Smoking & Tobacco Cessation

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Da te Smoking & Tobacco Cessation PY-0378 05/01/2020-07/31/2022 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject …………………………………………………………………………………………………………….. 2 B. Bac k g r ou nd ………………………………………………………………………………………………………. 2 C. Def initions ………………………………………………………………………………………………………… 3 D. Policy ………………………………………………………………………………………………………………. 3 E. Conditions of Co ve r age……………………………………………………………………………………….. 3 F. Related Policies/Rules ………………………………………………………………………………………… 5 G. Review/Revision History ………………………………………………………………………………………. 5 H. Ref er en ce s ……………………………………………………………………………………………………….. 6 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 service, m edical necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable r e f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limite d to, t hose 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, dysfunc t ion of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly 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. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Coverage) for the service(s) referenced herein. If there is a co n flict between th is Po licy 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. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A.Subjec t Smoking & Tobacco Cessation Smoking & To bac c o Ces s ati on GEORGIA MEDICAID PY-0378 Effec ti v e Date: 05/01/2020 B. Bac k ground Reimb urs ement policies are d esigned to ass is t y ou when s ubmitting c l a im s to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o licies are not a guarantee of p ayment. Reimb urs ement for claims m ay be subject to limitations and /o r q ualifications. Reimburs ement will b e established b ased upon a rev iew of the ac tual services provided to a member and will be determined when the claim is received for p rocessing.Health c are p ro v iders and their office s taff are enc ourag ed to us e s elf-serv ic e channels to v erify memb ers eligibility.I t is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriat e CP T/ HCP CS c o de(s) for the product or s ervice that is being provided. Th e inclusio n of a c ode i n t his p o lic y does no t imply any right to reimbursement o r guarant ee c laims p ayment.Th e us e of tobac co products generally leads to tobacco/nicotine dependence 3 and often results in s erio us health problems . Quitting smoking greatly reduces the ris k of d ev eloping s moking-related d is eas es . To bac co/nicotine d ependenc e is a condition that often req uires repeated treatments , as nic o tine is s tr o ng l y addictive. Because of t h is , quitting sm oking and end ing the use of tobac co use may b e a d iffic ult proc ess req uiring s everal, s taged attempts, and may involve s tres s, irritability, and o ther withdrawal s ymptoms for those addicted to nicotine 8, 9, 10. H o wev er, c ontinued tobac co use in any form is far more harmful. To b ac co smoke c ontains s erio us l y harmful chemicals and c arc inogens 5, 8, 11 and lead s to lung and other cancers , c hronic lung d is ease, heart disease, strokes, v ascular diseas e, and infertility . Additionally, s mokeless to b ac co is d irec tly link ed to c ancers of the mouth, tongue, c heek, gum, esophagus, and p anc reas. Co uns eling and medic ation are b oth effec tive means for end ing d ependenc y on tobacco products, and are ev en more ef fect ive together than either method alone 10. Couns eling can b e ef f ectiv e when delivered v ia indiv idual, group, or telephone counseling, o ne-on-one brief help s es s ions with a p rov ider, behavioral therapies, o r ev en thro ugh mobile phone apps . M ed ic ations which have been found to be ef f ec ti v e include pres cription non-nicotine medic ations s uc h as b upropion SR (Zyban ) and v arenic line tartrate (Chantix ), and nic otine replacement p ro d ucts s uch as nic otine patches, inhalers or nas al s prays av ailable by pres cription, and over-the-c o unter nic otine patches, gums or lozenges 10, 17 . T he United States gov ernment recognizes the health dangers and risk s as sociated with the use o f tobacc o in its c itizens and has s et up a f ree telephone s upport s erv ic e to help people stop smoking and stop the use of tobacco, 1-800-QUIT-NOW. Callers are ro uted thro ugh this s ervice to their s tates specif ic resourc e, and may be ab l e to o btain free support, adv ic e, and c ounseling f ro m ex perienc ed quit-line coac hes , a p ers onalized plan to quit, practic al information on how to q uit, inc luding way s to c ope with nicotine withdrawal, the latest information about s top-s mok ing med ic ations , free o r discounted medic ations (av ailable for at least some callers in mos t s tates), ref errals to other resourc es, and/or mailed self-help materials . C areSo urc e enc ourages all of i ts members to ref rain f rom the us e of tobacco, and if using it in any f o rm, to make c oncerted and ongoing attempts to quit its use as s oon as p ossible. 3 C. Def initionsSmoking & To bac c o Ces s ati on GEORGIA MEDICAID PY-0378 Effec ti v e Date: 05/01/2020 Tobacco products means any p roduct containing tobacco o r nicotine, including (but not limited to) cigarettes, pipes , cigars , cigarillos , bidis, hookahs, k retek s, e-c igarettes, v aporized and o ther inhaled tobac co and nic otine products, smokeless tobacco (e.g., d ip, c hew, snuff, s nus ), d iss olv able tobacc o (e.g., strips, s tic ks, orbs, lozenges), or o ther ing estible tobacco p ro d ucts, and /or c hewing tobac coD. Polic yI. Prio r autho rizations are req uired for participating (contracted) providers o nl y when the s erv ic es they are p roviding for tobacco c essation ex ceed the limits of this policy. II. No n-p artic ipating p roviders (not contracted wit h CareSource) should contact CareSource f or p rio r autho rization for these s ervices. III. CareSo urc e will reimburse i ts p articipating prov iders for the following tobacc o use interv entio n and c essation c are methods: A. An enc o unter for evaluation and management of the member on the sam e day as c o uns eling to prevent or c ease tobacco us e; and, B. Sc reening s for tobacco use as needed for members 20 and y ounger; C. One s c reening for tobacco us e per c alendar y ear for members 21 and older; and, D. Three ind iv idual tobacco c es sation c ounseling attempts p er c alendar y e ar . 1. Eac h attempt will not ex ceed 12 weeks of treatment. 