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