REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Screening and Surveillance f or Colorectal Cancer PY-0404 10/01/2020-11/30/2021 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 ………………………….. ………………………….. ……………………….. 6 F. Related Policies/Rules ………………………….. ………………………….. …………………………. 8 G. Review/Revision History ………………………….. ………………………….. ………………………. 8 H. Ref erences ………………………….. ………………………….. ………………………….. ……………. 8 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 servic e, 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 mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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. SubjectScreen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 Screening and Surveillance for Colorectal Cancer 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 receive d 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 guarant ee claims payment. The evidence is convincing that appropriate screening reduces colorectal cancer mortality in adults 50-75 years of age. The benefit of early detection of and intervention f or colorectal cancer declines af ter 75 years of age. Af rican Amer icans have been shown to have higher CRC rates of incidence and it is recommended by both the American College of Gastroenterology and the American Society f or Gastrointestinal Endoscopy that CRC screening begin at 45 years of age. C. Def initions Colorectal Cancer Screening – Detects early stage colorectal cancer and precancerous lesions in asymptomatic members with an average risk of colorectal cancer. Surveillance for Colorectal Cancer – For members who are at increase or high risk f or colorectal cancer. Colonoscopy – An endoscopic procedure allowing direct inspection of the lining of the entire colon with biopsy sampling and/or removal of polyps or early stage cancers. CT Colonography – Also known as virtual colonoscopy utilizing advanced comput ed tomography (CT) to produce 2 and 3 dimensional images of the colon and rectum to identif y early cancerous and precancerous lesions. Fecal Immunochemical Testing (FIT or iFOBT) – A home screening test unaf fected by f ood or medicines that utilizes a chemical reaction with hemoglobin to detect human blood f rom the lower intestine. Fecal Occult Blood Testing (FOBT) – A home screening test that detects hidden blood arising f rom anywhere in the digestive tract in the s tool through a chemical reaction. Flexible Sigmoidoscopy – An endoscopic examination of the lower half of the colon. Multi-Targeted Stool DNA (Cologuard) – a home screening test utilizing an algorithmic analysis of stool DNA amplif ied by polymerase chain r eaction (PCR) in combination with a f ecal immunochemical test (FIT) test. 3 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 Adenoma – Polyps that require surveillance as they have the potential to be malignant. Barium enema – Screening barium enema as an alternative to a screening f lexible sigmoidoscopy or screening colonoscopy. Increased or high risk for colorectal cancer – An individual has one or more of the f ollowing: o A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyposis; o A f amily history of f amilial adenomatous polyposis; o A f amily history of hereditary non polyposis colorectal cancer; o A personal history of adenomatous polyps; o A personal history of colorectal cancer; or o Inf lammatory bowel disease, including Crohns Disease, and Ulcerative Colitis. D. PolicyI. Colorectal Cancer Screening A. Prior authorization is not required f or par providers. B. Benef it coverage is f or members ages 45 years of age and older. C. Screening f or colorectal cancer claims must be submitted with one of the f ollowing ICD-10 codes: 1. Z12.10 Encounter for screening f or malignant neoplasm of intestinal tract, unspecif ied; 2. Z12.11 Encounter for screening for malignant neoplasm of colon; 3. Z12 .12 Encounter for screening for malignant neoplasm of rectum; or 4. Z12.13 Encounter for screening for malignant neoplasm of small intestine. D. Screening f lexible sigmoidoscopies (G0104) is covered once every 48 months for members 45 years of age and older. If during the course of this procedure a lesion or growth is detected that results in a biopsy or removal of the growth, the diagnostic procedure classif ied as a f lexible sigmoidoscopy with biopsy or removal should be billed, not G0104. This screening mus t be performed by a doctor of medicine or osteopathy. E. Screening colonoscopies (G0105) are covered at a f requency of every 24 months f or members at high risk f or colorectal cancer. If during the course of this procedure a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classif ied as a colonoscopy with biopsy or removal should be billed, not G0105. A doctor of medicine or osteopathy must perf orm this screening. F. Screening barium enema examinations (G0106 and G0120) are covered as an alternative to either a screening sigmoidoscopy or a screening colonoscopy. The sa me f requency parameters specified f or screening sigmoidoscopy and colonoscopy applies. G. Screening f ecal-occult blood test is covered once every 12 months f or members 45 years of age and older. H. A f ollow-up colonoscopy is reimbursed as part of the screening process when a noncolonoscopy test is positive. I. Screening with plasma or serum markers is NOT covered. J. PT modif ier is used when the colorectal cancer screening test was converted to a diagnostic test or other procedure. 4 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 II. Colonoscopy Surveillance for Colorectal Cancer A. Prior authorization is not required f or par providers B. Surveillance f or colorectal cancer claim must be submitted with one of the f ollowing ICD-10 codes: 1. Z85.038 Personal history of other malignant neoplasm of large intestine; 2. Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus; 3. Z80.0 Family history of malignant neoplasm of digestive organs; 4. Z86.010 Personal history of colonic polyps; 5. Z84.81 Family history of carrier of genetic disease; 6. Z15.89 Genetic susceptibility to other disease; 7. Z83.71 Family history of colonic polyps; or 8. Z84.81 Family history of carrier of genetic disease; 9. Z15.89 Genetic susceptibility to other disease; 10. Z83.71 Family history of colonic polyps; 11. Z85.038 Personal history of other malignant neoplasm of large intestine; 12. Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus; 13. Z80.0 Family history of malignant neoplasm of digest ive organs; 14. Z86.010 Personal history of colonic polyps; 15. Z92.3 Personal history of irradiation or radiation therapy; 16. K50.00 Crohns disease of small intestine without complications 17. K50.011 Crohns disease of small intestine with rectal bleeding 18. K50.012 Crohns disease of small intestine with intestinal obstruction 19. K50.013 Crohns disease of small intestine with f istula 20. K50.014 Crohns disease of small intestine with abscess 21. K50.018 Crohns disease of small intestine with other complications 22. K50.019 Crohns disease of small intestine with unspecified complications 23. K50.10 Crohns disease of large intestine without complications 24. K50.111 Crohns disease of large intestine with rectal bleeding 25. K50.112 Crohns disease of large intestine with intestinal obstruction 26. K50.113 Crohns disease of large intestine with f istula 27. K50.114 Crohns disease of large intestine with abscess 28. K50.118 Crohns disease of large intestine with other complication 29. K50.119 Crohns disease of large intest ine with unspecified complications 30. K50.80 Crohns disease of both small and large intestine without complications 31. K50.811 Crohns disease of both small and large intestine with rectal bleeding 32. K50.812 Crohns disease of both small and large intestine with intestinal obstruction 33. K50.813 Crohns disease of both small and large intestine with f istula 34. K50.814 Crohns disease of both small and large intestine with abscess 35. K50.818 Crohns disease of b oth small and large intestine with other complication 36. K50.819 Crohns disease of both small and large intestine with unspecified complications 37. K50.90 Crohns disease, unspecified, without complications 38. K50.911 Crohns disease, unspecified, with rectal bleeding 39. K50.912 Crohns disease, unspecified, with intestinal obstruction 5 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 40. K50.913 Crohns disease, unspecified, with fistula 41. K50.914 Crohns disease, unspecified with abscess 42. K50.918 Crohns disease, unspecified, with other complication 43. K50.919 Crohns disease, unspecified, with