2. Fac e to f ace c ounseling s essions are req uired every 30 day s during each 12 week treatment p eriod. E. Nico tine replacement or non-nicotine medications prescribed and approv ed for us e for to b ac co c es sation. IV. CareSo urc e will no t reimburse c laims for c ounseling to prevent or c ease tobacco us e in excess of 12 sess ions within a calendar y ear, unles s prior authorization has been obtained b y the p ro v ider. V. Th e numb er of CPT, HCP Cs, and diagnosis codes (ICD-10) p otentially ass ociated wit h the d iag no sis and treatment of tobacc o use and addiction is too g reat to lis t. As s uc h, the s p ec ific tobac co c essation c odes pro vided b elow are eligible to b e reimburs ed with any ap p ro priate, ass ociated c ode.VI. Ev aluation and Management s ervice for the member whic h is p rovided on the s ame day as c o uns eling to prevent or cease tobacc o use, s hould be reported wi th modifier-25 to indicate that the E&Ms ervice is s eparately identifiable from the counseling. A. CONDITIONS OF COVERAGEReim bursem ent is dependent on, b ut not limited to, s u bmi tti ng Geo r gi a Medicaid approved HCP CS and CP Tcodes a l on g wi th a pp r o pr i a te modifiers. Please refer to the Georgia Medicaid fee schedule. 4 Smoking & To bac c o Ces s ati on GEORGIA MEDICAID PY-0378 Effec ti v e Date: 05/01/2020 The following list(s) of codes is provided as a reference. This list m ay not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Reimb urs ement is dependent o n, but not limited to, s ubmitting Georgia Medicaid approved HCP CS and CPT codes along wit h appropriate m o di f i er s , if ap plicable. Pleas e refer to the ind iv idual Georgia Medicaid fee s chedule for appropriate codes . The following l i st(s) of codes is provided as a reference. This list may n ot be a ll i nclusive and is subject to updates.CPT Code Description 99406 Smo k ing and tobacco us e c es sation c ounseling visit; intermediate, g reater than 3 minutes up to 10 minutes 99407 Smo k ing and tobacc o use cess ation counseling visit; intensive, greater than 10 minutes E. Related Polic ies/RulesF.Rev iew/Rev ision History DATE ACTION Date Issued 9/20/2017 New Po licy Date Revised 8/19/2019 Date Effecti ve 05/01/2020 Date Archived 07/31/2022 This Po lic y is no lo nger ac tiv e and has been arc hiv ed. Pleas e no te that there c ould be other Polic ies that may hav e s o me of the s ame rules inc orporated and CareSource res erv es the rig ht to follow CMS/State/NCCI g uidelines witho ut a f ormal d ocumented Policy. G.Ref erenc esA. Physician Serv ic es Manual, 903.19, "To bacco c ess ation serv ic es for Medicaid e lig ib le memb ers ." Ib id. Appendix D, "Health chec k and ad ult prev entive v is it. (2017, July 1). B. CD C-Fac t Sheet-Quitting Smok ing-Smok ing & Tobac co Use. (n.d.). C. Co uns eling to Prev ent To bacco Us e. (Trans mittal 2058, 2010, September 30). Ce nters f o r M ed i c are & Medicaid Serv ices, Department of Health & Human Serv ic es. D. Treating Tobacco Us e and Dependence. Clinical Prac ti ce Guideline. ( n . d . ) . Fi o r e , Mi c hael C ( p anel c hair), Guid eline panel members. (Univ ersity of Wisconsin Medic al Sc hool, Center forTobac c o Res earc h and Intervention (Madison, WI) E. U. S . Department of Health and Human Services . Th e Health Cons equenc es of Smoking 50 Years of Progress : A Report of the Surg eon General. Atlanta: U. S. Department of Health and Human Serv ic es , Centers for Disease Co ntrol and Prevention, National Center for Chro nic Dis eas e Prevention and Health Promotion, Office o n Smoking and Health, 2014. F. Natio nal Ins t i tut e on Drug Abuse. Res earch Report Series: Is Nicotine Addic tive? Bethes da ( MD ): Natio nal Ins titutes of Health, National Ins titute on Drug Abus e, 2012. G. Americ an Society of Addiction Medic ine. Public Po li cy Statement on Nicotine Addic tion an d T o b ac c o. Chev y Chas e (MD): American Society of Addiction Medicine, 2008. H. U.S. Dep artment of Health and Human Serv ices. How To bacco Smoke Causes Disease: The Bio lo gy and Behavioral Basis for Smoking-Attributable Disease: A Rep ort of the Surgeon 5 Smoking & To bac c o Ces s ati on GEORGIA MEDICAID PY-0378 Effec ti v e Date: 05/01/2020 I. General. Atlanta: U.S. Department of Health and Human Services, Centers for Dis ease Control and Prev ention, National Center for Chronic Disease Prevention and Health Pro motion, Of fi ce on S mo k ing and Health, 2010. U.S. Dep artment of Health and Human Serv ices. Reducing To bacco Us e: A Rep ort of t he S urg eo n General. Atlanta: U. S. Department of Health and Human Serv ic es, Centers for Diseas e Co ntro l and Prev ention, National Center f or Chronic Disease Prevention and Health Promotion, Of f ic e on Smoking and Health, 2000. J. Fio re MC, Jan CR, Bak er TB , et al. Treating To bacco Us e and Dependenc e: 2008 Update Clinical Prac t ice Guidelines. Rockville (MD): U. S . Department of Health and Human Services,Pub lic Health Serv ice, Agency for Healthcare Res earch and Quality, 2008. K. Natio nal To x icology Program. Report on Carc inogens, Thirteenth Edition. Res earc h Triangle Park(NC): U. S . Dep artment of Health and Human Sciences, National Ins t i tute of Environmental HealthSc ienc es , National To xicology Program, 2014. L. U.S. Dep artment of Health and Human Serv ices. The Health Co nsequences of Smoking: A Rep o rt of the Surgeon General. Atlanta: U.S. Department of Health and Human Serv ic es, Centers f or Disease Control a nd Prevention, National Center f or Chro nic Disease Prevention and H ealth Pro motion, Office o n Smoking and Health, 2004. M. U. S . Dep artment of Health and Human Serv ic es. The Health Benefits of Smoking Cessation: ARep o rt of the Surgeon General. Atlanta: U.S. Department of Health and Human Serv ic es, Centers for Disease Control and Prev ention, Center for Chronic Disease Prev ention and Healt h P ro mo tion, Offic e on Smoking and Health, 1990. N. Centers f or Disease Control a nd Prevention. Quitting Smok ing Among A d ul t sUnited States , 2000 2015. Mo rb idity and Mortality Week ly Report 2017:65(52):1457-64. O. Centers f or Dis ease Contro l and Prevention. Youth Risk Behavior Surv eillanceUnited States , 2015. Mo rb idity and Mortality Week ly Report [serial online] 2016:66 (SS 6): 1 174.P. Centers f or Disease Control a nd Prevention. Th e Guide to Community Prev entive Services:Red uc ing To bacco Us e and Secondhand Smoke Expos ure. Q. U. S . Fo od and Drug Administration. Th e FDA Approves Novel Medication for Smoking Cessation. FD A Co ns umer, 2006. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-832 Date Issued: 05/01/2020 DCH Approved: 01/28/2020

