REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Sacroiliac Joint Procedures PY-1091 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, 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 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 Archived Sacroiliac Joint Procedures GEORGIA MEDICAID PY-1091 Effective Date: 06/01/2020 2 A. Subject Sacroiliac Joint Procedures 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 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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely 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 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 fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Sacroiliac Joint Procedures: corticosteroid and local anesthetic therapeutic injections into the SIJ to treat pain that hasnt responded to conservative therapies. D. Policy I. Sacroiliac Joint Procedures A. A prior authorization (PA) is required for each sacroiliac joint injection for pain management. B. Sacroiliac joint injections 1. Two (2) diagnostic injections per joint to evaluate pain and attain therapeutic effect, repeating no more than once every seven (7) days and with at least a 75% or > reduction in pain after the first injection. 2. Once the diagnostic injections are performed and the diagnosis is established, two (2) therapeutic injections per joint may be performed 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 four (4) injections (including both diagnostic and therapeutic) per joint in 12 months. C. Radiofrequency Facet Ablation for Sacroiliac Pain 1. Thermal or pulsed, cooled neurotomy by Radiofrequency Facet Ablation (RFA) or other techniques for sacroiliac pain are NOT covered. Archived Sacroiliac Joint Procedures GEORGIA MEDICAID PY-1091 Effective Date: 06/01/2020 3 E. Conditions 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 Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Sacroiliac Joint Procedures Description 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed F. Related Policies/Rules Sacroiliac Joint Procedures MM-0215 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 0 6/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019 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-P – 0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Radiofrequency Facet Ablation PY-1082 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, 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 applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Archived Radiofrequency Facet Ablation GEORGIA MEDICAID PY-1082 Effective Date: 06/01/2020 2 A. Subject Radiofrequency Facet Ablation 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 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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporat es 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 pr ocedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Radiofrequency Facet Ablation: is performed using percutaneous introduction of an elect rode under fluoroscopic guidance to thermocoagulate medial branches of the dorsal spinal nerves. D. Policy I. Radiofrequency Facet Ablation A. A prior authorization (PA) is required for each radiofrequency facet joint degeneration /ablation for pain management . B. For each spinal region (cervical/thoracic or lumbar) two (2) radiofrequency facet ablations per rolling 12 months, involving no more than four (4) joints per session, e.g., two (2) bilateral level s or four (4) unilateral levels . C. A repeat RFA in the same spine region requires documented pain relief of at least 50% for a minimum of 6 months after the initial RFA . D. Repeat RFA cannot be performed for at least six (6) months following the initial RFA E. Radiofrequency facet ablation should be performed with imaging guidance . 1. Coverage for image guidance and any injection of contrast are inclusive components and are not reimbursed separately. Archived Radiofrequency Facet Ablation GEORGIA MEDICAID PY-1082 Effective Date: 06/01/2020 3 E. Conditions 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 Georgia Medicaid fee schedule for appropriate codes. The following list (s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Radiofrequency Facet Ablation Description 64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint 64634 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) 64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint 64636 Destruction by neurolytic agen t, paravertebr al facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) F. Related Policies/Rules Radiofrequency Facet Ablation MM-0216 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 06/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedul es. Retrieved November 8, 2019 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-P – 0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Spinal Cord Stimulator PY-1075 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Polici es. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o 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 ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Implantable Spinal Cord Stimulator GEORGIA MEDICAID PY-1075 Effective Date: 06/01/2020 2 A. Subject Implantab l e Spinal Cord Stimulator 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 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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely 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 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 fo r the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Implantable 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. Policy I. 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 authorization for implantable spinal cord services is not required for the following: a. Electronic anal ysis/studies post implantation 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 . Archived Implantable Spinal Cord Stimulator GEORGIA MEDICAID PY-1075 Effective Date: 06/01/2020 3 E. Conditions 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 Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Implantable Spinal Cord Stimulator Cod es 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 performe d 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 st udy, 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 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 low er 95970 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 neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with brain, cranial nerve, spinal cord, peripheral nerve, or sacral nerve, neurostimulator pulse generator/tra nsmitter, without programming Archived Implantable Spinal Cord Stimulator GEORGIA MEDICAID PY-1075 Effective Date: 