unspecified complications 44. K51.00 Ulcerative (chronic) pancolitis without complications 45. K51.011 Ulcerative (chronic) pancolitis with rectal bleeding 46. K51.012 Ulcerative (chronic) pancolitis with intestinal obstruction 47. K51.013 Ulcerative (chronic) pancolitis with f istula 48. K51.014 Ulcerative (chronic pancolitis with abscess 49. K51.018 Ulcerative (chronic) pancolitis with other complication 50. K51.019 Ulcerative (chronic) pancolitis with unspecified complications 51. K51.20 Ulcerative (chronic) proctitis without complications 52. K51.211 Ulcerative(chronic) proctitis with rectal bleeding 53. K51.212 Ulcerative(chronic) proctitis with intestinal obstruction 54. K51.213 Ulcerative (chronic) proctitis with f istula 55. K51.214 Ulcerative (chronic) proctitis with abscess 56. K51.218 Ulcerative (chronic) proctitis with other complication 57. K51.219 Ulcerative (chronic) proctitis with unspecified complications 58. K51.30 Ulcerative (chronic) rectosigmoiditis without complications 59. K51.311 Ulcerative(chronic) rectosigmoiditis with rectal bleeding 60. K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction 61. K51.313 Ulcerative (chronic) rectosigmoiditis with f istula 62. K51.314 Ulcerative (chronic) rectosigmoiditis with abscess 63. K51.318 Ulcerative (choronic) rectosigmoiditis with other complication 64. K51.319 Ulcerative (ch ronic) rectosigmoiditis with unspecified complications 65. K51.40 Inf lammatory polyps of colon with complications 66. K51.411 Inf lammatory polyps of colon with rectal bleeding 67. K51.412 Inf lammatory polyps of colon with intestinal obstruction 68. K51.413 Inf lammatory polyps of colon with fistula 69. K51.414 Inf lammatory polyps of colon with abscess 70. K51.418 Inf lammatory polyps of colon with other complication 71. K51.419 Inf lammatory polyps of colon with unspecified complications 72. K51.50 Lef t sided colitis without complications 73. K51.511 Lef t sided colitis with rectal bleeding 74. K51.512 Lef t sided colitis with intestinal obstruction 75. K51.513 Lef t sided colitis with f istula 76. K51.514 Lef t sided colitis with abscess 77. K51.518 Lef t sided colitis with other complication 78. K51.519 Lef t sided colitis with unspecified complications 79. K51.80 Other ulcerative colitis without complications 80. K51.811 Other ulcerative colitis with rectal bleeding 81. K51.812 Other ulcerative colitis with intestinal obstruction 82. K51.813 Other ulcerative colitis with fistula 83. K51.814 Other ulcerative colitis with abscess 84. K51.818 Other ulcerative colitis with other complication 85. K51.819 Other ulcerative colitis with unspecified complications 86. K51.90 Ulcerative colitis, unspecified, without complications 87. K51.911 Ulcerative colitis, unspecified with rectal bleeding 88. K51.912 Ulcerative colitis, unspecified with intestinal obstruction 89. K51.913 Ulcerative colitis, unspecified with f istula 6 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 90. K51.914 Ulcerative colitis, unspecified with abscess 91. K51.918 Ulcerative colitis, unspecified with other complication 92. K51.919 Ulcerative colitis, unspecified with unspecified complications 93. K52.0 Gastroenteritis and colitis due to radiation 94. K52.1 Toxic gastroenteritis and colitis 95. K52.21 Food protein-induced enterocolitis syndrome 96. K52.22 Food protein-induced enteropathy 97. K52.29 Other allergic and dietetic gastroenteritis and colitis 98. K52.3 Indeterminate colitis 99. K52.81 Eosinophilic gastritis or gastroenteritis 100. K52.82 Eosinophilic colitis 101. K52.831 Collagenous colitis 102. K52.832 Lymphocytic colitis 103. K52. 838 Other microscopic colitis 104. K52.839 Microscopic colitis, unspecified 105. K52.89 Other specified noninfective gastroenteritis and colitis 106. K52.9 Non inf ective gastroenteritis and colitis, unspecified. 107. Conditions of Coverage 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 Codes Description G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema. G0328 Colorectal cancer screening; f ecal occult blood test, immunoassay, 1-3 simultaneous 44388 Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 44389 Colonoscopy through stoma; with biopsy, single or multiple 44390 Colonoscopy through stoma; with removal of f oreign body(s) 44391 Colonoscopy through stoma; with control of bleeding, any method 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy f orceps 7 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45330 Sigmoidoscopy, f lexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, f lexible; with biopsy, single or multiple 45332 Sigmoidoscopy, f lexible; with removal of foreign body(s) 45333 Sigmoidoscopy, f lexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy f orceps 45334 Sigmoidoscopy, f lexible; with control of bleeding, any method 45335 Sigmoidoscopy, f lexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, f lexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when perf ormed 45338 Sigmoidoscopy, f lexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, f lexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, f lexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, f lexible; with transendoscopic ultrasound guided intramural or transmural f ine needle aspiration/biopsy(s) 45378 Colonoscopy, f lexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45379 Colonoscopy, f lexible; with removal of f oreign body(s) 45380 Colonoscopy, f lexible; with biopsy, single or multiple 45381 Colonoscopy, f lexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, f lexible; with control of bleeding, any method 45384 Colonoscopy, f lexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy f orceps 45385 Colonoscopy, f lexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, f lexible; with transendoscopic balloon dilation 45391 Colonoscopy, f lexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, f lexible; with transendoscopic ultrasound guided intramural or transmural f ine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and ad jacent structures 74270 Radiologic examination, colon; contrast (e.g., barium) enema, with or without KUB 74280 Radiologic examination, colon; air contrast with specif ic high density barium, with or without glucagon 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplif ication of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and f ecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (C ologuard) 8 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; f eces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card f or consecutive collection) 82272 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, f eces, 1 – 3 simultaneous determinations, perf ormed for other than colorectal neoplasm screening 82274 Blood, occult, by f ecal hemoglobin determination by immunoassay, qualitative, f eces, 1-3 simultaneous determinations F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 11/1/2017Date Revised Date Effective 10/01/2020 Date Archived 11/30/2021 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 formal documented Policy H. Ref erences1. Wolf , A., Fontham, E., Church, T., Flowers, C … Smith, Robert. (2018). Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. Retrieved November 7, 2019 f rom www.onlinelibrary.wiley.com 2. Rex, D., Boland, Richard, Dominitz, J., Giardiello, F., Johnson, D., Kaltenbach, T. Robertson, D. (2017). Colorectal cancer screening: Recommendations for physicians. GASTROI NTESTINAL ENDOSCOPY, 86 (1), 18 33. doi: http://dx.doi.org/10.1016/j.gie.2017.04.003 www.asge.org/ 3. Wilkins, T., Mcmechan, D., Talukder, A. (2018, May 15). Colorectal Cancer Screening and Prevention. Retrieved November 7, 2019 from www.aaf p..org 4. Lieberman, D., Rex, D., Winawer, S., Giardiello, F., Johnson, D., & Levin, T. (2012, September). Guidelines for Colonoscopy Surveillance After Screening. Retrieved November 7, 2019 f rom www.acgcdn.gi.org 5. Qaseem, A., Crandall, C. J., Mustaf a, R. A., Hicks, L. A., & Wilt, T. J. (2019, November 5). Screening f or Colorectal Cancer in Asymptomatic Average-Risk Adults: A Guidance Statement From the American College of Physicians. Retrieved November 6, 2019, f rom www.annals.org 6. Doubeni, C. (2019, June 28). Tests for screeni ng for colorectal cancer. Retrieved November 6, 2019 f rom www.uptodate.com 7. Centers f or Medicare and Medicaid Services. (n.d.). Information on Essential Health Benefits (EHB) Benchmark Plans. Retrieved January 7, 2020 from www.cms.gov 8. American College of Surgeons. (2016, May 1). Coding and reimbursement for colonoscopy. Retrieved January 31, 2020 from https://bulletin.facs.org 9 Screen in g an d Surveillan ce fo r Co lo rectal Can cerGEORGIA MEDICAID PY-0404 Effective Date: 10/01/2020 9. EncoderPro. (n.d.). ICD10 CM Guidelines . Retrieved January 31, 2020 from www.encoderprofp.com 10. United States Preventive Services Task Force (2016, June). Colorectal Cancer: Screening. Retrieved January 7, 2020 f rom www.uspreventiveservicestaskf orce.org 11. Georgia Department of Community Health Division of Medicaid. (2020, January 1). Part IIPolicies and Procedures for Physician Services. Retrieved January 31, 2020 f rom www.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-183853 Date Issued 11/01//2017 DCH Ap p roved 07/27/2020
R EIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Unbundled cost PY-0 924 09/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, 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, dysfu nction 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 d oes 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 Contents Reimbursement Policy Statement ……………………………………………………………………………………1A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ……………………………………………………………………………………………………………2 C. Definitions ……………………………………………………………………………………………………………..2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 7 F. Related Policies/Ru les ………………………….. ………………………….. ………………………….. …….. 9 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 9 H. References ………………………….. ………………………….. ………………………….. ……………………. 9 Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 2A. Subject Obstetrical Care Unbundled cost B. Background Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e i v e in a h o s p i t a l o r b ir t h in g c e n t e r a s we l l all associated outpatient services. The services provided must be appropriate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. C. Definitions Prenatal profile – Initial laboratory services . Initial and prenatal visit – Practitioner visit to determine member is pregnant . Unbundled (partial) obstetrical c are – The practitioner would bill delivery, antepartum care, and postpartum care independently of one another. o Antepartum care (prenatal) – T he initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. o Delivery services – A dmission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or wit hout episiotomy, with or without forceps), or cesarean delivery. o Postpartum care – Hospital and office visits following vaginal or cesarean section delivery . The American College of Obstetricians and Gynecologists (ACOG ) recommends contact within the first 3 weeks postpartum , ongoing care are needed concluding with a postpartum visit no later than 12 weeks after birth. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 weeks of pregnancy . Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 weeks. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and management (E/M) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care . Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 3B. Unbundled Obstetric Care – Report the services performed using the most accurate, most comprehensive procedure code available based on what services the practitioner performed. Th e practitioner would bill delivery, antepartum care, and postpartum care independently of one another. 1. Unbundled o bstetric care s hould be billed when any of the following occur : a. The member has a change of insurer during pregnancy b. The member has received part of the obstetrical care ( antenatal care , deliver, or postpartum care) elsewhere, e.g. from another group practice c. The member leaves your group practice before the global obstetrical care is complete d. The member must be referred to a provider from another group practice or a different licensure (e.g. midwife to MD) for a cesarean delivery e. The member has an unattended precipitous delivery f. Termination of pregnancy without delivery (e.g. miscarriage, ectopic pregnancy) 2. Antepartum car e only Antepartum care only does not include delivery or postpartum care : a. Use the appropriate CPT and trimester code (s) : CPT Code Description59425 Antepartum care only; 4-6 visits59426 Antepartum care only; 7 or more visits E/M For antepartum care for 1-3 visits b. For E/M codes, bill with a diagnosis code O02.81-O92.70. c. E/M codes for antepartum care are limited to 3. d. Use the appropriate modifier (This list may not be all inclusive): Modifier Description24 To indicate that the E/M visit was not related to typical postpartum care during the global period e. Only one code, either 59425 or 59426 can be billed per pregnancy.f. Antepartum care only code includes the following (This list may not be all inclusive ): 01. Monthly visits up to 28 weeks gestation 02. Biweekly visits to 36 weeks gestation 03. Weekly from 36 weeks until delivery 04. Fetal heart tones 05. Initial/subsequent history 06. Physical exams 07. Recording of weight/blood pressures 08. Physician/other qualified health care professional providing all or a portion of antep artum/postpartum care, but no delivery 09. Routine chemical urinalysis Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 410. Termination of pregnancy by abortion 11. Referral to another physician for delivery 3. Delivery only Use i f only a delivery was performed a. Deliveries must be greater or equal to 20 weeks gestation to be billed as a delivery. b. Use the appropriate CPT and delivery outcome code (s): CPT Code Description59409 Vaginal delivery only (with or without episiotomy and/or forceps)59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery(with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery c. Services (This list may not be all inclusive)Services included that may NOTbe billed separatelyServices excluded and therefore may be billed separately Admission history and physical Scalp blood sampling on newborn Admission to hospital External cephalic version Management of uncomplicated labor Administration of anesthesia Physical exam Vaginal delivery with or without episiotomy or forceps Vaginal delivery after prior cesarean sectionPrevious cesarean delivery who present with expectation of vaginal deliverySuccessful vaginal delivery after previous cesarean deliveryCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean deliveryCesarean deliveryClassic cesarean section Low cervical cesarean section Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 5Inducing labor using pitocin or oxytocin Injecting anesthesiaArtificial rupturing of membranes prior to delivery Insertion of a cervical dilator for vaginal delivers when occurs on the same date as deliveryDelivery of placenta unless it occurs at a separate encounter from the deliveryMinor laceration repairsInpatient management after delivery/discharge services E/M services provided within 24 hours of deliveryd. Modifiers 01. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 02. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be request ed . e. Use the appropriate modifier (This list may not be all inclusive):CPT Code Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 80 Assistant surgeon – may be used for delivery only if no antepartum or postpartum care was performed UB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) 4. Delivery and postpartum care only If only delivery and postpartum care were provided a. Use the appropriate CPT and outcome code: Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 6CPT Code Description 59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 Cesarean delivery only; including postpartum care59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum careb. Modifiers 01. A modifier UB, UC, or UD appended to the billed delivery procedure code is REQUIRED or the delivery claim will be denied. 02. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be requested. c. Services included in the delivery only and postpartum care codes; and therefore are NOT allowed to be billed separately (This list may not be all inclusive): 01. Admission history 02. Admission to hospital 03. Artificial rupture of membranes 04. Care provided for uncomplicated pregnancy including delivery, antepartum, and postpartum care 05. Hospital/office visits following cesarean section or vaginal delivery 06. Management of uncomplicated labor 07. Physical exam 08. Vaginal delivery with or without episiotomy or forceps 09. Caesarean delivery 10. Classic cesarean section 11. Low cesarean section 12. Successful vaginal delivery after previous cesarean delivery 13. Previous cesarean delivery who present with the expectation of a vaginal delivery 14. Caesarean delivery following unsucce ssful vaginal delivery attempt after previous cesarean delivery 5. Postpartum care only – If postpartum care only was provided: a. Use code 59430 postpartum care only. b. Only one 59430 can be billed per pregnancy as this includes all E/M pregnancy related visits provided for postpartum care. c. There is no specified number of visits included in the postpartum code . This includes h ospital and office visits following vaginal or cesarean Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 7section delivery. ACOG recommends contact within the first 3 weeks postpartum. d. Postpartum care may include; and therefore are NOT allowed to be billed separately (This list may not be all inclusive) : 01. Hospital, o ffice and outpatient visits following cesarean section or vaginal delivery 02. Qualified health care professional providing all or portion of antepartum/postpartum care, but no delivery due to referral to another physician for delivery or termination of pregnancy by abortion e. The following are billable separately during the postpartum period (This list may not be all inclusive): 01. Co nditions unrelated t o pregnancy i.e. respiratory tract infection 02. Treatment and management of complications during the postpartum period that require additional services II. Member eligibilityA. If a member was not eligible for Medicaid for the 9 months before delivery, the practitioner MUST use the appropriate delivery only or delivery and postpartum code to be reimbursed. Charges for hospital admission, history and physical or normal hospital evaluation and management services are not reimbursable. B. If a membe r becomes eligible for Medicaid due to a live birth, no prenatal services including laboratory services are reimbursable . I. Multiple gestations.A. Include diagnosis code for multiple gestations . B. Modifier 51 should be added to the second and any subsequent vaginal births identifying multiple procedures were performed . C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births. D. Modifier 22 should be added to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . IV . High risk deliveriesA. High risk pregnancy should be the first listed diagnosis for prenatal outpatient visits and from the category O09 Supervision of high-risk pregnancy. B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided . E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 8CPT Code Description 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits E/M For antepartum care for 1-3 visits 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59514 Cesarean delivery only 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59410 Vaginal delivery only (with or without episiotomy and/or forceps);including postpartum care 59515 Cesarean delivery only; including postpartum care 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery including postpartum care 59430 Postpartum care only. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during the postoperative period 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct Procedural Service 80 Assistant surgeon – may be used for delivery only if no antepartum or postpartum care was performed UB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 9F. Related Policies/Rules Obs tetrical Care Hospital Admissions MM-0850 Obstetrical Care Total Cost PY-0231 G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy. Date Revised 04/01/2020 New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed total care information, updated most content, included modifiers and updated codes. Date Effective 09/01/2020 Date Archived H. References1. The American College of Obstetricians and Gynecologist. (2018, May). Presidential Task Force on Redefining the Postpoartum Visit. Retrieved June 27, 2019, from https://www.acog.org 2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use. CPT Assistant . 3. American Medical Association (2015, January). Maternity Care and Delivery. CPT Assistant. 4. Georgia Department of Community Health Division of Medicaid. (2019, Ap ril 1). PART II Policies and Procedures for Physician Services. Retrieved June 14, 2019 from https://www.mmis.georgia.gov 5. American Academy of Professional Coders. (2013, August 1). From Antepartum to Postpartum, Get the CPT OB Basics. Retrieved June 14, 2019 from https://www.aapc.com 6. American Academy of Professional Coders. (2011, December). Code Obstetrical Care with Confidence. Retrieved on August 1, 2019 from https://www.aapc.com 7. EncoderPro.com for Payers Professional. (2019) Retrieved June 27, 2019, from https://www.encoderprofp.com 8. The American College of Obstetricians and Gynecologists. (n.d.). Coding for Postpartum Services (The 4 th Trimester). Retrieved June 27, 2019, from https://www.acog.org 9. The American College of Obstetricians and Gynecologists. (n.d.). Reporting a Services with Modifier 22. Retrieved June 27, 2019, from https://www.acog.org 10. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Sch eduling Induction of Labor. Retrieved July 31, 2019, from https://www.acog.org 11. American College of Obstetricians and Gynecologists. (2011, December). Patient Safety Checklist: Scheduling Planned Cesarean Delivery. Retrieved July 31, 2019 from https://www.a cog.org 12. American College of Obstetricians and Gynecologists. (2019), April Correct Coding Initiative Version 25.1. Retrieved June 14, 2019 from https://www.acog.org Obstetrical Care Unbundled costGEORGIA MEDICAIDPY-0924 Effective Date: 09/01/2020 1013. American College of Obstetricians and Gynecologists. (2018, May). Optimizing Postpartum Car e. Retrieved August 1, 2019, from https://www.acog.org 14. American College of Obstetricians and Gynecologists. (2019, January). Preterm Labor and Birth. Retrieved August 1, 2019 from https://www.acog.org The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as definedin the Reimbursement Policy Statement Policy and is app roved.GA-MED-P-105 010 Date Issued 07/01/2017 DCH Approved 06/09/2020
R EIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Obstetrical Care Total Cost PY-0231 09/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical neces sity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referra l, 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, dysfu nction 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 d oes 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 pr ovided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………..1A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ……………………………………………………………………………………………………………2 C. Definitions ……………………………………………………………………………………………………………..2 D. Policy ……………………………………………………………………………………………………………………2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Obstetrical Care Total costGEORGIA MEDICAIDPY-0231 Effective Date: 09/01/2020 2A. Subject Obstetrical Care Total cost B. Background Obstetrical care refers to the health care treatment given in relation to pregnancy and delivery of a newborn child. This include care during the prenatal period, labor, birthing, and the postpartum period. CareSource covers obstetrical services members r e c e i v e in a h o s p it a l o r b ir t h in g c e n t e r a s we l l all associated outpatient services. The services provided must be appropri ate to the specific medical needs of the member. Determination of medical necessity is the responsibility of the physician. Submission of claims for reimbursement will serve as the providers certification of the medical necessity for these services. Proper billing and submission guidelines must be followed. This includes the use of industry standard, compliant codes on all claims submissions. Services should be billed using Current Procedure Terminology (CPT) codes, Healthcare Common Procedu re Coding System (HCPCS) codes and/or revenue codes. The codes denote services and/or the procedure performed. The billed codes are required to be fully supported in the medical record. Unless otherwise noted, this policy applies to only participating prov iders and facilities. C. Definitions Prenatal profile – Initial laboratory services . Initial and prenatal visit – Practitioner visit to determine member is pregnant . Total obstetrical care – Includes antepartum care, delivery, and postpartum care. High risk delivery – Labor management and delivery for an unstable or critically ill pregnant patient. Premature birth – Delivery before 39 weeks of pregnancy . Pregnancy – For the purpose of this policy, pregnancy begins on the date of the initial visit in which pregnancy was confirmed and extends for 280 days or 40 week s. D. PolicyI. Obstetrical Care A. Initial Visit and Prenatal Profile 1. The initial visit and prenatal profile are reimbursed separately from other obstetrical care. These are to be billed immediately after first contact. 