Thyroid Testing

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Thyroid Testing PY-0903 05/01/2020-11/30/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. …………………… 1A. Subject ………………………….. ………………………….. ………………………….. ………………………… 2B. Background ………………………….. ………………………….. ………………………….. ………………….. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 3 H. Ref erences ………………………….. ………………………….. ………………………….. …………………… 3 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of servic e, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the mem ber or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling docum ent 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. SubjectThyroid Testing Th yro id TestingGEORGIA MEDICAID PY-0903 Effective Date: 05/01/2020 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 no t imply any right to reimbursement o r guarantee claims p ayment. Thyro id function studies are used to d etect the p resence or ab sence of hormonal abnormalities of the thyro id and pituitary glands. These abnormalities may be either primary o r secondary and o f ten but not always accompany clinically defined signs and symptoms ind icative of thyroid d ysfunction. CareSource considers testing thyroid function medically nec essary for members co nsistent with symptoms of thyro id d isease. C. Def initions Hyperthyroidism: Co ndition occurs when the thyro id g land p roduces too much thyroxine causing sudden weig ht loss, rap id or irregular heartbeat, sweating and nervousness. Hypothyroi dism: Co ndition o ccurs when the thyroid gland doesnt produce enough ho rmo nes causing weight gain, jo int pain, infertility and heart disease. D. PolicyI. CareSo urce d oes not require a p rior authorization for thyroid testing. II. Thyro id testing are used to test for thyroid function and d isease. Thyro id testing may be reaso nab le and necessary to: A. Distinguish between primary and secondary hypothyroidism B. Co nf irm or rule o ut primary hypothyroidism C. Mo nito r thyroid ho rmone levels (for example, p atients with goiter, thyroid nodules, or thyroid cancer) D. Mo nito r drug therapy in patients with primary hypothyroidism E. Co nf irm or rule o ut primary hyperthyroidism F. Mo nito r therapy in p atients with hyperthyro idism III. Thyro id testing may be covered up to two times a year in clinically stable p atients; more f req uent testing may b e reasonable and necessary for patients whose thyroid therap y has b een altered or in whom symptoms or signs of hyperthyroidism or hypothyroidism are noted. A. When these tests are b illed at a g reater frequency than the no rm (two p er year), the o rd ering physicians d ocumentation must support the medical necessity of this frequency must be made available upon CareSources req uest. IV . Reimb ursement is based on submitting a claim with the appropriate ICD-10 d iagnosis code to match the thyroid testing CPT code. 3 Th yro id TestingGEORGIA MEDICAID PY-0903 Effective Date: 05/01/2020 V. If the ap p ropriate ICD-10 d iagnosis code is no t submitted with the CPT code, the claim will be d enied . Note: Altho ug h this service does no t req uire a p rior authorization, CareSource may req uest d o cumentation to support medical necessity. Appropriate and complete documentation must be p resented at the time of review to validate medical necessity. E. Conditions of Coverage Reimb ursement is dependent o n, b ut no t limited to, submitting Georgia Medicaid ap proved HCPCS co des and the appropriate modifiers, if applicable. The ap propriate ICD-10 diagnosis code must match the correct CPT and /or HCPCS code within this policy. Please refer to the Georgia Med icaid fee schedule for appro priate 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 84436 Thyro xine; total 84439 Thyro xine; free 84443 Thyro id stimulating hormone (TSH) 84479 Thyro id ho rmone (T3 or T4) up take or thyroid hormone binding ratio (THBR) ICD 10 CodesA18 D3A E06 E24 E43 E88 F32 G47 R06 C56 D44 E07 E25 E44 E89 F33 I48 R61 C73 D49 E08 E27 E45 F03 F34 N91 Z00 C79 D89 E09 E28 E46 F05 F39 N92 Z01 C7A E00 E10 E29 E66 F06 F41 N94 Z86 C7B E01 E11 E31 E67 F07 F53 N97 D09 E02 E13 E35 E78 F22 F63 O90 D27 E03 E20 E40 E79 F23 G25 O92 D34 E04 E22 E41 E83 F30 G30 O99 D35 E05 E23 E42 E87 F31 G31 R00 F. Related PoliciesN/A G. Review/Revision History DATE ACTIONDate Issued 05/01/2020 New p o licyDate Revised Date Effective 05/01/2020 Date Archived 11/30/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f ormal documented P olicy 4 H. Ref erencesTh yro id TestingGEORGIA MEDICAID PY-0903 Effective Date: 05/01/2020 1. Natio nal Co verage Determination (NCD) for Thyroid Testing (190.22). Retrieved July 26, 2019, f ro m https ://www.c ms .go v/medicare-coverage-database/details/ncd – d etails.aspx?NCDId=101&ncdver=1&bc=AgEAAAAAAAAAAA%3D%3D& 2. Med icare National Coverage Determinations (NCD) Co ding Policy Manual and Chang e Report ICD-10-CM. Retrieved July 26, 2019, from http s:// www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual 201601_ICD1 0.p d f 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 Ap p ro ved 1/28/2020

Readmission

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 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 l ocal 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 i s 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 affiliatesmay use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSE ME NT POLICYS TA TE ME NTGEORGIA MEDICAID Policy Name Policy Number Effective Date Readmission PY-0731 08/01/2019-08/31/2021 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject …… 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Read mission GEORGIA MEDICA ID PY-0731 Effective Date: 08/01/2019 2 A. SubjectB. BackgroundReimbursement policies are designed to assist you when submittin g claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims of Readmissions f or our Medicare Advantage members may be subject to limitations and/or qualif ications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is re ceived f or processing. Health care providers and their of fice staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s ) f or the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Following a hospitalization, readmission within 3 days is of ten a costly preventable event an d is a quality of care issue. It has been estimated that readmissions within 3 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result f rom many situations but most of ten are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, f amily and caregivers. However, there are some readmissions that are unavoi dable due to the inevitable progression of the disease state or due to chronic conditions. The purpose of this policy is to improve the quality of inpatient and transitional care that is being rendered to the members of CareSource. This includes but is not limited to the f ollowing: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perf orm pre discharge assessment to ensure pati ent is ready to be discharged, and 4. provide ef fective post discharge coordination of care. C. Def initions Readmission : a subsequent inpatient admission to any acute care f acility which occurs within 3 days of the discharge date f or the same or related problem, excluding psychiatric services. Same or a related problem : a problem or diagnosis that is the same or a similar problem or diagnosis that is documented on the initial admission. Same Day : CareSource delineates same day as midnight to midnight of a single day. D. PolicyI. This is a reimbursement policy that def ines the payment rules for hospitals and acute care f acilities that are reimbursed f or inpatient services. Read mission GEORGIA MEDICA ID PY-0731 Effective Date: 08/01/2019 3 II. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review f or medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim. III. All Readmissions f or the same or related problem within 3 days of the initial discharge is considered the same admission and will be reimbursed as one claim, EXCEPT f or the f ollowing when the diagnosis f or the exclusion is in the admitting or the primary diagnosis position of the claim: A. Psychiatric services limited to short term acute care. IV. Readmissions greater than 3 days f ollowing a previous hospital discharge are treated as separate stays f or payments purposes, but are subject to medical review f or up to 30 days af ter the discharge date. V. Claim Payment Review and Appeals Process:1. CareSource reserves the right to monitor and review claim submissions to minimize the need f or post-payment claim adjustments as well as review payments retrospectively. a. Medical records f or both admissions may be requested to determine if the admission(s) is appropriate or is considered a readmission. 01. Failure f rom the acute care f acility or inpatient hospital to provide complete medical records when requested will result in an automatic denial of the claim. b. Medical records f or both admissions must be submitted with the claim if both admissions originate d f rom the same f acility or Tax Identif ication Number (TIN). 01. Failure from the acute care f acility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim c. If the included documentation determines the readmission to be an inappropriate, medically unnecessary or potentially preventable admission, the hospital must be able to provide addit ional documentation to CareSource upon request or the claim will be denied. d. If the readmission is determined at the time of documentation review to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admiss ion and paid as one claim to cover both, or all, admissions. 2. Appeals Process a. All acute care f acilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer review or formal appeal. Read mission GEORGIA MEDICA ID PY-0731 Effective Date: 08/01/2019 4 E. Conditions of CoverageRei mb urs e m en t is d ep end ent o n, b ut no t l i mi ted to , s ub mi tti ng CMS ap p ro v ed HCP CS and CP T c o d es al o ng wi th ap p ro p ri ate mo d i f i ers . Pl eas e ref er to the CMS f ee s c hed ul e f o r ap p ro p ri ate co d es. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 06/01/2019Date Revised 9/17/2019 A d d ed Sec ti o n IV ., 1., a. & b. Date Effective 08/01/2019 Archived Date 08/31/2021 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f ormal documented Policy H. Ref erences1. Mc Il v enn a n, C. K ., Eap en, Z. J ., & A l l en, L. A . (2015 ). Ho s p i tal read mi s s i o n s red uc ti o n p ro g ram. Ci rc ul ati o n , 131 (2 0 ), 1796-8 0 3. Mc Il v e n n a n, C. K ., Eap en, Z. J ., & A l l en, L. A . (2015 ). Ho s p i tal read mi s s i o ns red uc ti o n p ro g ram. Ci rc ul ati o n , 131 (2 0 ), 1796-803. 2. Ho s p i tal Read mi s s i o n Red uc ti o n Pro g ram. (2018, Dec emb e r 04). Retri ev ed f ro m https:/ /www.cms.gov 3. Geo rg i a Med i c ai d Manual f o r Ho s p i tal Serv i c es , Sec ti o n 904: Li mi ted Inp ati ent Serv i c es . Retreived f ro m https:/ /www.mmis.georgia.gov The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0691 DCH A p p ro v ed : 05/08/2 0 1 9