06/01/2020 4 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 neurostimulation, 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 by physician or other qualified health care professional 95972 Electronic analys is 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 neurostimulation, 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 o ther qualified health care professional F. Related Policies/Rules Implantable Spinal Cord Stimulator MM-0812 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 0 6/01/2020 Date Archived H. References 1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019 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-P – 0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Implantable Pain Pump PY-1069 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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 requ irements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of ser vice, 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 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 me mber 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 procedure s. 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 pl an 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 Po licy 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 ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Implantable Pain Pump GEORGIA MEDICAID PY-1069 Effective Date: 06/01/2020 2 A. Subject Implantable Pain Pump B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the act ual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the su bmitting provider to submit the most accurate 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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely 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 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. I nterventional procedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Implantable Pain Pump : Implantable pain pumps are medical devices which are inserted subcutaneously to deliver drugs for infusion through intrathecal catheters. Implantable pain pumps allow drug delivery directly to specific sites and can be programmed for continuous or variable rates of infusion . D. Policy I . Implantable Pa in Pump A. Prior authorization (PA) is required for all implantable pain pumps, including trial administration, permanent placement and single shot intrathecal injections for the treatment of severe chronic intractable pain of malignant or non-malig nant origin. 1. Prior Authorizations for implantable pain pump services are not required for the following: a. Implantable device is considered part of the procedure and does not require a separate PA. b. Removal/revision of implanted device c. Electronic analysis post transplantation B. Short term and permanent Implantable Pain Pumps are considered medically necessary according to the criteria found in the Implantable Pain Pump Medical policy MM-0802 . Archived Implantable Pain Pump GEORGIA MEDICAID PY-1069 Effective Date: 06/01/2020 3 E.Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes.F. Related Policies/RulesImplantable Pain Pump MM-0 802G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 06/01/2020 Date Archived H.References1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. GA-P-0881 12/11/2019 DCH Approved 03/02/2020 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Facet Medial Branch Nerve Blocks PY-1061 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, 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 applica ble referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good med ical 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, Evidenc e 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 t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used t o 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 ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Facet Medial Branch Nerve Blocks GEORGIA MEDICAID PY-1061 Effective Date: 06/01/2020 2 A. Subject Facet Medial Branch Nerve Blocks 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 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. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely favorable for most patients, but a small percentage of patients symptoms are categorized as chronic. Chronic pain is defined by the International Association f or the Study of Pain as: pain that persists beyond normal tissue healing time, which is assumed to be three months. Interventional procedures for management of acute and chronic pain are part of a comprehensive pain management care plan that incorporat es 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 pr ocedures for the management of pain unresponsive to conservative treatment should be provided only by physicians qualified to deliver these health services. C. Definitions Facet Medial Branch Nerve Blocks: Injection of a local anesthetic with or without a cor ticosteroid into the vicinity of the medial branch nerves of the dorsal rami. D. Policy I. Facet Medial Branch Nerve Blocks A. A prior authorization (PA) is required for each facet medial branch nerve block injection for pain management. 1. Dual MBBs (a series of two MBBs) are necessary to diagnose facet pain due to the unacceptably high false positive rate of single MBB injections. a. A second confirmatory MBB is allowed if documentation indicates the first MBB produced significant relief of primary (index) pain 50%. 2. A maximum of six (6) facet injection sessions inclusive of medial branch blocks, intraarticular injections, and facet cyst rupture and facet medial branch neurtomies may be performed per rolling 12 months in the cervical/thoracic spine and six (6) in the lumbar spine. 3. Neither conscious sedation nor Monitored Anesthesia Care (MAC) is routinely necess ary for intra-articular facet joint injections or medial branch blocks and are not rout inely reimbursable. Individual consideration may be given for payment in rare unique circumstances if the medical necessity of sedation is unequivocal and clearly documented. Archived Facet Medial Branch Nerve Blocks GEORGIA MEDICAID PY-1061 Effective Date: 06/01/2020 3 4. Per CPT guidelines, imaging guidance and any injection of contrast are inclusiv e components of all facet medial branch nerv e blocks and are not reimbursed separately. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes al ong with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list ma y not be all inclusive and is subject to updates. Facet Medial Branch Nerve Blocks Description 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 64491 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure 64493 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level 64494 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level ( List separately in addition to code for primary procedure 64495 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) F. Related Policies/Rules Facet Medial Branch Nerve Blocks MM-0214 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 06/01/2020 Date Archived Archived Facet Medial Branch Nerve Blocks GEORGIA MEDICAID PY-1061 Effective Date: 06/01/2020 4 H. Ref erences 1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019, from https://www.mmis.georgia.gov/portal/PubAccessProviderInformation/FeeSchedules/tabid/56/BMLUsed/20160127/Default.aspx 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-P – 0881 12/11/20 19 DCH Approved 03/02/1010 Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Epidural Steroid Injections PY-1054 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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 ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 5 Epidural Steroid Injections GEORGIA MEDICAID PY-1054 Effective Date: 06/01/2020 2 A. Subject Epidural Steroid 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 actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nearly 84% of adults experience back pain during their lifetime. Long term outcomes are largely 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 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-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 Epidural Steroid Injections: for persistent or chronic radicular pain involve injection of corticosteroid, local anesthetic, opioid, or combination medication into the epidural space, requiring fluoroscopic imaging and injection of an appropriate agent to achieve a selective reproducible blockage of a specific nerve root. Anatomic locations for epidural injections may involve the interlaminar space at the midline between vertebral bodies, caudal epidural injections, or transforaminal epidural injections. Epidural injections may be diagnostic for localizing and determining the cause of radiating pain and providing short term pain relief. D. Policy I. Epidural Steroid Injections A. A prior authorization (PA) is required for each epidural injection for pain management, excluding labor and delivery in childbirth and for post-surgical pain B. Interlaminar or Caudal Epidural Injections 1. More than 1 epidural injection per treatment date will not be authorized. 2. Bilateral injections and modifiers will not be recognized and coverage will be denied. 3. Prior authorization will be required for each epidural injection by the same or any physician. Epidural Steroid Injections GEORGIA MEDICAID PY-1054 Effective Date: 06/01/2020 3 4. Repeat injections sooner than 3 weeks may not reach pharmacodynamic effect of the corticosteroid and will not be covered. 5. Requests for repeat injections beyond 3 weeks without documentation of suitable pain score reduction and functional improvements, or other documented rationale as described in Policy section will not be covered. C. For Transforaminal Epidurals or Selective Nerve Root Blocks (SNRBs) 1. Transforaminal Epidurals provided to more than 2 vertebral levels per treatment date, whether unilateral or bilateral, will not be authorized and will not be covered. 2. Bilateral injections require the appropriate modifier. 3. Prior authorization is required for treatment sessions per each spine region. 4. Repeat injections sooner than 3 weeks may not reach pharmacodynamic effect of the corticosteroid and will not be covered. 5. Requests for repeat injections beyond 3 weeks without documentation of suitable pain score reduction and functional improvements, or other documented rationale as described in Policy section will not be covered. D. The maximum epidurals of all types of epidural injections a member can receive in a rolling 12 months is a total of 6, regardless of the number of levels involved. E. Real-time image guidance and any injection of contrast are inclusive components of epidural injections and are not compensated for separately, or unbundled, for coverage. Ultrasound guidance for epidural injections is inappropriate. F. Conscious sedation, if required for co-morbidities or patient/physician preference, may be provided without prior authorization but services will be considered part of the procedure and are not eligible for additional reimbursement if administered by a second provider. Coverage for monitored anesthesia will not be provided as not medically necessary. If anesthesia services are provided they must be delivered by CareSource credentialed providers, including anesthesiologists and/or CRNAs. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Epidural Description 62320 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62321 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62322 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar Epidural Steroid Injections GEORGIA MEDICAID PY-1054 Effective Date: 06/01/2020 4 epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) 62324 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance 62325 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) 62326 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance 62327 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) 64479 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64480 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64483 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) F. Related Policies/Rules Epidural Steroid Injections MM-0217 G. Review/Revision History DATE ACTION Date Issued 12/11/2019 Date Revised N/A Date Effective 06/01/2020 Date Archived Epidural Steroid Injections GEORGIA MEDICAID PY-1054 Effective Date: 06/01/2020 5 H. References 1. Georgia Department of Community Health Fee Schedules. Retrieved November 8, 2019, from https://www.mmis.georgia.gov/portal/PubAccessProviderInformation/FeeSchedules/tabid/56/BMLUsed/20160127/Default.aspx. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0881 12/11/2019 DCH Approved 03/02/2020