2. Evaluation and Management ( E/M ) codes are utilized when services were provided to diagnose the pregnancy. These are not part of antepartum care . B. Total Obstetrical Care (for uncomplicated care provided to the member includi ng antepartum, delivery, and postpartum care ) 1. If a member meets all of the following criteria, the practitioner designated in the members medical record MUST bill for total obstetrical care under that practitioners number: a. Is eligible for Medicaid for the duration of pregnancy ; b. Is cared for by one practitioner or group practice for the antepartum care, delivery, and postpartum care ; and c. Attending physician is designated in the medical record with services billed under that practitioner tax identifi cation number. 2. Billing for total obstetrical care cannot be done until the date of delivery . Obstetrical Care Total costGEORGIA MEDICAIDPY-0231 Effective Date: 09/01/2020 33. Total obstetrical care cannot be billed for a delivery of less than 20 weeks gestation. 4. Total obstetrical care c odes a. A corresponding obstetrical diagnosis with outcome of birth must be listed on the claim. A code from category Z34 should be listed as the first diagnosis for routine obstetric care. b. Reimbursement is provided for one of the following code s per pregnancy : CPT Code Description59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. 5. Modifiers a. A modifier UB, UC, and UD, appended to the billed delivery proce dure code is REQUIRED or the delivery claim will be denied. b. Deliveries with modifiers UB or UD must show medical necessity and medical documentation may be requested. c. Use appropriate modifiers (this list may not be all inclusive): Modifier Description22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. UB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) Obstetrical Care Total costGEORGIA MEDICAIDPY-0231 Effective Date: 09/01/2020 46. Services (this list may not be all inclusive) : Services included that may NOTbe billed separately Services excluded and therefore may be billed separately Admission history Greater than 13 antepartum visits due to high-risk condition Admission to hospital Complications of pregnancyArtificial rupture of membranes Surgical complications or other problems related to pregnancyCare provided for an uncomplicated pregnancy including delivery as well as antepartum and postpartum Cephalic versionCesarean delivery UltrasonographyCesarean delivery following an unsuccessful vaginal delivery attempt after previous cesarean delivery Fetal nonstress test Classic cesarean section Maternal or fetal echographyEach month up to 28 weeks gestation Fetal echocardiography proceduresEvery other week from 29 to 36 weeks gestation Fetal biophysical profileFetal heart tones Amniocentesis, any methodHospital/office visits following cesarean section or vaginal delivery Chorionic villus sampling, any method Initial/subsequent history Fetal contraction stress testLow cervical cesarean section Hospital and observation care visits for premature labor prior to 36 weeks of gestationManagement of uncomplicated labor High risk pregnancies requiri ng more visits or more laboratory data Obstetrical Care Total cost GEORGIA MEDICAID PY-0231 Effective Date: 0 9/01/2020 5 Physical Exams Conditions unrelated to pregnancy i.e. hypertension, glucoseintoleranceRecording of weight/blood pressures Treatment and management of complications during the postpartum period that require additional services Routine chemical urinalysis Laboratory tests outside of routine chemical urinalysis Routine prenatal visits Cordocentesis Successful vaginal delivery after previous cesarean delivery OB ultrasounds Patients with previous cesarean delivery who present with the expectation of a vaginal delivery RH immune globulin administration Vaginal delivery with or without episiotomy or forceps Weekly from 36 weeks until delivery II. Multiple gestations.A. Include diagnosis code for multiple gestations .B. Total obstetrical care billing for multiple gestations should include one procedure code and a delivery only code for each subsequent delivery with the appropriate diagnosis code and modifier for the multiple gestations.C. When all deliveries were performed by a cesarean section, only a single cesarean delivery code is to be reported regardless of how many cesarean births.D. Modifier 22 may be added to support substantial additional work. Documentation must be submitted wit h the claim demonstrating the reason and the additional work provided.III. High risk deliveriesA. High risk pregnancy with appropriate trimester should be the first listed diagnosis for prenatal outpatient visits and from the category O09 s upervision of high-ri sk pregnancy.B. Modifier 22 may be added to the delivery code to support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided .E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS andCPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. Obstetrical Care Total costGEORGIA MEDICAIDPY-0231 Effective Date: 09/01/2020 6 The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Codes Description 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps and postpartum care), after previous cesarean delivery 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpart um59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery. Modifiers Description 22 To support substantial additional work. Documentation must be submitted with the claim demonstrating the reason and the additional work provided. 51 To indicate that a second and any subsequent vaginal births occurred identifying multiple procedures were performed 52 To indicate reduced services i.e. patient begins antepartum care late in pregnancy. 59 Distinct procedural services UB Medically-necessary delivery prior to 39 weeks of gestation UC Delivery at 39 weeks of gestation or later UD Non-medically necessary delivery prior to 39 weeks of gestation (Elective non-medically necessary deliveries less than 39 weeks gestation) F. Related Policies/Rules Obstetrical Care – Hospital Admissions MM-0850 Obstetrical Care Unbundled Cost PY-0924 G. Review/Revision HistoryDATE ACTIONDate Issued 07/01/2017 New Policy.Date Revised 04/01/2020 New title used to be Global Obstetrical Services policy broken into two policies. Updated definitions, reorganized topics, removed unbundled information, updated most content, included modifiers and upda ted codes. Date Effective 09/01/2020 Date Archived Obstetrical Care Total cost GEORGIA MEDICAID PY-0231 Effective Date: 0 9/01/2020 7 H. References1. The American College of Obstetricians and Gynecologist. (20 18 , May ). PresidentialTask Force on Redefining the Postpoartum Visit. Retrieved June 27, 2019, from https://www.acog.org2. American Medical Association. (1997, April). Global OB Codes: Reporting and Use.CPT Assistant .3. American Medical Association (2015, January). Maternity Care and Delivery. CPTAssistant.4. Georgia Department of Community Health Division of Medicaid. (2019, April 1).PART II Policies and Procedures for Physician Services. Retrieved June 14, 2019from https://www.mmis.georgia.gov5. American Academy of Professional Coders. (2013, August 1). From Antepartum toPostpartum, Get the CPT OB Basics. Retrieved June 14, 2019 from https://www.aapc.com6. American Academy of Professional Coders. (2011, December). Code ObstetricalCare with Confidence. Retrieved on August 1, 2019 from https://www.aapc.com7. EncoderPro.com for Payers Professional. (2019) Retrieved June 27, 2019, from https://www.encoderprofp.com8. The American College of Obstetricians and Gynecologists. (n.d.). Coding forPostpartum Services (The 4 thTrimester). Retrieved June 27, 2019, fromhtt ps://www.acog.org9. The American College of Obstetricians and Gynecologists. (n.d.). Reporting aServices with Modifier 22. Retrieved June 27, 2019, from https://www.acog.org10. American College of Obstetricians and Gynecologists. (2011, December). PatientSaf ety Checklist: Scheduling Induction of Labor. Retrieved July 31, 2019, from https://www.acog.org11. American College of Obstetricians and Gynecologists. (2011, December). PatientSafety Checklist: Scheduling Planned Cesarean Delivery. Retrieved July 31, 2019from https://www.acog.org12. American College of