Emergency Department Electrocardiogram (EKG/ECG) Interpretation

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Emergency Department Electrocardiogram (EKG/ECG) Interpretation PY-0792 10/1/2019 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 …………………………………………………………………………………………………………. 4 Emergency Department Electrocardiogram (EKG/ECG) Interpretation GEORGIA MEDICAID PY-0792 Effective Date: 10/1/2019 2 A. Subject Emergency Department Electrocardiogram (EKG/ECG) Interpretation 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. An electrocardiogram (EKG/ECG) is a non-invasive test that records the electrical activity of the heart. It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardiogram (EKG/ECG) may need to be performed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. C. Definitions Emergency medical condition-is a medical condition with sudden severity and onset that in the absence of immediate medical attention could placing the patient’s health in serious jeopardy. This includes labor and delivery, but not routine prenatal or postpartum care, or services related to an organ transplant procedure. Electrocardiogram (EKG/ECG) is a test that records the electrical activity of the heart. For the purpose of this policy EKG will be used to represent both EKG and ECG. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs completed in the Emergency Department (Place of service (POS) 23). A. Regardless of POS, the modifier appended to the CPT code determines a duplicate service. II. CareSource will reimburse the first EKG claim that is received for the member of the date of service. A. If another claim for the same service EKG is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same date of service. B. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member. 1. Example: 93010 is received and is reimbursed. Another 93010 claim is received for the same date of service and is denied as duplicate service. C. If a second EKG is medically necessary, on the same date of service, to determine a cardiac change before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG for reimbursement. Emergency Department Electrocardiogram (EKG/ECG) Interpretation GEORGIA MEDICAID PY-0792 Effective Date: 10/1/2019 3 1. Example: 93010 is received and reimbursed. Another 93010 is completed and submitted for reimbursement. The second 93010 has modifier 76 or 77 (whichever is applicable) appended (93010-76 or 93010-77) to distinguish between the first and second EKG performed on the same member on the same date of service. III. CareSource expects providers to work with other departments, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. 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. CPT Code Description 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93226 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report 93227 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 10/1/2019 New policy Emergency Department Electrocardiogram (EKG/ECG) Interpretation GEORGIA MEDICAID PY-0792 Effective Date: 10/1/2019 4 Date Revised Date Effective 10/1/2019 H. References 1. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/health-topics/electrocardiogram. 2. Schedule Maximum Allowable Payments Physician Jan 2019. (2019, January). Retrieved 3/12/2019 from https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FEE%20SCHEDULES/Schedule%20of%20Maximum%20Allw%20Pymt%20Physician%20Jan%202019%2020190122163207.pdf. 3. 31-11-81. Definitions. (2019). Retrieved 3/12/2019 from https://advance.lexis.com/documentpage/?pdmfid=1000516&crid=767747dc-63b5-456d-99a7-c9361c74f27d&title=%c2%a7+31-11-81.+Definitions&populated=false&haschildren=&level=4&nodepath=%2fROOT%2fABF%2fABFAAQ%2fABFAAQAAF%2fABFAAQAAFAAD&nodeid=ABFAAQAAFAAD&config=00JAA1MDBlYzczZi1lYjFlLTQxMTgtYW E3OS02YTgyOGM2NWJlMDYKAFBvZENhdGFsb2f eed0oM9qoQOMCSJFX5qkd&pddocfullpath=%2fshared%2fdocument%2fstatutes-legislation%2furn%3acontentItem%3a5V8M-CKR0-004D-8226-00008-00&ecomp=k357kkk&prid=1f80bc5c-d9ac-4d65-af2a-5cb9a2042494. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Independent medical review 2/2015 GA-P-0718 DCH Approved: 07/25/2019

Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center

Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y require ments, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of servic e, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal 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 t o as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. 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.REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center PY-0847 10/1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. …………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 7 G. Review/Revision History ………………………….. ………………………….. ………………………….. …… 7 H. References ………………………….. ………………………….. ………………………….. …………………….. 7 2 A. SubjectDental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center GEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery Center B. BackgroundReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarant ee claims payment.Most dental care can be provided in a traditional dental office setting with local anesthesia and if medically necessary, a continuum of behavior guidance strategies, ranging from simple communicative techniques to nitrous oxide, enteral or parenteral sedation. Monitored Anesthesia Care or Sedation (Minimal, Moderate or Deep) may be a requirement of some patients including those with challenges related to age, behavior or developmental disabilities, medical status, intellectual limitation s or other special needs. As noted by the American Academy of Pediatric Dentistry (AAPD) and the American Society of Anesthesiologists (ASA), there are certain situations where appropriate candidates may require as a medical necessity, general anesthesia i n a healthcare facility such as an Ambulatory Surgical Center or Outpatient Hospital facility. C. DEFINITIONS Ambulatory Surgical Center (ASC) is defined as any freestanding institution, building, or facility or part thereof, devoted primarily to the provisi on of surgical treatment to patients not requiring hospitalization, as provided under provisions of Georgia Code Section 88 – 1901. Such facilities do not admit patients for treatment, which normally requires overnight stay, nor provide accommodations for t reatment of patients for period of twenty-four (24) hours or longer. It is not under the operation or control of a hospital. The term does not include individual or group practice offices of private physicians or dentists, unless the offices have a distinc t part used solely for outpatient surgical treatment on a regular and organized basis, and has been regulated and certified by the state as such. Inpatient Hospital is defined as a facility, other than psychiatric, which primarily provides diagnostic, ther apeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. Off Campus-Outpatient Hospital is defined as a portion of an off-campus hospital prov ider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. On Campus-Outpatient Hospital is defined as a p ortion of a hospitals main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. SPU Short procedure unit A unit of a hospital organized for the delivery of ambulatory surgical, diagnostic or medical services. 3 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 Minimal Sedation (Anxiolysis ) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffe cted. Moderate Sedation/Analgesia (Conscious Sedation) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Monitored Anesthesia Care (MAC) does not describe the continuum of depth of sedation; rather it describes a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. ** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Deep Sedation/Analgesia is a dr ug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require ass istance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimul ation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of s edation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (Conscious Sedation) should be able to rescue*** patients who enter a state of Deep Sedatio n/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia. *** Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. D. PolicyMost dental care and/or oral surgery is effectively provided in an office setting. However, some members may have a qualifying condition that requires the procedure be provided in a hospital setting or ambulatory surgical center under general anesthesia. The purpose of this document is to provide reimbursement and billing guidance for facility related services when dental procedures are rendered in a in a Hospital or Ambulatory Surgical Center (ASC) Place of Service (POS) under general anesthesia. Hospital Inpatient or Outpatient Facility services and ASC Facility services for the provision of dental care under general anesthesia are addressed in this policy, not dental care or oral surgery in an office setting. Professional dental services are covered only to the extent that the member has dental benefits and guidelines for dental services are provided in the applicable dental policy manual. CareSource policy notes the intent of Hospital, Outpatient, and ASC facility requests is the medical necessity of gene ral anesthesia services to perform dental procedures on a 4 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 member. Requests with the goal of no, minimal, moderate or deep sedation services, will only be considered in extenuating circumstances mandated by systemic disease for which the patient is under current medical management and which increases the probability of complications, such as respiratory illnes s, cardiac conditions or bleeding disorders. Medical Record and Physician attested letter would be required with authorization requests. I. Prior authorizationA. A prior authorization is required for all Hospital Inpatient or Outpatient Facility or Ambulatory Surgery Center Facility procedures that require general anesthesia or anesthesia monitoring with sedation. B. The review for dental services in a Hospital Inpati ent or Outpatient Facility or Ambulatory Surgery Center Facility under anesthesia is a two-step process. 1. STEP ONE is completed by the Treating Dentist . An authorization for the requested dental services is sent to the Dental Utilization Management (UM – DM) team who will determine the medical necessity of the services being completed in a hospital or outpatient setting. a. For authorization requests for POS (19, 21, 22, or 24) medical necessity review, the Treating Dentist should submit at least one (1) unit of (D9420) hospital or ambulatory surgical center call. b. The pre-determination letter (PDL) or authorization is sent to the treating/submitting dentist and to the member. c. The treating/submitting dentist must provide the facility with the PDL. 2. STEP TWO is completed only after the first step has been approved. a. The Facility will submit a precertification/authorization to the medical management team and must include a copy of the PDL. b. The Medical Utilization Management (UM-MM) team will complete AL Lof the following: 01. Verify that facility is in or out of network AND; 02. Review the pre-determination letter (PDL) or authorization AND; 03. Determine medical necessity for any other non-dental CPT/HCPCS codes submitted AND; 04. The Medical Management approval of D9420 is sent via a letter to the facility, member, and Treating Dentist. This letter indicates approval of D9420 for (19) Off Campus-Outpatient Hospital, (21) Inpatient Hospital, (22) On Campus-Outpatient Hospital, or (24) Ambulatory Surgical Center se tting and General Anesthesia Services if applicable. II. Additional guidelines on the benefit limits/frequencies of D9420 can be found in the Dental Health Partner Provider Manual.NOTE: Please remember that the provider who submits the authorization for the dental therapeutic services must be the provider that performs the services. If the authorized provider does not perform the service, claims will deny. In the event the authorized provider is unable to perform the services or the location changes, CareSou rce must be notified to update the authorization prior to the services being performed. 5 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 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. Revenue codes and additional information can be found in the Department ofCommunity Health and ASC Policy manuals as well as the Dental Health Partner Pro vider Manual. Outpatient Hospital Facility (SPU) POS (19, 22)CPT Code DescriptionD9420 D9420 for the technical component to the facility SPU/OR use is calculated in time units 1 unit = 30 minutes. The maximum units reimbursable per date of service is 6 units Operating Room – When a hospital outpatient, SPU or organized outpatientclinic operating room is used for patient dental services, a single HCPCS code for reporting the fa cility technical component of multiple dentoalveolar procedures is used. That code must be utilized rather than reporting the tests or procedures individually. (CPT/HCPCS code 41899, discontinued by State, should not be used). Facility should use D9420 wit h appropriate billed charges of OR time use for dental services performed. Any other Dcodes listed will be for procedural documentation only and not for reimbursement. No HCPCS required Recovery Room – Recovery Room is intended for cases when a patient requires recovery from deep sedation or anesthesia. Recovery room use is reimbursable only when billed for the same date of service as a surgery that is not considered a common office proc edure. No HCPCS required HCPCSrequired for revenue code 0636*Hospital Add-On (HAO) services only applicable if state or contract required.Separate reimbursement may not be applicable. Maximum allowances may be applicable6 0017000170 is calculated in Anesthesia Services – Anesthesiology professional Services for intraoral procedures. Time units for physician and CRNA services – both personally performed and medically directed are determined by dividing the actual 7 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 CMS Base units. The Base unit =5 units. Reimbursement will be subject to maximum allowances. anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized, the time unit is rounded to one decimal place. Total minutes are listed as the units (i.e. 75 minutes) 75 = 6 units (of 15 min increments). CM SBase units =5. Maximum state allowances may be applicable. Inpatient Hospital Facility POS (21) All of the above facility codes as well as any additional Room and Board fees would have to be pre-certified and receive medical necessity review. Services a re subject to benefit provisions Ambulatory Surgical Center POS (24) CPT Code Description D9420 D9420 for the technical component to the facility or ASC use is calculated in time units 1 unit = 30 minutes. The maximum units reimbursable per date of service is 6 units. Operating Room – A single code for reporting the facility fee must be used for the ASC or Facility should use D9420. (CPT/HCPCS code 41899), discontinued by State, should not be used. CareSources policy is aligned with State policy is D9420 is used a global code for ASC facility services. 00170 00170 is calculated in CMS Base units. The Base unit =5 units. Reimbursement will be subject to maximum allowances. General Anesthesia for intraoral procedures, including biopsy; not otherwise specified – Anesthesiology professional Services for intraoral procedures. Time units for physician and CRNA services – both personally performed and medically directed are determined by dividing the actual anesthesia time by 15 minutes or fraction thereof. Since only the actual time of a fractional unit is recognized , the time unit is rounded to one decimal place. Total minutes are listed as the units (i.e. 75 minutes) 75 = 6 units (of 15 min increments). CMS Base units =5. Maximum state allowances may be applicable. Dental/Oral Surgery Professional Services The scope of this policy is limited to medical plan coverage of the facility and/or general anesthesia services provided in conjunction with dental treatment, and not the dental or oral surgery services. The professional dental procedure codes listed are f or reference only and do not imply coverage of dental procedures. Information on dental benefits, please consult Dental Health Partner manual for clinical guidelines, policies and procedures 8 Dental Procedures in a Hospital, Outpatient Fac ility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 CPT Code Description (D0000 – D9999) Reimbursed according to provider contractual rate Dental Services using the CDT codes – Follow applicable clinical policy guidelines in Dental Health Partner Provider Manual Dental service charges will be paid directly to the TREATING DENTIST PAYEE GORUPAll dental services that require authorization must receive prior authorization via Dental Management.ICD-10 and CPT code for Oral or Maxillofacial region Other Services Oral or Macillofacial Services using CPT codes – Follow applicable benefit guidelines in Health Partner manual for CPT code All medical services of the oral, maxillofacial, head and neck regions performed in the hospital/ASC must receive pri or authorization from the Medical Management team F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 10/1/2019 New PolicyDate Revised Date Effective 10/1/2019 H. References1. Part II Policies and Procedures for Ambulatory Surgical and Birthing Center Services (2019, April). Retrieved on 6/1/22019 from https:// www.mmis.georgia .gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Ambu latory%20Surgical%20and%20Birthing%20Center%20Services%2020190325210148.pdf 2. Part II Policies and Procedures for Dental Services (2019, April). Retrieved on 6/1/22019 from https:// www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Denta l%20Svcs%2020190320145248.pdf 3. Part II Policies and Procedure for Hospital Services (2019, April). Retrieved on 6/1/22019 from https:// www.mmis.georgia.gov/portal/Portals/0/StaticCon tent/Public/ALL/HANDBOOKS/Hospi tal_Services%2020190401195313.pdf 4. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. (2014, October 15). Retrieved June 12, 2019, from https:// www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation – definition-of-general-anesthesia-and-levels-of-sedationanalgesia 5. American Academy of Pediatric Dentistry. Oral Health Pol icies and Recommendations. Retrieved March 22, 2019 from: https://www.aapd.org/research/oral-health-policies — recommendations/ 6. American Association of Oral and Maxillofacial Surgeons, Ambulatory Surgical Center Coding and Billing. Retrieved April 5, 2019 from :https://www.aaoms.org/images/uploads/pdfs/asc_coding_and_billing.pdf 9 Dental Procedures in a Hospital, Outpatient Facility or Ambulatory Surgery CenterGEORGIA MEDICAID PY-0847 Effective Date: 10/1/2019 The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0776 DCH Approved: 07/25/2019