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Positive Airway Pressure Devices for Pulmonary Disorders PY-0854 06/01/2020-04/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies.In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of serv ice, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures .This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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 …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 4 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 5 H. Ref erences …………………………………………………………………………………………………………. 5 Positive Airway Pressure Devices for Pulmonary DisordersGEORGIA MEDICAIDPY-0854 Effective Date: 06/01/2020 2A. Subject Positive Airway Pressure Devices for Pulmonary DisordersB. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office sta ff 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 incl usion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to tr eat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bilevel or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulm onary disease (COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome. C. Definitions Compliance-is defined as documented consistent use of PAP for either: o greater than or equal to () four (4) hours for five (5) days each week for at least 70% of the time for a thirty (30) consecutive day period any time during the first three (3) months of coverage in the trial period; o average of four (4) hours per day of PAP availability. Medically Necessary-means the following: o care based upon generally accepted medical practices in light of conditions at the time of treatment. o is appropriate and consistent with the diagnosis and the omission of which c ould adversely affect or fail to improve the eligible enrollee's condition. o is compatible with the standards of acceptable medical practice in the United States. o is provided in a safe and appropriate setting given the nature of the diagnosis and the severity of the symptoms. o is not provided solely for the convenience of the eligible enrollee or the convenience of the health care provider or hospital; and o is not primarily custodial care, unless custodial care is a covered service or benefit under the eli gible enrollee's evidence of coverage. Positive Airway Pressure Devices for Pulmonary DisordersGEORGIA MEDICAIDPY-0854 Effective Date: 06/01/2020 3D. Policy I. CareSource requires a prior authorization for PAP machines (CPAP/BiPAP). A. CPAP (E0601) and BiPAP (E0470, E0471 and E0472) machines are a 10 month rent to purchase. CareSource prior authorizations are f or 3 months initial rental for PAP machines. B. After initial 3 months rental, providers must submit documentation for continued rental that shows the members compliance with the use of the PAP machine during the first 3 months of use. Prior authorization may be obtain for the remaining rental period (months 4-10). II. Providers that dispense the PAP machine must ensure and document the members compliance with its use. A. Documentation that confirms compliance must be submitted along with the prior authorization request. B. Complianace for continued rental for members under 21 years of age is defined as: if criteria one (1) is met and one of criteria two (2) or three (3) are also met:: 1. There is documented improvement in sleep disruption, daytime sleepiness, and behavioral problems with use of the PAP, AND 2. The member has b een reevaluated for continued use of the PAP machine and demonstrates ongoing clinical benefit and compliance with use, defined as use of PAP for at least four (4) hours per night on 70% of the nights in a consecutive thirty (30) day period (remainder of the rental period considered for approval); OR 3. The member has been reevaluated for continued use of the PAP within the first ninety (90) days and demonstrates ongoing clinical benefit from use of the device during periods of use, but due to pediatric age or conditions that affect behavior (autism, etc.) and the ability to meet standard compliance guidelines will be considered on a case-by-case basis through the prior approval process. 4. Members that meet these criteria for extended coverage will be considered for reimbursement of the remaining seven (7) rental months. In order to receive the remaining seven (7) rentals in the ten (10) month rental period, the member must be compliant for at least two four (2-4) hours per night on 40% of the nights in a co nsecutive thirty-day period. C. Compliance for continued rental for members 21 years of age or older is defined as: 1. Greater than or equal to () four (4) hours for five (5) days each week for at least 70% of the time for a thirty (30) consecutive day period any time during the first three (3) months of coverage in the trial period or; 2. Average of four (4) hours per day of CPAP availability III. Members that are not compliant with the use of their PAP machines will not be authorized further rental.A. Any reimbursement, for the PAP machine, that was dispensed during the time of noncompliance will be recouped by CareSource.B. Any reimbursement, for the supplies, that were dispensed during the time of noncompliance will be recouped by CareSource.Positive Airway Pressure Devices for Pulmonary DisordersGEORGIA MEDICAIDPY-0854 Effective Date: 06/01/2020 4E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the Georgia Medicaid fee schedule for appropriate codes. The following list(s ) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description A4604 Tubing with integrated heating element for use with positive airway pressure device A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each A7028 Oral cushion for combination oral/nasal mask, replacement only, each A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair A7030 Full face mask used with positive airway pressure device, each A7031 Face mask interface, replacement for full face mask, each A7032 Cushion for use on nasal mask interface, replacement only, each A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Headgear used with positive airway pressure device A7035 Headgear used with positive airway pressure device A7036 Chinstrap used with positive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, nondisposable, used with positive airway pressure device A7044 Oral interface used with positive airway pressure device, each A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0471 Respiratory assist device, bi-level pressure capabilit y, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) E0561 Humidifier, non-heated, used with positive airway pressure device E0562 Humidifier, heated, used with positive airway pressure device E0601 Continuous positive airway pressure (CPAP) device Modifiers Description RR Rental (use the RR’ modifier when DME is to be rented) NU New equipment (use the NU modifier when DME is purchased) Positive Airway Pressure Devices for Pulmonary DisordersGEORGIA MEDICAIDPY-0854 Effective Date: 06/01/2020 5F. Related Policies/Rules N/A G. Review/Revision History DATE ACTIONDate Issued 12/11/2019 New PolicyDate Revised Date Effective 06/01/2020 Date Archived 04/30/2021 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 follow CMS/State/NCCI guidelines without a formal documented Policy. H. References1. CPAP-NHLBI, NIH. (2019, July 29). Retrieved 7/29/19 from https://www.nhlbi.nih.gov/healthtopics/cpap. 2. GA Medicaid DME Services Fee Schedule. (2019, July 1). Retrieved 7/29/19 from https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FEE%20SCH EDULE S/Durable%20Medical%20Equipment%20Fee%20Schedule%20%2020190627123538.pdf 3. O.C.G.A. 33-20A-31. (2019). Retrieved 7/29/19 from https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=afc7052b-2f4a-4323-932d7e3ac838e691&config=00JAA1MDBlYzczZi1lYj FlLTQxMTgtYWE3OS02YTgyOGM2NWJlMD YKAFBvZENhdGFsb2feed0oM9qoQOMCSJFX5qkd&pddocfullpath=%2fshared%2fdocument %2fstatutes-legislation%2furn%3acontentItem%3a5WF7-T1M0-004D-84YP-0000800&pddocid=urn%3acontentItem%3a5WF7-T1M0-004D-84YP-00008-00&pdcontentcomponentid=234186&pdteaserkey=sr0&pditab=allpods&ecomp=g5x8kkk&ear g=sr0&prid=25b71602-4391-4514-966e-911df64f1edb. 4. POLICIES AND PROCEDURES for DURABLE MEDICAL EQUIPMENT SERVICES. (2019, July). Retrieved 7/29/19 from https://www.mmis.georgia.gov/portal/Portals/ 0/StaticContent/ Public/ALL/HANDBOOKS/Part%20II%20Policies%20and%20Procedures%20for%20Durable %20Medical%20Equipment%20Services%20%2020190701130956.