Obstetricians and Gynecologists . (2019 ) , April Correct CodingInitiative Version 25.1. Retrieved June 14, 2019 from https: //www.acog.org13. American College of Obstetricians and Gynecologists. (2018, May). OptimizingPostpartum Care. Retrieved August 1, 2019, from https://www.acog.org14. American College of Obstetricians and Gynecologists. (2019, January). Prete rmLabor and Birth. Retrieved A ugust 1, 2019 from https://www.acog.org The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. GA-MED-P – 105010 Date Issued 07/01/201 7 DCH Approved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Trigger Point Injections PY-1099 09/01/2020 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, re gulatory 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 th e 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 patient can be expected to suffer prolonged, increased or new morbidit y, 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 convenie nce 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 Poli cy 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 app lying 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Trigger Point InjectionsGEORGIA MEDICAIDPY-1099 Effective Date: 09/01/2020 2 A. SubjectTrigger Point Injections 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 Trigger Point Injections – A trigger point is a hyper excitable area of the body, where the applic ation of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. D. Policy I. Trigger Point Injections A. A prior authorization (PA) is required for each trigger point injection for pain management. B. Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. For trigger-point injections of a local anesthetic or a steroid, Trigger Point InjectionsGEORGIA MEDICAIDPY-1099 Effective Date: 09/01/2020 3 payment will be made for no more than eight dates of service per calendar year per patient. C. Injections may be repeated only with documented positive results to prior trigger point injection s of the same anatomic site. Documentation should include at least 50% improvement in pain, functioning and activity tolerance. D. Localization techniques to image or otherwise identify trigger point anatomic locations are not indicated and will not be covered for payment when associated with trigger point injection procedures. E. Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for s ervice rendered to a particular patient on a particular date. F. A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed. E. Conditi ons of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes alo ng with appropriate modifiers. 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. Trigger Point InjectionsDescription 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles F. Related Policies/Rules Trigger Point Injections MM-0221 G. Review/Revision History DATE ACTIONDate Issued 12/11/2019Date Revised 05/13/2020 Annual Update: PA required Date Effective 09/01/2020 Date Archived Trigger Point InjectionsGEORGIA MEDICAIDPY-1099 Effective Date: 09/01/2020 4 H. References1. Georgia Department of Community Health Fee Schedules. Retrieved from www.mmis.georgia.gov on May 1, 2020. 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. GA-MED-P-131362 Date Issued 12/11/2019 DCH Approved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1091 09/01/2020-05/31/2021 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 ………………………….. ………………………….. ………………………. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………… 3 G. Review/Revision History ………………………….. ………………………….. ……………………… 4 H. Ref erences ………………………….. ………………………….. ………………………….. …………… 4 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, 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 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 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 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 Sacro iliac Jo in t Pro ceduresGEORGIA MEDICAID PY-1091 Effective Date: 09/01/2020 Joint ProceduresB. 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 inclusio n of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Sacroiliac joint injections using local anesthetic and/or corticosteroid medication have been shown to be ef f ective for diagnostic purposes, but provide limi ted short-term relief f rom pain resulting f rom SI joint dysf unction. C. Def initions Sacroiliac Joint Injections – corticosteroid and local anesthetic therapeutic injections into the sacroiliac joint to treat pain that hasnt responded to conservative therapies . Radiofrequency Facet Ablation (RFA) – is performed using percutaneous introduction of an electrode under f luoroscopic guidance to thermocoagulate medial bra nches of the dorsal spinal nerves. D. PolicyI. Sacroiliac Joint Procedures A. A prior authorization (PA) is required f or each sacroiliac joint procedure f or pain management. B. Sacroiliac Joint Injection Codes 1. Codes 64451 and 27096 are considered the same procedure and may not be billed together. C. Sacroiliac Joint Injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic ef f ect, repeating no more than once every seven (7) days and with at least a 75% or greater reduction in pain af ter the f irst injection. 2. Once the diagnostic injections are perf ormed and the diagnosis is established, two (2) therapeutic injections per joint may be perf ormed over a 12 month period. 3. Injections should not be repeated more frequently than every two (2) months with no more than a total of f our (4) injections (including both diagnostic and therapeutic) per joint in 12 months. A. SubjectSacroiliac 3 Sacro iliac Jo in t Pro ceduresGEORGIA MEDICAID PY-1091 Effective Date: 09/01/2020 D. Image guidance and/or injection of contrast is included in sacroiliac injection procedures and may not be billed separately F. Initial Radiof requency Ablation of the SI Joint 1. A maximum of one (1) radiof requency ablation f or SI Joint pain per side per rolling twelve (12) months when CareSource medical policy MM-0010 clinical criteria has been met. G. Repeat Radiof requency Ablation of the SI Joint 1. Conservative therapy an d diagnostic injections are not required if there has been a reduction in pain f or at least twelve (12) months or more f rom the initial RFA within the last thirty-six (36) months. 2. When there has not been a repeat RFA in the last thirty-six (36) months, a diagnostic injection is required. E. Conditions of Coverage 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 be all inclusive and is subject to updates. Sacroiliac JointProcedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (f luoroscopy or CT) including arthrography when perf ormed 64451 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography 64625 Radiof requency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, f luoroscopy or computed tomography) F. Related Policies/RulesSacroiliac Joint Procedures MM-0215 G. Re view/Revision History DATE ACTIONDate Issued 12/11/2019Date Revised 05/13/2020 Revised to add coverage f or ablation of the SI Joint; added codes: 64451 64625. Date Effective 09/01/2020 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. 4 H. Ref erencesSacro iliac Jo in t Pro ceduresGEORGIA MEDICAID PY-1091 Effective Date: 09/01/2020 1. Georgia Department of Community Health Fee Schedules. Retrieved May 1, 2020 f rom www.