative treatment. (1) Unless pain prevents the patient f rom participating in conservative therapy, which must be documented in the contemporaneous medical record. F. Real-time image guidance and any injection of contrast are inclusive components of epidural inj ections and are not compensated f or separately or unbundled f or coverage. G. Ultrasound guidance f or epidural injections is inappropriate. H. Conscious sedation, if required f or co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible f or additional reimbursement if administered by a second provider. 1. Coverage f or monitored anesthesia will not be provided as not medically necessary. 2. When anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. 4 E. Conditions of CoverageEp id ural Stero id In jectionsGEORGIA MEDICAID PY-1054 Effective Date: 12/01/2020 Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modif iers, if applicable. Please ref er to the individual f ee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not beall inclusive and is subject to updates.Epidural Description 62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, f luoroscopy or CT) 62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlam inar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, f luoroscopy or CT) 62324 Injection(s), including indwelling catheter placement, continuous inf usion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62325 Injection(s), including indwelling catheter pla cement, continuous inf usion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, f luoroscopy or CT) 5 62326 Injection(s), including indwelling catheter placement, continuous inf usion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62327 Injection(s), including indwelling catheter placement, continuous inf usion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, f luoroscopy or CT) 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (f luoroscopy or CT); cervical or thoracic, single level 64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (f luoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code f or primary procedure) 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (f luoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (f luoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) F. Related Policies/RulesEpidural Steroid Injections GA MCD MM-0217 G. Review/Revision HistoryDATE ACTION Date Issued 12/11/2019 Date Revised 06/10/2020 Annual Update: No cha nges Date Effective 12/01/2020 Date Archived 05/31/2021 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 f ollow CMS/State/NCCI guidelines without a f ormal documented Policy 6 Ep id ural Stero id In jectionsGEORGIA MEDICAID PY-1054 Effective Date: 11/01/2020 H. Ref erences1. Georgia Department of Community Health Fee Schedules. Retrieved on May 20, 2020 f rom mmis.georgia.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-MED-P-165374 Date Issued 12/11/2019 DCH Ap p ro ved 07/27/2020
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