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0881 12/11/2019 DCH Approved 03/02/2020Positive Airway Pressure Devices for Pulmonary DisordersGEORGIA MEDICAIDPY-0854 Effective Date: 06/01/2020 6
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID PLANS Policy Name Policy Number Effective Date Robotic-Assisted Surgery PY-0959 06/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased, or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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 ………………………………………………………………………………………….. 3 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Robotic-Assisted Surgery GEORGIA MEDICAID PLANS PY-0959 Effective Date: 06/01/2020 2 A. Subject Robotic-Assisted Surgery B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Robot-assisted surgery involves the use of a robot and computer technology under the direction and guidance of a surgeon. These surgeries are minimally invasive procedures using robotic devices designed to access surgical locations through smaller incisions or ports. There surgeries are generally performed using a workstation console containing remote controls for the surgical instruments as well as a computer equipped with a three-dimensional magnified video monitor of the surgical site through use of miniature cameras. The primary difference between robotic and conventional laparoscopic procedures is that the surgical instruments are manipulated indirectly through computer controls rather than manually by the surgeon. The robotic controls allow the surgical tools to emulate the movement of the surgeon performing cuts, clamps and suturing in a similar fashion as would be done in an open procedure. Examples of robotic surgical systems include the da Vinci Surgical System (Intuitive Surgical, Inc.) and the ZEUS Robotic Surgical System (Computer Motion, Inc.) C. Definitions Robotic Assisted Surgery-is defined as the performance of operative procedures with the assistance of robotic technology. D. Policy I. Robotic-Assisted Surgery, HCPCS S2900, is included in the primary surgical procedure and not separately reimbursable. II. Modifier 22 (increased procedural services): 1. Should be used only to report complications or complexities during the surgical procedure that are unrelated to the use of the robotic system, such as increased intensity, increased time, increased difficulty of procedures, or severity of patients condition Robotic-Assisted Surgery GEORGIA MEDICAID PLANS PY-0959 Effective Date: 06/01/2020 3 Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the Georgia Medicaid fee schedule for appropriate codes. E. Related Policies/Rules F. Review/Revision History DATE ACTION Date Issued 10/16/2019 New Policy Date Revised Date Effective 06/01/2020 Date Archived G. References 1. Robotic surgery. MedLine Plus Web site. http://www.nlm.nih.gov/medlineplus/ency/article/007339.htm. Published May 2013. Accessed October 9, 2019. 2. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services; http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 3. Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage 4. Daniel M. Herron, MD. A consensus Document on Robotic Surgery. Prepared by the SAGES-MIRA Robotic Surgery Consensus group. Position Papers/ Statement published on: 11/2007. Accessed October 9, 2019. Available at URL address: http://www.sages.org/publications/guidelines/consensus-document-robotic-surgery / The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0867 10/16/2019 DCH Approved 03/02/2020
REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Glycosylated Hemoglobin A1C PY-0160 06/01/2020-11/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement 1A. Subject ………………………….. ………………………….. ………………………….. …………………. 2B. Background ………………………….. ………………………….. ………………………….. …………… 2 C. Def initions ………………………….. ………………………….. ………………………….. …………….. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………… 2 E. Conditions of Coverage ………………………….. ………………………….. ……………………….. 3 F. Related Policies/Rules ………………………….. ………………………….. …………………………. 5 G. Review/Revision History ………………………….. ………………………….. ………………………. 5 H. Ref erences ………………………….. ………………………….. ………………………….. ……………. 5 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y 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 A. SubjectGlycosylated Hemoglobin A1C Glyco sylated Hemo g lobin A1CGEORGIA MEDICAID PY-0160 Effective Date: 06/01/2020 B. BackgroundReimb ursement p olicies are d esigned to assist you when submitting claims to CareSource. They are ro utinely updated to p romote accurate coding and policy clarification. These proprietary p o licies are not a g uarantee of payment. Reimb ursement for claims may be subject to limitations and /o r q ualifications. Reimbursement will b e established b ased upon a review of the actual services provided to a member and will be d etermined when the claim is received for p rocessing. Health care p ro viders and their office staff are encourag ed to use se lf-service channels to verify memb ers eligibility. It is the resp o nsibility of the submitting p rovider to submit the most accurate and ap propriateCPT/HCPCS co de(s) for the product or service that is b eing p rovided. The inclusion of a code in this p o licy does not imply any right to reimbursement o r guarantee claims p ayment. Glycated hemoglobin/protein testing is widely accepted as medically necessary for the manag ement and control of d iabetes. Glycosylated hemoglobin A1C/protein levels are used to d etermine lo ng-term glucose control in d iabetes. Glycosylated hemoglobin levels reflect the averag e level of g lucose in the blood over a three-month period. C. Def initions Glycosylated Hemoglobin (A1C) a b lood test that measures your average blood sugar levels o ver the p ast 3 months. It is one of the commonly used tests to diagnose p rediabetes