Drug Testing

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Date Effective Drug Test ing PY-0156 09/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical 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 ca re 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 necess ary 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 a n 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 Cove rage), 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 6 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 7 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 7 Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 2 A. Subject Drug Testing 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 does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent versio n of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members with substance use disorder (SUD); for members who are at risk for abuse/misuse of drug s; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Urine is the most common specimen to monitor drug use. There are two main typ es of urine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory /Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Early and Periodic Screening, Diagnostic and Treatment ( EPSDT ) – This benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. Random drug test-A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Residential services-Psychiatric Residential Treatment Facility (PRTF) services provide comprehensive mental health and substance abuse treatment to children, adolescents, and young adults 21 years of age or younger who, due to severe emotional disturbance, are in need of quality active treatment that can only beArchivedDrug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 3 provided in an inpati ent treatment setting and for whom alternative, less restrictive forms of treatment have been unsuccessful or are not medically indicated. PRTFs serve as the most intensive, inpatient treatment for youth/young adults with severe behavioral health disorders . 1NOTE: Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0127 . Please refer to this policy for in-depth information on medical necessity for drug tes ting, d ocumentation requirements , and CareSource monitoring and review of drug testing claims. D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the I CD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, OR if they fall within the standards of care under EPDST guidelines. 1. PA is required for UDT for members when a confirmatory test for greater than 14 drug classes (Codes G0482 & G0483) are ordered . These higher number drug panels are rarely indicated for routine urine drug testing as lower number panels are sufficient for modifying treatment plans in the majority of cases. 2. PA is required for any non-participating provider with CareSource for non-emergency room setting . 3. PA is required for any non-participating lab/ facility with CareSource for non-emergency room setting. 4. PA is not required in an emergency room setting . UDT utilization will be monitored by CareSource. 5. PA needs to make a clear case for medical necessity for the level of testing being requested . B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent be ing tested until the PA process is complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. 1https://www.mmis.georgia.gov/portal/portals/0/staticcontent/public/all/handbooks/psychiatric%20residential%20treatment%20facility%2020190108214956.pdfArchived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 4 D. If needed, the licensed practitioner that is operating in his/her scope o f practice must obtain the prior authorization. III. Quantity Limitations A. CareSource will reimburse up to 25 UDT in a calendar year for each member. 1. Each CPT code is counted as one test toward the 25 total drug tests in a calendar year. 2. UDT G0482 and G0483 (requiring a PA as noted above) will also count toward the 25 total UDT in a calendar year. B. Only one presumptive testing CPT code may be billed per member per day. 1. 80305 2. 80306 3. 80307 C. Only one confirmatory testing CPT code (drug class) may be billed per member per day. 1. G0480 2. G0481 3. G0482 4. G0483 IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes service s ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. V. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is billable for comprehensive and preventive health care s ervice for children under age 21 . VI. Non-Urine Testing A. CareSource will reimburse blood testing in e mergency room settings . B. Drug testing with blood samples performed in any other setting outside of an e mergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VII. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following:ArchivedDrug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 5 a. Presumptive testing was negative for prescription medications AND pro vider was expecting the test to be positive for prescribed medication AND member reports taking medication as prescribed OR b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member dispu tes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VIII. Non-Billable Drug Testing A. Testing that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing re quired by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 7. Testing with another pay source that is primary such as a county, state or federal agency. 8. Testing for marriage license. 9. Foren sic. 10. Testing for other admin purposes. 11. Routine physical/medical examination EXCEPT for the EPSDT program. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed o utside of the emergency room. E. Hair, saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negative presumptive expected result.ArchivedDrug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 6 I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. K. A confirmatory test prior to discussing results of presumptive test with member. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits , recovery of overpayments identified, and provider prepay re view . E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes . Please refer to the Georgia Medicaid fee schedule . The following list(s) of cod es is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e . g . , immunoassay); capable of being read by direct optical observation only (e . g . , dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures ( e.g. , immunoassay); read by instrument assisted direct optical observation ( e.g. , dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers ( e.g. , utilizing immunoassay [ e.g. , EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography ( e.g. , GC, HPLC), and mass spectrometry either with or without chromatography, ( e.g. , DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quan titative/Confirmatory Tests-Description G0480 Drug Test definitive/Quantitative 1-7 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stab le isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e. g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug Test definitive/Quantitative 8-14 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or ta ndem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2)Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 7 stable isotope or other universally recognized internal standards in all samples (e.g., to c ontrol for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quanti tative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed G0482 Drug testing definitive/Quantitative 15-21 classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) me thod or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed G0483 Drug testing definitive/Quantitative 22+ classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessa rily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isot ope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0127 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11 / 29 / 2017 Date Revised Date Effective 09/01/2019 Updated clinical indications, quantity limits , and prior authorizations requirements H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11 /20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdfArchived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 0 9 / 0 1 / 2 0 1 9 8 3. American Society of Addict ion Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https://www.asam.org/docs/default-source/public-policy-statemen ts/1drug-testing — clinical-10-10.pdf?sfvrsn=1b11ac97_0#search=”urine drug testing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on 12/13/2018 from https://jo urnals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Recommendati ons and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty=HTML&h=L&n=pt42.1.8&r=PART#se42.1.8_12 7. GAMMIS. Policies and Procedures for Independent Laboratory Services (2019). Retrieved on 2/26/2019 from https://ww w.mmis.georgia.gov/portal/portals/0/staticcontent/public/all/handbooks/independent%20lab%20services%2020181220175744.pdf 8. GAMMIS. Policies and Procedur e s for Physician Services (2019). Retrieved on 2/26/2019 from https://www.mmis.georgia.gov/portal/portals /0/staticcontent/public/all/handbooks/physician%20services%2020190207174419.pdf 9. GAMMIS. Policies and Procedures for Psychiatric Residential Treatment Facilities (2019). Retrieved on 2/26/2019 from https://www.mmis.georgia.gov/portal/portals/0/staticcontent /public/all/handbooks/psychiatric%20residential%20treatment%20facility%2020190108214956.pdf 10. Medicaid. Early and Periodic Screening, Diagnostic, and Treatment. (n.d.) Retrieved on 12/11/2018 from https://www.medicaid.gov/medicaid/benefits/epsdt/index.html 11. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 12. U.S. Departm ent of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf 13. Washington State Interagency Guideline on Opioid Dos ing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%20on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20D rug%20Testing%20Guidance.pdf 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 – 0726 DCH Approved: 05/30/2019 Archived