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-131362 Date Issued 02/11/2019 DCH Ap p ro ved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Fusion PY-1216 09/01/2020-05/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 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, 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 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 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 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 prov ided in a particular case and may modify this Policy at any time. 2 A. SubjectSacroiliac Joint Fusion Sacro iliac Jo in t FusionGEORGIA MEDICAID PY-1216 Effective Date: 09/01/202 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 guarantee of payment. Reimbursement f or c laims 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. The sacroiliac (SI) joints are f ormed by the connection of the sa crum and the right and lef t iliac bones. The sacrum is the triangular-shaped bone in the lower portion of the spine, below the lumbar spine. While most of the bones (vertebrae) of the spine are mobile, the sacrum is made up of f ive vertebrae that are f used together and do not move. The iliac bones are the two large bones that make up the pelvis. As a result, the SI joints connect the spine to the pelvis. The sacrum and the iliac bones (ileum) are held together by a collection of strong ligaments. There is relatively little motion at the SI joints. There are normally less than 4 degrees of rotation and 2 mm of trans lation at these joints. Sacroiliac Joint (SIJ) dysf unction is indicated by the abnormal movement or malalignment of the sacroiliac joint and is the main source of lower back pain in 15% to 30% of patients. The condition causes disability and pain and may b e caused by prior lumbar sacral f usion, trauma, inf lammatory arthritis, sacral tumors, osteoarthritis or pregnancy. Patients may present with low back, groin and/or gluteal pain. SI joint pain can of ten appear to be disogenic or radicular back pain. This c an lead to the potential f or inaccurate diagnosis and treatment, reviews caution dif f icult diagnosis and evidence for ef f icacy. Open SIJ f usion typically involves opening the SIJ, denuding of cartilage, and bone graf ting. To stabilize the SIJ, the iliac crest bone and the sacrum are typically held together by plates or screws or an interbody f usion cage until the 2 bones fuse. C. Def initions Conservative Therapy – is a multimodality plan of care. Multimodality care plans include ALL of the f ollowing: o Active Conservative Therapies – such as physical therapy, occupational therapy or a physician supervised home exercise program (HEP) Home Exercise Program (HEP) – inclu des two components that are both required to meet CareSource policy for completion of conservative therapy: 3 Sacro iliac Jo in t FusionGEORGIA MEDICAID PY-1216 Effective Date: 09/01/2020 An exercise prescription and/or plan documented in the medical record. A f ollow up documented in the medical record regarding completion of a HEP (af ter suitable six (6) week period), or inability to complete a HEP due to a stated physical reason-i.e. increased pain, inability to physic ally perf orm exercises. (Patient inconvenience or noncompliance without explanation does not constitute inability to complete). o Passive Conservative Therapies – such as rest, ice, heat, medical devices, TENS unit and prescription medications D. PolicyI. Sacroiliac Joint Fusion A. Prior authorization is required f or minimally invasive f usion/stabilization of the sacroiliac joint (SIJ) f or the treatment of back pain when the medically necessary criteria in the Sacroiliac Jo int Fusion Medical policy, MM-0838, has been met. II. ExclusionsA. Percutaneous SIJ f usion for SIJ pain is NOT indicated in the presence of : 1. Systemic arthropathy such as ankylosing spondylitis or rheumatoid arthritis; 2. Generalized pain behavior (e.g. somatof orm disorder) or generalized pain disorder (e.g. fibromyalgia); 3. Inf ection, tumor, or f racture; 4. Acute, traumatic instability of the SIJ; 5. Neural compression as seen on an MRI or CT that correlates with the patients sym ptoms or other more likely source f or their pain. 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. CPT Code Description 27279 Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graf t when performed, and placement of transf ixing device 4 F. Related Policies/RulesSacroiliac Joint Fusion MM-0838 G. Review/Revision HistorySacro iliac Jo in t FusionGEORGIA MEDICAID PY-1216 Effective Date: 09/01/2020 DATE ACTIONDate Issued 05/13/2020 New PolicyDate Revised Date Effective 09/01/2020 Date Archived 05/31/2021 No longer ef f ective as of 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/Sta te/NCCI guidelines without a f ormal documented Policy. H. Ref erences1. Georgia Department of Community Health Fee Schedules. Retrieved on April 15, 2020 f rom gammis.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-131362 Date Issued 05/13/2020 DCH Ap p ro ved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Overpayment Recovery PY-1112 09/01/2020 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, 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 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 09/01/2020 2 A. SubjectOverpayment Recovery 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. Retrospective review of claims paid to providers assist CareSource with ensuringac curacy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified . Fraud, waste and abuse investigations ar e an exception to this policy. In theseinvestigations, the look back period may go beyond 2 years.C. Definitions Overpayment – A payment that exceeds amounts properly payable to a provider. These commonly are discovered during a post-payment review . Examples include but a re not limited to incorrect coding, non-covered services, and billing discrepancies . Coordination of benefits (COB) – A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the me mber. Retroactive eligibility – A payment for a member who was retroactively terminated from the state . Member is not eligible for benefits. Improper payment – A payment that should not have been made or an overpayment was made. Examples include but are not limited to payment made for the ineligible member, ineligible service, payment made for a service not received, and duplicate payments. D. Policy I. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider : A. The name a nd patient account number of the member to whom the service (s) were provided ; B. The date(s) of services provided ; Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 09/01/2020 3 C. The amount of overpayment;D. The reason for the re coupment ; and E. That the provider has a ppeal rights . II. Overpayment RecoveriesA. Lookback period is 12 months from the last date of service or discharge . B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit R ecoveriesA. Lookback period is 12 months from the last date of service or discharge . B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timefr ame is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility RecoveriesA. Lookback period is 12 months from date CareSource is no tified by Medicaid of the updated eligibility status. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely fil ing guidelines. 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. F. Related Policies/Rules National Agreement, Article V. CLAIMS AND PAYMENTS, 5.11 (d). G. Review/Revision History DATE ACTIONDate Issued 02/05/2020Date Revised Date Effective 09/01/2020 New policy Date Archived Overpayment RecoveryGEORGIA MEDICAIDPY-1112 Effective Date: 09/01/2020 4 H. References1. Georgia General Assemb ly. (2018). O.C.G.A. 33-20A-62 Payment. Retrieved January 28, 2020 from www. ga.elaws.us 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. GA-MED-P-131362 Date Iss ued 02/05/2020 DCH Approved 06/09/2020
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 Spinal Cord Stimulator PY-1075 09/01/2020 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 ………………………….. ………………………….. ………………………….. ……… 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 5 H. References ………………………….. ………………………….. ………………………….. …………………….. 5 2 A. SubjectImplantable Spinal Cord Stimulator Implantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 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-mana gement 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 qualifi ed to deliver these health services. C. Definitions Implantable Spinal Cord Stimulator: Spinal cord (dorsal column) stimulation (SCS) is a pain relief technique that delivers a low-voltage electrical current to the spinal cord to block the sensation of pain . D. PolicyI. Implantable Spinal Cord Stimulator A. Prior authorization (PA) is required for all implantable spinal cord stimulators, including short-term trial placement and permanent placement. 1. Prior authorizations for implantable spinal cord stimulator services are not required for the following: a. Implantable device and device components are considered part of the procedure and does not require a separate PA. b. Removal/revision of implanted device. 