REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Date Next Annual Review Effective Date 11/29/2017 07/ 26 /2019 07/ 26 /2018 Policy Name Policy Number Drug Testing PY-0156 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medical ly 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, inc reased 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 m ainly 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 6 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 7 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 7 H.REFERENCES ………………………………………………………………………………………… 7Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 2 A.SUBJECT Drug Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Monitoring for controlled substances is performed to detect the use of prescription medications and illegal substances of concern for the purpose of medical treatment. Monitoring for controlled substances plays a key role particularly in the care of persons undergoing medical treatment with chronic pain therapy and substance-related disorder . Drug testing that is medically necessary for the management of members being treated with drugs that are potentially abusive or addictive such as opioids and related medications, or for members suspected of using illicit drugs solely or in combination with prescribed controlled substances is billable to CareSource . Qualitative/presumptive drug testing performed as part of routine, prenatal care for pregnant members is also billable to CareSource. Providers should have a working knowledge of analytic detection including primary agents, metabolites, lab threshold concentrations, and time periods involved in detection. The combination of a patient’s self-report and drug testing results serve as important tools in controlled substance monitoring, as well as a point of patient engagement. Qualitative/presumptive testing is a routine part of care, used when immediate results are needed, knowing results may be less accurate than quantitative/confirmatory tests. Quantitative/confirmatory testing is used when results may affect changes in medication, when patients dispute presumptive/qualitative results, or in treatment transitions. Anecdotal evidence to support testing for individual patients should be balanced with the limited population evidence for added value of multiple tests for chronic pain patients or SUD patients. For example, in a 2015 evaluation of 2,551,611 de-identifie d patients urine drug test results over four years in the U.S., Quest Diagnostics identified that the best achieved yearly inconsistency rate (when the results of a drug screen are not consistent with the patients history and prescribed medicines) in all urine drug tests was 53% (in 2014 vs 63% in 2011). C. DEFINITIONS Qualitative analysis-The testing of a substance or mixture to determine its chemical constituents, also known as presumptive testing. Quantitative test-A test that determines the amount of a substance per unit volume or weight, also known as confirmatory testing. Early and Periodic Screening, Diagnostic and Treatment ( EPSDT ) – this benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPDST is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services through early diagnosis and treatment. The program specifically covers c omprehensive health and developmental histor ies, immunizations, health education, vision services, dental Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 3 services, hearing services, and any additional health care diagnostic and treatment services for physical and mental illnesses that are coverable under the f ederal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered, regardless of whether the service is covered in a state’s Medicaid plan. Under the EPSDT program, a ny Medicaid provider can find a problem, make a referral or provide treatment. This includes doctors, nurses, dentists, physical therapists, occupational therapists, speech therapists, psychologists, psychiatrists and other health care professionals . Random alcohol and drug test a lab test administered at an irregular interval which is not announced in advance to the person being tested, and which detects the presence of alcohol, drugs or substances in the individual. Independent laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/Non-participating Participating means in-network and contracted with CareSource. Non-participating means out-of-netw ork, not contracted by CareSource. D. POLICY NOTE : Although the drug testing covered by this policy may or may not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. I. General Criteria for Coverage : Clinical guidelines, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, posted here: https://www.caresource.com/providers/policies/ . Please refer to this policy for in-depth information on medical necessity for drug testing, documentation required for claims, and CareSource monitoring and review of drug testing claims. II.Individualized Testing : In all cases other than routine qualitative drug testing as part of prenatal care, medical necessity for submitted charges must be individualized and documented in the members medical record and included in the treatment plan of care. CareSource does not provide coverage for drug testing for forensic, legal, employment, transportation, school purposes or other third party requirement. III. Non-Urine Testing : CareSource will reimburse blood testing without a prior authorization in emergency department settings only, to evaluate acute overdose. Drug testing with blood samples performed in any other setting outside of an ER requires the provider or lab to obtain prior authorization in order to be reimbursed. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered without prior authorization. Additionally, when non-urine drug testing is prior authorized, that non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing. NOTE : Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. IV. Urine Testing : Urine for clinical drug testing is the specimen of choice because of its high drug concentrations and well-established testing procedures. Nevertheless, urine is one of the easiest specimens to adulterate. A. If the provider suspects such an occurrence, the provider may choose to evaluate specimen validity using validity tests. Specimen validity testing is considered to be a quality control issue and is included in the CPT code payment. Additional codes for Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 4 specimen validity testing should not be separately billed to CareSource. Tests for creatinine, specific gravity, temperature or nitrates are not billable to and will not be reimbursed by CareSource when submitted simultaneously with a drug testing CPT code and ICD substance-related disorder code. Failure to document customized tests with medical necessity information for each individual member and for each of the drug tests ordered will result in the denial of the claim for reimbursement, audit, and/or overpayment requests, and any other program means for enforcing this policy. B. Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse. C. Orders for custom profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or to conduct additional testing as needed, are not billable to and will not be reimbursed by CareSource. D. Testing on a routine basis is neither random nor individualized. Routine or reflex testing is not billable to and will not be reimbursed by CareSource. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random. E. CareSource does not provide coverage for testing as a requirement to stay in a facility, for example, in sober living or residential locations. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. V. Provider Orders : CareSource requires that the ordering provider s name appear in the appropriate lines of the claims forms;. A signed and dated provider order for drug testing is required. The provider s order must specifically match the number, level and complexity of the testing components performed. VI. Non-participating providers : Non-participating providers are not covered for drug testing laboratory services. Non-participating providers may use participating laboratories for drug testing services. VII. Documentation Requirements : All documentation must b e accurate, complete, maintained in the members medical record and available to CareSource upon request. The following documentation requirements apply: A. Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering provider/treating provider must indicate the medical necessity for performing a qualitative drug test. B. Every page of the record must be legible and include appropriate member identification information (e.g., complete name, dates of service(s)). C. The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the member. D. The submitted medical record should support the use of the selected ICD-10-CM code(s) with appropriate indications for urine drug testing . E. The submitted CPT/HCPCS code should accurately describe the service performed. F. Copies of test results alone without the proper provider s order for the test are not sufficient documentation of medical necessity to support a claim. G. Drug testin g records and related entries in a members medical record must be provided to CareSource upon request for auditing of medical necessity. Documentation must support medical necessity and specify why each test is ordered. Documentation must also support the number of analytes requested for testing, and what action the provider will take upon the findings. VIII. Confirmatory and Duplicative Testing A. Routine multi-drug quantitative/confirmatory testing is not billable to and will not be reimbursed by CareSource . Quantitative/confirmatory testing must be individualized and Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 5 medically necessary. Routine confirmations (quantitative) of drug tests with negative results are not deemed medically necessary and are not covered by CareSource. Quantitative/confirmatory testing is covered for a negative drug/drug class test when the negative finding is inconsistent with the members documented medical history and/or current documented chronic pain medication list. B. Routine nonspecific or wholesale orders for drug testing (qualitative), confirmation, and quantitative drugs of abuse testing are not billable. IX. Independent Laboratories A. Drug tests conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. CareSource may require documentation of FDA-approved complexity level for instrumented equipment, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab. C. Both participating providers and non-participating providers may potentially order laboratory tests for CareSource members D. Only participating independent laboratories can bill for quantitative/confirmatory drug tests. E. Laboratories must have the appropriate level of CLIA certification for the testing perform ed and be contracted (participating) with CareSource. F. Claims are not billable to CareSource if submitted by laboratories that are non-participating (not contracted) with CareSource. G. The ordering/referring provider must include the clinical indication/medical necessity in the order for the drug test as outlined above. H. The independent laboratory performing the drug testing must maintain hard copy documentation of the lab results, along with copies of the ordering/referring provider s order for the drug test. I. Participating laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource . X. Other Non-Billable Drug Testing A. Standing orders set up between a provider and laboratory which are prewritten and/or result in the same drugs and drug classes to be tested on a routine, repeat basis, are not billable to CareSource. B. Drug testing is not billable to and will not be reimbursed by CareSource if required by a third party such as: 1. For medico-legal purposes (e.g., court-ordered drug testing); 2. For employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment); 3. As a condition of: 3.1 Participation in school or community athletic activities or programs 3.2 Participation in school or community extra circular activities or programs 4. As a component of a routine physical/medical examination; e.g. (enrollment in school, enrollment in the military, etc.) EXCEPT for once yearly screening in EPSDT programs. 5. As a component of medical examination for any other administrative purposes not listed above (e.g., for purposes of marriage licensure, insurance eligibility, etc.). 6. As a requirement to live in sober housing or residential services. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 6 NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Georgia Medicaid fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. If covered, non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing.Codes Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service. 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. 