Readmission

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDIC AID Policy Name Policy Number Effective Date Readmission PY-0 731 08/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirem ents, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on the date of service , medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal 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 ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan c ontract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y 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 Readm ission GEORGIA MEDICAID PY-0731 Effective Date: 0 8 / 0 1 / 2 0 1 9 2 A. Subject Re a dmission 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 of Readmissions for our Medicare Advantage members may be subject to limitations and/or qualifications. Reimbu rsement 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. Following a hospitalization, readmission within 3 days is often a costly preventable event and is a quality of care issue . It has been estimated that readmissions within 3 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result from many situations but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress t o the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progression of the disease state or due to chronic conditions. The purpose of this policy is to improve the quality of inpatient and tran sitional care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communication between the patient, caregivers and clinicians, 2. provide the patient with the education needed to maintain thei r care at home to prevent a readmission, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission : a subsequent inpatient admission to any acut e care facility which occurs within 3 days of the discharge date for the same or related problem, excluding psychiatric services . Same or a r elated p roblem : a problem or diagnosis that is the same or a similar problem or diagnosis that is documented on the initial admission. Same Day : CareSource deli neat es same day as midnight to midnight of a single day . D. Policy I. This is a reimbursement policy that defines the payment rules for hospitals a nd acute care facilities that are reimbursed for inpatient services . Archived Readm ission GEORGIA MEDICAID PY-0731 Effective Date: 0 8 / 0 1 / 2 0 1 9 3 II. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical necessity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim . III. A ll Readmissions for the same or related problem within 3 days of the initial discharge is consid ered the same admission and will be reimbursed as one claim, EXCEPT for the following : A. Psychiatric services limited to short term acute care. IV. Claim Payment Revie w and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissions to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical reco rds for both admissions must be included with th e claim submission to determine if the admission (s) is appropriate or is considered a readmission. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. If the included documentation determines the readmission to be an inappropriate or medically unnecessary admission , the hospital must be able to provide additional documentation to CareSource upon request or the claim will be denied . c. If the documentation provided d oes not substantiate medical necessity and appropriateness, CareSource reserves the right to deny, reduce or recoup reimbursement . 2. Appeals Process a. All acute care facilities and inpatient hospitals have the right to appeal any readmission denial and request a peer-to-peer review or formal appeal. E. Conditions of Coverage Reimbursement is dep endent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS f ee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT ION Da te Issue d 06/01/2019 Da te Re vise d Archived Readm ission GEORGIA MEDICAID PY-0731 Effective Date: 0 8 / 0 1 / 2 0 1 9 4 Da te Effe ctive 08/01/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803.McIlvenn an, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803. 2. Hospital Readmission Reduction Program. (2018, December 04). Retrieved from https://www.cms.gov 3. Georgia Medicaid Manual for Hospital Services, Section 904: Limited Inpatient Services. Retreived from https://www.mmis.georgia.gov 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 – 0691 DCH Approved: 05/08/2019 Archived

Avastin for use in Ophthalmology Billing Guideline

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Avastin for use in Ophthalmology Billing Guideline PY-0734 08/01/2019 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 …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Avastin for use in Ophthalmology Billing Guideline GEORGIA MEDICAID PY-0734 Effective Date: 08/01/2019 2 A. Subject Avastin for use in Ophthalmology Billing Guideline 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. Avastin is a drug used in the treatment of wet age-related macular degeneration, diabetic eye disease and other problems of the retina. Avastin is injected into the eye and helps to slow down disease related vision loss. The use of Avastin to treat eye disease is considered off-label, which is allowed by the FDA when doctors are well informed regarding the drug and there are studies that prove its an effective treatment option. There is no cure for macular degeneration, treatment is aimed at slowing down the progression of the disease and preventing vision loss. C. Definitions Macular Degeneration a progressive vision impairment resulting from deterioration of the central part of the retina, known as macula. D. Policy I. CareSource does not require a Prior Authorization for the use of Avastin in Ophthalmology, when billed with the following codes: A. J3490 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. B. J3590 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. E. Conditions of Coverage HCPCS J3490, J3590 NDC 50242-0061-01 or 50242-0060-01: F. Related Policies/Rules N/A Avastin for use in Ophthalmology Billing Guideline GEORGIA MEDICAID PY-0734 Effective Date: 08/01/2019 3 G. Review/Revision History DATE ACTION Date Issued 06/01/2019 New policy Date Revised Date Effective 08/01/2019 H. References 1. Boyd, K. (2018, May 22). What Is Avastin? Retrieved October 29, 2018, from https://www.aao.org/eye-health/drugs/avastin 2. “Off-Label” and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices-Information Sheet. (2018, July 12). Retrieved October 29, 2018, from https://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0669 DCH Approved: 05/08/2019

Medical Drug Reimbursement Rates

REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Medical Drug Reimbursement Rates PY-0796 08/01/2019-12/3 1/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Stat ement ………………………….. ………………………….. ……………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 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 service, m edical necessity, adherencet o 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 w ithout w hich 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 low est cost alternative, and are not provided mainly for the convenience of the member or provid er. 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 betw eenthis Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill 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. SubjectMedical Drug Reimbursement Rates Med ical Drug Reimbursemen t Rates GEORGIA MEDICAIDPY-0796 Effective Date: 08/01/2019 B. BackgroundReim bursem ent policies are designed to assist you when subm itting claim s to CareSource. They are routinely updated to prom ote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of paym ent. Reim bursement f or claim s m ay be subject to lim itations and/or qualif ications. Reim bursem ent will be established based upon a review of the actual services provided to a m em ber and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encourag ed to use self-service channels to verif y m em bers eligibility. It is the responsibility of the subm itting provider to subm it the m ost accurate and appropriateCPT/HCPCS code(s) f or the product or service that is being provided. The inclus ion of a code in this policy does not im ply any right to reim bursem ent or guarantee claim s paym ent. C. Def initions Average Wholesale Price (AWP) – is the m anuf acturer’s list price of the drug when sold to the wholesaler. Average Sales Price (ASP) a rate that is calculated by the m anuf acture on a quarterly basis and subm itted to Medicare. Medicare then places these rates in a f ile and uploads to the Medicare Part BDrug Average Sales Price Drug Pricing Files tab on cm s.gov. D. PolicyI. This is a reim bursem ent policy that outlines reim bursem ent rates f or drugs that are billed and adm inistered in the f ollowing places of service under the m em bers m edical benef it only when drug reim bursem ent rates are not specif ically called out in the provider contr act or the drug code is not listed on the Georgia Medicaid Fee Schedule: A. Place of Service 11 Of f ice 1. Medicares ASP (Average Sales Price) plus 6% B. Place of Service 12 Hom e 1. Manuf actures AWP (Average Wholesale Price) m inus 15% C. Place of Service 22 On Cam pus-Outpatient Hospital 1. Manuf actures AWP (Average Wholesale Price) m inus 15% E. Conditions of CoverageReim bursem ent is dependent on, but not lim ited to, subm itting Georgia Medicaid approved HCPCS and CPT codes along with appropriate m odif iers. Please ref er to the individual Georgia Medicaid f ee schedule f or appropriate codes. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 06/01/20193 Med ical Drug Reimbursemen t Rates GEORGIA MEDICAIDPY-0796 Effective Date: 08/01/2019 Date Revised Date Effective 8/01/2019 Date Archived 12/3 1/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented P olicy H. Ref erencesThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0705 DCH Approved: 04/30/2019