and d iab etes. Glycated protein – a b lo od test that is used to assess g lycemic control over a period of 1-2 weeks and lo ng-term control in diabetic p atients with abnormalities of erythrocytes. D. PolicyI. Prio r autho rization is not required for p articipating pro viders for glycosylated hemoglobin (A1C)/p ro tein b lood testing. Note: Altho ugh CareSource does not require a p rior authorization for g lycosylated hemo g lobin (A1C)/protein blood testing, CareSource may request documentation to sup p ort medical necessity. Appropriate and complete documentation must be p resented at the time of review to validate medical necessity. II. CareSo urce considers screening for the d iagnosis of d iabetes as medically necessary p reventive care for the following member groups according to the United States Preventive Services Task Fo rce (USPSTF): A. Asymptomatic members age 40 to 70 years who are o verweight or obese B. Asymptomatic members of any age o r weight who are in the following high-risk groups : 1. Immed iate family history of d iabetes 2. Histo ry of g estational diabetes or p olycystic ovarian syndrome 3. Af rican Americans 4. Native Americans 5. Alaskan Natives 6. Asian Americans 3 7. Hisp anics and Latinos8. Native Hawaiians 9. Native Pacific Islanders Glyco sylated Hemo g lobin A1CGEORGIA MEDICAID PY-0160 Effective Date: 06/01/2020 C. Asymptomatic p regnant wo men who have reached 24 weeks of gestation. III. CareSo urce considers diagnostic testing for the management of diabetes as medically necessary for the following member groups, with the specified frequencies: A. Memb ers whose diabetes is controlled, once every 3 months B. Memb ers whose diabetes is not controlled may req uire testing more than four times a year C. Preg nant wo men, once p er month Note: CareSo urce may request documentation to support medical necessity, if testing is in excess of the above g uidelines. IV . Alternative testing, including g lycated pro tein, for example, fructosamine, may be indicated for mo nito ring the d egree of g lycemic control. A. It is theref o re conceivable that a p atient will have both a g lycated hemoglobin and g lycated protein o rdered on the same day. B. This sho uld be limited to the initial assay of g lycated hemoglobin, with subsequent exclusive use of glycated pro tein. C. These tests are no t considered to be medically necessary for the d iagnosis of d iabetes. V. Reimb ursement is based o n submitting a claim with the appropriate ICD-10 d iagnosis code to match the CPT co de listed within this policy. If the ap propriate ICD-10 diagnosis code is no t sub mitted with the CPT co de, the claim will be denied. E. Conditions of Coverage Reimb ursement is dependent o n, b ut not limited to, submitting Georg ia Medicaid approved HCPCS and CPT co d es alo ng with appropriate modifiers, if applicable. Please ref er to the Geo rg ia Medicaid fee schedule for ap propriate 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 82985 Glycated p rotein 83036 Hemo g lobin; glycosylated (A1C) ICD-10 Description D13.7 Benig n neo plasm of endocrine p ancreas E08. Diab etes mellitus due to underlying condition with (Any ICD-10 starting with E08.) E09. Drug or chemical induced d iabetes mellitus with (Any ICD-10 starting with E09.) E10. Typ e 1 d iab etes mellitus with (Any ICD-10 starting with E10.) E11. Typ e 2 d iab etes mellitus with (Any ICD-10 starting with E11.) E13. Other sp ecified diabetes mellitus with (Any ICD-10 starting with E13.) E15 No nd iab etic hypoglycemic coma E16.0 Drug-ind uced hypoglycemia without coma E16.1 Other hyp o glycemia E16.2 Hyp o glycemia, unspecified E16.3 Increased secretion of glucagon 4 Glyco sylated Hemo g lobin A1CGEORGIA MEDICAID PY-0160 Effective Date: 06/01/2020 E16.8 Other sp ecified disorders of p ancreatic internal secretion E16.9 Diso rder of pancreatic internal secretion, unspecified E31.0 Auto immune polyglandular failure E31.1 Po lyglandular hyperfunction E31.20 Multip le endocrine neoplasia [MEN] syndrome, unspecified E31.21 Multip le endocrine neo plasia [MEN] type I E31.22 Multip le endocrine neo plasia [MEN] type IIA E31.23 Multip le endocrine neo plasia [MEN] type IIB E31.8 Other p o lyglandular dysfunction E31.9 Po lyglandular dysfunction, unspecified E74.8 Other sp ecified disorders of carbohydrate metabolism E79.0 Hyp eruricemia without signs of inflammatory arthritis and tophaceous disease E83.10 Diso rder of iron metabolism, unspecified E83.110 Hered itary hemochromatosis E83.111 Hemo chro matosis due to repeated red blood cell transfusions E83.118 Other hemo chromatosis E83.119 Hemo chro matosis, unspecified E83.19 Other d isord ers of iron metabolism E88.02 Plasminogen d eficiency E89.1 Po stprocedural hypoinsulinemia H44.2E1 Deg enerative myopia with o ther maculopathy, right eye H44.2E2 Deg enerative myopia with o ther maculopathy, left eye H44.2E3 Deg enerative myopia with o ther maculopathy, bilateral eye I21.9 Acute myocardial infarction, unspecified I21.A1 Myo cardial infarction type 2 I21.A9 Other myo cardial infarction type K86.0 Alco hol-induced chronic p ancreatitis K86.1 Other chro nic pancreatitis K91.2 Po stsurgical malabsorp tion, not elsewhere classified L97. No n-p ressure chronic ulcer of other p art of (Any ICD-10 starting with L97.) L98.415 No n-p ressure chronic ulcer of b uttock with muscle involvement without evidence of necro sis L98.416 No n-p ressure chronic ulcer of b uttock with bone involvement without evidence of necro sis L98.418 No n-p ressure chronic ulcer of b uttock with other specified severity L98.425 No n-p ressure chronic ulcer of b ack with muscle involvement without evidence of necro sis L98.426 No n-p ressure chronic ulcer of b ack with bone involvement without evidence of necro sis L98.428 No n-p ressure chronic ulcer of b ack with other specified severity L98.495 No n-p ressure chronic ulcer of skin of other sites with muscle involvement without evid ence of necro sis L98.496 No n-p ressure chronic ulcer of skin of other sites with bone involvement without evid ence of necro sis O24. Pre-existing type 1 d iabetes mellitus, in preg nancy (Any ICD-10 starting with O24.) O30. Preg nancy (Any ICD-10 starting with O30.) O99.810 Ab no rmal g lucose complicating pregnancy O99.815 Ab no rmal g lucose complicating the p uerp erium R73.01 Imp aired fasting glucose R73.02 Imp aired g lucose tolerance (oral) R73.03 Pred iab etes R73.09 Other ab no rmal glucose R73.9 Hyp erg lycemia, unspeci fied 5 Glyco sylated Hemo g lobin A1CGEORGIA MEDICAID PY-0160 Effective Date: 06/01/2020 R78.71 Ab no rmal lead level in b lood R78.79 Find ing of abnormal level of heavy metals in blood R78.89 Find ing of other specified substances, no t no rmally found in b lood R79.0 Ab no rmal level