3 c. Electronic analysis/studies post implantation Implantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 B. Short term and permanent Implantable Spinal Cord Stimulators are considered medically necessary according to the criteria found 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 modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes is provided as a r eference. This list may not be all inclusive and is subject to updates. Implantable Spinal Cord Stimulator Codes Description 63650 Percutaneous implantation of neurostimulator electrode array, epidural 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) plac ed via laminotomy or laminectomy, including fluoroscopy, 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 from 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 from 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 Implantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from 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, frequency [Hz], on/of f cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial ner ve, 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, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming b y physician or other qualified health care professional 95972 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimu lation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional F. Related Policies/RulesImplantable Spinal Cord Stimulator MM-0812 G. Review/Revision HistoryDATE ACTIONDate Issued 05/13/2020Date Revised Date Effective 09/01/2020 Date Archived 01 /01/2021 5 H. ReferencesImplantable Spinal Cord StimulatorGEORGIA MEDICAID PY-1075 Effective Date: 09/01/2020 1. Georgia Department of Community Health Fee Schedules. Retrieved on April 22, 2020 from 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. GA-MED-P-131362 Date Issued 05/13/2020 DCH Approved 06/09/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Facet Joint Interventions PY-116 2 09/01 /2020 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 Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on th e 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 morbidit y, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Poli cy 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 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 Interventions GEORGIA MEDICAID PY-1162 Effective Date: 09/0 1 /2 02 02A. Subject Facet 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 are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qu alifications. 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-servic e 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 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. 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-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 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 zygapophy seal 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 the facet joint as the pain source. Radiofrequency Facet Ablation (RFA) is performed using percutaneous introduction of an elec trode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves . D. Policy I. Facet Joint Interventions A. A p rior authorization (PA) is required for each facet joint intervention for pain management.. II. Diagnostic Medial Branch Nerve Block Injections A. An initial medial branch nerve block injection in the lumbar and cervical/thoracic region is required for diagnosis. Diagnostic injections are necessary due to the high false positive rates of single injections. Facet Joint Interventions GEORGIA MEDICAID PY-1162 Effective Date: 09/0 1 /2 02 031. The member must meet the medically necessary criteria in the corresponding Facet Joint Interventions medical policy, MM-0967, before a diagnostic injection is performed. III. Medial Branch Nerve Block Injections A. Once a positive diagnostic medial branch nerve block injection has been established, a maximum of six (6) injections may be performed in the cervical/thoracic spine and six (6) in the lumbar spine per rolling twelve (12) month period. B. Per CPT guidelines, imaging guidance and any injection 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, MM-0967. B. A maximum of two (2) radiofrequency facet ablations per rolling 12 months for each spinal region (cervical/thoracic or lumbar) involving no more than four (4) joints per session (e.g., two (2) bilateral levels or four (4) unilateral levels). 1. Repeat Radiofrequency Facet Ablation in the same spinal region and vertebral location is considered medically necessary when ALL of the criteria in the corresponding Facet Joint Interventions medical policy , MM-0967 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 f ee schedule for appropriate codes. F. Related Policies/Rules Facet Joint Interventions MM-0974 Facet Joint Interventions GEORGIA MEDICAID PY-1162 Effective Date: 09/0 1 /2 02 04G. Review/Revision History DATE ACTIONDate Issued 05/13/2020 This policy replaces the Facet Medial Branch Nerve Block MM-1061 and Radiofrequency Facet Ablation MM-1082 policies.Date Revised Date Effective 09/01 /2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedul es. Retrieved on April 15, 2020 from www.mmis.georgia.gov The Reimbursement Po lic y Sta te m ent d etai le d a bo ve h as r ecei ved due c on sidera tio n a s d efi ned i n the ReimbursementPo lic y St ate m ent Polic y a nd i s a pp ro ved. GA-MED-P-131362 Date Issued 05/ 13/2020 DCH Approved 06/09/2020
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, 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, 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 t he plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder w ill 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 Three-Day Payment Window PY-1043 09/01/2020-07/31/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject …………………………………………………………………………………………………………………. 2 B. Background …………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………….. 2 D. Policy …………………………………………………………………………………………………………………… 2 E. Conditions of Coverage …………………………………………………………………………………………… 3 F. Related Policies/Rules ……………………………………………………………………………………………. 3 G. Review/Revision History ………………………………………………………………………………………….. 3 H. References ……………………………………………………………………………………………………………. 3 2 A. SubjectThree-Day Payment Window Three-Day Payment Window GEORGIA MEDICAID PY-1043 Effective Date: 09/01/2020B. 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 staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting prov ider 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.Services provided within 3 days of an inpatient admission or discharge for the same or related diagnosis provided by the same facility are considered part of the admission.C. DefinitionsInpatient-A member who has been admitted to a participating hospital on recommendation of a licensed doctor and is receiving room, board, and professional services in the hospital on a continuous twenty-four hour a day basis. A length of stay less than twenty-four hours may be considered inpatient if the service can only be provided on an inpatient basis. Transfers between units within the hospital are not considered new admissions. Outpatient services-A member who is receiving professional services at a participating hospital. Same or related diagnosis-Primary diagnosis code based on the first three digits of the ICD-10 code. D. PolicyI. Three-Day Payment Rule A. Claims submitted for outpatient services (including laboratory and radiology services) that were provided within the three calendar days prior to the inpatient admission for the same member will be denied because the inpatient and outpatient services must be combined. 1. This only applies when: a. The same or related diagnosis are considered part of the inpatient admission; and b. Services are provided by the same facility. B. The outpatient services and inpatient services must be submitted on one inpatient claim. C. The dates of the claim should inclusive of the outpatient and inpatient services. 3 Three-Day Payment Window GEORGIA MEDICAID PY-1043 Effective Date: 09/01/2020 D.If an outpatient claim is paid before the inpatient claim is submitted, the inpatient claim will be denied with EOB 6516 Outpatient services performed three days prior to inpatient admission. To resolve this denial, providers should void the outpatient claim in history, incorporate the outpatient services into the inpatient claim, and resubmit the corrected inpatient claim. 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. E.Related Policies/RulesF. Review/Revision History DATE ACTION Date Issued 04/29/2020 Date Revised Date Effective 09/01/2020 Date Archived 07/31/2022 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a form al documented Policy. G.References 1. Georgia Department of Community Health Division of Medicaid. (2019, October).PART II Policies and Procedures for Hospital Services. Retrieved November 1, 2019from www.mmis.georgia.govThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-MED-P-131362 Date Issued 04/29/2020 DCH Approved 06/09/2020
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