Provider Home Visits

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 inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying thi s Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Date Next Annual Review Effective Date 12/1/2018 02/01/2020 02/01/2019 Policy Name Policy Number Provider Home Visits PY-0437 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS …………………………………………….. Error! Bookmark not defined. A. SUBJECT ………………………………………………………… Error! Bookmark not defined. B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2 D. POLICY ………………………………………………………….. Error! Bookmark not defined. E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RULES ………………………….. ………………………….. ………….. 14 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. ……….. 14 H. REFERENCES ………………………….. ………………………….. ………………………….. …. 14 2 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 A. SUBJECTProvider Home Visits 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 appropriateCPT/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. Provider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. C. DEFINITIONS Medically necessary, medical necessity or medically necessary and appropriate – means medical services or equipment based upon generally accepted medical practices in light of conditions at the time of treatment, including: o Appropriate and consistent with the diagnosis of the treating physician and the omission of which could adversely affect the eligible members medical condition; o Compatible with the standards of acceptable medical practice in the United States; o Provided in a safe, appropriate and cost-effective setting given the nature of the diagnosis and the severity of the symptoms; o Not provided solely for the convenience of the member or the convenience of the health care provider or hospital; o Not primarily custodial care unless custodial care is a covered service or benefit under the members evidence of coverage; and o There must be no other effective and more conservative. Place of Service (POS) – A two-digit code that indicates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner or a physician assistant. Home An individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. D. POLICY I. CareSource does not require a prior authorization for provider home/domicile visits. A. CareSource reimburses for home visit services per the state Medicaid fee schedule. B. Claim submission must include the appropriate CPT codes along with any applicable modifier with the appropriate place of service (POS) code. II. Place of service (POS) for provider services in the home or domicile include the following:A. POS 12 Home 3 B. POS 13 Assisted LivingC. POS 14 Group Home D. POS 31 Skilled Nursing Facility (SNF) E. POS 32 Nursing Facility F. POS 33 Long-term Facility III. Home services for CareSource members:Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 A. CareSource members do not need to be confined to their home to receive home services, provided by a physician. B. The CareSource members medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. C. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiarys home. Note: Although CareSource does not require a prior authorization for provider home visits, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting state Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the individual state Medicaid fee schedule for appropriate codes. The following PDF list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Place ofService Description 12 Location, other than a hospital or other facility, where the patient receives care in a private residence. Code Description 99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family. 99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. 99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are 4 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 provided consistent with the nature of the problem(s) and the patient’s and/orfamily’s needs. Usually, the presenting problem(s) are of moderate to high severity.Typically, 45 minutes are spent face-to-face with the patient and/or family. 99344 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) an d the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. 99345 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family. 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typically, 40 minutes are spent face-to- face with the patient and/or family. 99350 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s ) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. 5 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 Place of Service Description 13 Congregate residential facility with self-contained living units providing assessment of each residents needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of th e problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting prob lem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the proble m(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting 6 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patientand/or family or caregiver.99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patien t may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Place ofService Description 14 A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration). Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenti ng problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed 7 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 examination; and Medical decision making of moderate complexity. Counselingand/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A compr ehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, o r agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s a nd/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem 8 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 requiring immediate physician attention. Typically, 60 minutes are spent with thepatient and/or family or caregiver.Place ofService Description 31 A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. Code Description 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualifi ed health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or co ordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor 9 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 complication. Typically, 15 minutes are spent at the bedside and on thepatient’s facility floor or unit.99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and manageme nt of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate 10 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 severity. Typically, 55 minutes are spent at the bedside and on the patient’shospital floor or unit.99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professional s, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the present ing problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit. Place of ServiceDescription 32 A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to individuals other than those with intellectual disabilities. Code Description 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the prob lem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with t he nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit . 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused 11 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 interval history; A problem focused examination; Straightforward medical decisionmaking. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant co mplication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the 12 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 problem(s) and the patient’s and/or family’s needs. Usually, the presentingproblem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and /or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit. Place ofService Description 33 A facility which provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other quali fied health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting 13 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 problem(s) are of moderate to high severity. Typically, 45 minutes are spent withthe patient and/or family or caregiver.99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consis tent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the natur e of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Th e patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. 14 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 Modifiers Description 24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service 33 Preventive Services 57 Decision for Surgery 59 Distinct Procedural Service A1 Dressing for one wound AI Principal physician of record AM Physician, team member service AQ Physician providing a service in an unlisted health professional shortage area (HPSA) CC Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) GC This service has been performed in part by a resident under the direction of a teaching physician GV Attending physician not employed or paid under arrangement by the patient’s hospice provider GW Service not related to the hospice patient’s terminal condition HE Mental health program HO Masters degree level Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Q8 Two Class Bfindings RT Right side (used to identify procedures performed on the right side of the body) SA Nurse practitioner rendering service in collaboration with a physician UC Medicaid level of care 12, as defined by each state UD Medicaid level of care 13, as defined by each state F. RELATED POLICIES/RULESN/A G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 12/1/2018 New policyDate Revised Date Effective 02/01/2019 H. REFERENCES1. Medicare Claims Processing Manual. (2018, June 13). Retrieved 7/1/2018 from https:// www.cms.gov/Regulations-and – Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 15 Provider Home VisitsGEORGIA MEDICA ID PY-0437 Effective Date: 02/01/2019 2. Place of Service Codes – Centers for Medicare & Medicaid Services. (2012, March 5). Retrieved 7/1/2018 from https:// www.cms.gov/Medicare/Coding/place-of-service – codes/index.html. 3. Place of Service Code Set – Centers for Medicare & Medicaid Services. (2016, November 17). Retrieved 7/1/2018 from https:// www.cms.gov/Medicare/Coding/place-of-servic e- codes/Place_of_Service_Code_Set.html. 4. POLICIES AND PROCEDURES FOR MEDICAID/PEACHCARE FOR KIDS GEORGIA DEPARTMENT OF COMMUNITY HEALTH. (2018, July 1). Retrieved 7/1/2018 from https:// www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Part% 201%20Polices%20and%20Procedures%20for%20Medicaid_PeachCare%20for%20Kids_% 2020180801201151.pdf. The Reimbursement Policy Statementdetailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Independent medical review 2/2015

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