of b lood mineral R79.89 Other sp ecifi ed abnormal findings of b lood chemistry R79.9 Ab no rmal finding of b lood chemistry, unspecified T38.3X1A Po isoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentio nal), initial encounter T38.3X2A Po isoning by insulin and oral hypoglycemic [antidiabetic] drugs, intentional self-harm, initial enco unter T38.3X3A Po isoning by insulin and oral hypoglycemic [antidiabetic] drugs, assault, initial enco unter T38.3X4A Po isoning by insulin and oral hypoglycemic [antidiabetic] drugs, undetermined, initial enco unter Z00.00 Enco unter for general adult medical examination without abnormal findings Z00.01 Enco unter for general adult medical examination with abnormal findings Z01.812 Enco unter for preprocedural laboratory examination Z13.1 Enco unter for screening for diabetes mellitus Z13.9 Enco unter for screening, unspecified Z79.3 Lo ng term (current) use of hormonal contraceptives Z79.4 Lo ng term (current) use of insulin Z79.84 Lo ng term (current) use of oral hypoglycemic d rugs Z79.891 Lo ng term (current) use of opiate analgesic Z79.899 Other lo ng term (current) d rug therapy Z86.2 Perso nal history of diseases of the b lood and b lood-forming o rgans and certain d iso rders involving the immune mechanism Z86.31 Perso nal history of diabetic foot ulcer Z86.32 Perso nal history of gestational diabetes Z86.39 Perso nal history of other endocrine, nutritional and metabolic disease F. Related Policies/RulesN/A G. Review/Revision History DATE ACTIONDate Issued 10/16/2019 New p o licyDate Revised Date Effective 06/01/2020 Date Archived 11/30/2021 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and Care Source reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented Policy H. Ref erences1. Ab no rmal Blood Glucose and Type 2 Diabetes Mellitus: Screening. (2015, October). Retrieved 8/29/2019 f ro m https ://www.usprev ent iveservicestaskforce.org /Page/Document/Update SummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=diabetes. 2. Centers f o r Medicare and Medicaid Services. (2019). NCD 190.21 – Glycated Hemo g lobin/Glycated Protein (190.21). 3. Gestatio nal Diabetes Mellitus, Screening. (2014, January). Retrieved 8/29/2019 from 6 Glyco sylated Hemo g lobin A1CGEORGIA MEDICAID PY-0160 Effective Date: 06/01/202 4. http s :// www.us p rev en ti v es e rv i c es tas k f o rc e.o rg /P ag e/ Do c u me nt /Up d at e Su m m a ry Fi n al /g es t ati o nal – d iab etes-mellitus-screening?ds=1&s=diabetes. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0887 10/16/2019 DCH Ap p ro ved 03/02/2020
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Nutritional Supplements PY-0778 05/01/2020 Policy Type Medical Administrative Pharmacy REIMBURSEMENT 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, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to 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 …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 7 F. Related Policies/Rules ………………………………………………………………………………………….. 9 G. Review/Revision History ……………………………………………………………………………………….. 9 H. References …………………………………………………………………………………………………………. 9 Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 2 A. Subject Nutritional Supplements B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Nutrition may be delivered through a tube into the stomach or small intestine. Enteral Nutrition may be medically necessary for dietary management to provide sufficient caloric and nutrition needs as a result of limited or impaired ability to ingest, digest, absorb or metabolize nutrients; or for a special medically determined nutrient requirement. Considerations are given to medical condition, nutrition and physical assessment, metabolic abnormalities, gastrointestinal function, and expected outcome. Enteral nutrition may be either for total enteral nutrition or for supplemental enteral nutrition. This policy includes nutrition that is for medical purposes only. C. Definitions Enteral Nutrition Nutrition delivered through an enteral access device into the gastrointestinal tract bypassing the oral cavity. Medical Food Food specially formulated and processed to be consumed or administered by oral intake or enteral access device. The intent is to meet distinctive nutritional requirements of a disease or condition when dietary management cannot be met by modifying a normal diet. Enteral Access Device A tube or stoma is placed directly into the gastrointestinal tract for the delivery of nutrients. Inborn Errors Of Metabolism (IEM) Inherited biochemical disorders resulting in enzyme defects that interfere with normal metabolism of protein, fat, or carbohydrate. Therapeutic oral non-medical nutrition: o Food Modification Some conditions may require adjustment of carbohydrate, fat, protein, and micronutrient intake or avoidance of specific allergens. i.e. diabetes mellitus, celiac disease o Fortified Food Food products that have additives to increase energy or nutrient density. o Functional food Food that is fortified to produce specific beneficial health effects. Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 3 o Texture Modified Food and Thickened Fluids-Liquidized/thin puree, thick puree, finely minced or modified normal. o Modified Normal Eating normal foods, but avoiding particulate foods that are a choking hazard. D. Policy I. Claim submission A. All claims must include clinical documentation to determine medical necessity. B. To be reimbursed, claims for enteral nutrition supplies must be submitted with the purchase NU modifier. II. Prior Authorization A. Prior authorization is NOT required for the following supplies: 1. B4034-Enteral Feeding Supply Kit; Syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape 2. B4035-Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressing, tape 3. B4036-Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape 4. B4081-Nasograstric tubing with stylet 5. B4082-Nasogastric tubing without stylet 6. B4083-Stomach tube-Levine type 7. B4087-Gastrostomy/jejunostomy tube, standard, any material, any type, each 8. B4088-Gastrostomy/jejunostomy tube, low-profile, any material, any type, each 9. B9998 without a U1 modifier-Mickey extension B. Prior authorization is required for the following: 1. Enteral formulas a. B4149-Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit b. B4150-Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit c. B4152-Enteral formula, nutritionally complete, calorically dense (Equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100calories = 1 unit d. B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 4 e. B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit f. B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. Glutamine, Arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit g. B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit h. B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit i. B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit j. B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit. k. B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit l. B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit 2. Supplies a. B9998 with a U1 modifier (MicKey gastrostomy low-profile feeding tube kit) must have a prior authorization for enteral nutrition services 3. Oral Medical Foods (including S9435) a. During the prior authorization process for medical foods, the provider must submit 01. The invoice for a review and pricing AND 02. If available, the MSRP and discount applied to purchase price. B. Prior authorization is required for non-participating providers. Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 5 II. Age Limits A. There are no age restrictions for enteral nutrition supplies except for B9998-U1 (Mic-Key Gastrostomy Low-Profile Feeding Tube Kit) which is restricted for members who are younger than 36 months of age. B. Member must be under the age of 21 for the provider to bill for the following enteral formulas: a. B4149-Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit b. B4150-Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit c. B4152-Enteral formula, nutritionally complete, calorically dense (Equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100calories = 1 unit d. B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit e. B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit f. B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers), proteins/amino acids (e.g. Glutamine, Arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit g. B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit h. B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit i. B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit j. B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 6 proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit. k. B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit l. B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit III. Quantity Limits A. No more than one HCPCS code can be submitted for reimbursement at a time except for B4155 (Enteral Formula, nutritionally incomplete/modular nutrients) which can be submitted with another code for members needing replacement of nutritional elements who lack the ability to sustain optimal nutritional well-being. i.e. amino acid deficiencies, pancreatic insufficiencies B. Orders for supplies will not exceed 12 months C. Per the Georgia Provider Handbook, Enteral formulas are reimbursed on a per unit basis. Use the following formula to calculate units: Number of calories per day /100 Xnumber of days billed = units. (e.g., A patient received 1450 calories per day, during the month of March 1991. 1450 /100 X 31 days = 449.5 or 450 units (fraction of a unit should be rounded. 1/2 or 5/10 (.5) is rounded up to the next whole unit).1 D. Only one month supply (enteral nutrition, supplies, or oral medical food) can be submitted for reimbursement at one time 3. Medical food is limited to one unit for the total amount approved per month. 4. All enteral formulas are limited to 900 units per month E. B9998 with U1 modifier (MicKey gastrostomy low-profile feeding tube kit) cannot be billed separately for any of the supplies in the kit during the same 30 days II. CareSource does not reimburse for the following A. Enteral nutrition for members 21 years of age and older B. Enteral nutrition for members with advanced dementia C. When member is underweight and is able to meet nutritional needs through regular food D. When use of product is for convenience or preference of member/caregiver E. When the prescription and/or qualifying medical condition is absent F. Services billed by a home health agency G. Services or DME that exceeds limitations H. Shipping costs 1 https://www.mmis.georgia.gov/portal/portals/0/staticcontent/public/all/handbooks/durable%20medical%20equipment%20services_feb%202019%2020190218190229.pdfNutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 7 I. When the service is included in the rate for nursing or skilled nursing facility J. When the service is part of a home and community-based care waiver K. Items that cannot withstand repeated use L. Items not medically necessary M. Claims for enteral nutrition supplies not submitted with the NU modifier N. Codes not on GA fee schedule including but not limited to: 1. B4100 Food thickener 2. B4104 Additive for enteral formula 3. B4105 In-line cartridge containing digestive enzyme 4. B9002 Enteral nutrition infusion pump 5. S9340 Home therapy; enteral nutrition 6. S9341 Home therapy; enteral nutrition 7. S9342 Home therapy; enteral nutrition 8. S9343 Home therapy; enteral nutrition NOTE: Proof of delivery that is signed and dated by the member/caregiver must be on file and presented to CareSource upon request. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting GA Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual GA Medicaid fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description B4034 Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape B4035 Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape B4036 Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape B4081 Nasogastric tubing with stylet B4082 Nasogastric tubing without stylet B4083 Stomach tube-Levine type B4087 Gastrostomy/jejunostomy tube, standard, any material, any type, each B4088 Gastrostomy/jejunostomy tube, low-profile, any material, any type, each B4149 Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 8 B4150 Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4152 Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat (e.g., medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit B9998 MicKey Extension S9435 Medical foods for inborn errors of metabolism Modifiers Description Nutritional Supplement GEORGIA MEDICAID PY-0778 Effective Date: 05/01/2020 9 U1 MicKey low-profile gastrostomy tube kit (under 3 yrs) (under 36 months of age) F. Related Policies/Rules Nutritional Supplements MM-0759 G. Review/Revision History DATE ACTION Date Issued 05/01/2020 Date Revised Date Effective 05/01/2020 New policy H. References 1. Georgia Department of Community Health. (2019). Part II Policies and Procedures for Durable Medical Equipment Services. Retrieved on 7/2/2019 from https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Durable%20Medical%20Equipment%20Services%2020190401195108.pdf The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0832 Date Issued 05/01/2020 DCH Approved 1/28/2020
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