80307 () Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per dat e of service. G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, singl e or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g ., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/M S (any type, single or tandem and excluding immunoassays (e.g., IA, Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 7 EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all so urces, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed. G0482 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural i somers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydroge nase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality cont rol material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. G0483 Drug test(s), defin itive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interf erences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes spe cimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. F. RELATED POLICIES/RUL ES Drug Testing Medical Policy, MM-0127 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/29/2017 New Policy. Date Rev ised Date Effective 07/ 26 /2018 H.REFERENCES 1.Provider Manuals, “Policies and Procedures for Physician Services.”(n.d.). Section 903.12 H, Laboratory Service: Drug Testing. 2. Provider Manuals, “Policies and Procedures for Independent Laboratory Services.”(n.d.). Section 903.7 H, Drug Testing. 3.Physician Fee Schedule Search. (2017, January 1). 4. A. Barthwell, “Statement of Consensus on the Proper Utilization of Urin e Testing in Identifying and Treating Substance Use Disorders,” 2015. [Online]. Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 07/26/2018 8 5. Pesce, C. West, K. Egan City and J. Strickland, “Interpretation of urine drug testing in pain patients,” Pain Medicine, vol. 13, no. 7, pp. 868-85, 2012. 6. Mayo Clinic, “Approximate detection times of drugs of abuse,” Oct 2016. [Online]. 7. K. E. Moeller, K. C. Lee and J. C. Kissack, “Urine drug screening: Practical guide for clinicians,” Mayo Clinic Proceedings, vol. 83, no. 1, pp. 66-76, Jan 2008. 8. S. Vakili, S. Currie and N. el-Guebaly, “Evaluating the utility of drug testing in an outpatient addiction program,” Addictive Disorders and their Treatment, vol. 8, no. 1, pp. 22-32, 2009. 9. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye, “Review and recommendations for drug testing in substance use treatment contexts,” Journal of Reward Deficiency Syndrome and Addiction Science, vol. 2, no. 1, pp. 28-45, 2016. 10. K. Dolan, D. Rouen and J. Kimber, “An overview of the use of urine, hair, sweat and saliva to detect drug use,” Drug and Alcohol Review, vol. 23, no. 2, pp. 213-217, 2004. 11. A. G. Verstraete, “Detection times of drugs of abuse in blood, urine, and oral fluid,” Therapeutic Drug Monitoring, vol. 26, no. 2, pp. 200-205, 2004. 12. ASAM, Principles of Addiction Medicine, 5th Edition ed., R. K. Ries, D. A. Fiellin, S. C. Miller and R. Saitz, Eds., Philadelphia, PA: Lippincott Williams & Wilkins, 2014. 13. A. Rzetelny, B. Zeller, N. Miller, K. E. City , K. L. Kirsh and S. D. Passik, "Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study, “International Journal of Mental Health and Addiction, vol. 14, no. 1, pp. 64-80, 2016. 14. J. Dupouy, V. Macmier, H. Catala, M. Lavit, S. Oustric and M. Lapeyre-Mestre, “Does urine drug abuse screening help for managing patients? A systematic review,” Drug and Alcohol Dependence, vol. 136, pp. 11-20, 2014. 15. E. Y. Hilario, M. L. Griffin, R. K. McHugh, K. A. McDermott, H. S. Connery, G. M. Fitzmaurice and R. D. Weiss, “Denial of urinalysis-confirmed opioid use in prescription opioid dependence, “Journal of Substance Abuse Treatment, vol. 48, no. 1, pp. 85-90, 2015. 16. ASAM, “Drug Testing: A White Paper of the American Society of Addiction Medicine,” American Society of Addiction Medicine, Chevy Chase, MD, 2013. 17. Quest Diagnostics Health Trends Prescription Drug Monitoring Report 2015, Prescription Drug Misuse in America, Diagnostic Insights in the Continuing Drug Epidemic Battle. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAIDOriginal Issue Date Next Annual Review Effective Date 09/20/2017 07/15/2019 07/15/2018 Policy Name Policy Number Smoking & Tobacco Cessation PY-0 378 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies 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 o r 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 par t, 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 authorizati on 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RULES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 3 H.REFERENCES ………………………………………………………………………………………… 4Archived Smoking & Tobacco Cessation GEORGIA MEDICAID PY-0378 Effective Date: 07/15/2018 2 A. SUBJECT Smoking & Tobacco Cessation B. BACKGROUND The use of tobacco products generally leads to tobacco/nicotine dependence 3and often results in serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases . Tobacco/nicotine dependence is a condition that often requires repeated treatments, as nicotine is strongly addictive. Because of this, quitting smoking and ending the use of tobacco use may be a difficult process requiring several, staged attempts, and may involve stress, irritability, and other withdrawal symptoms for those addicted to nicotine 8, 9, 10. However, continued tobacco use in any form is far more harmful. Tobacco smoke contains seriously harmful chemicals and carcinogens 5, 8, 11and leads to lung and other cancers, chronic lung disease, heart disease, strokes, vascular disease, and infertility. Additionally, smokeless tobacco is directly linked to cancers of the mouth, tongue, cheek, gum, esophagus, and pancreas. Counseling and medication are both effective means for ending dependency on tobacco products, and are even more effective together than either method alone 10. Counseling can be effective when delivered via individual, group, or telephone counseling, one-on-one brief help sessions with a provider, behavioral therapies, or even through mobile phone apps. Medications which have been found to be effective include prescription non-nicotine medications such as bupropion SR (Zyban ) and varenicline tartrate (Chantix ), and nicotine replacement products such as nicotine patches, inhalers or nasal sprays available by prescription, and over-the-counter nicotine patches, gums or lozenges 10, 17. The United States government recognizes the health dangers and risks associated with the use of tobacco in its citizens and has set up a free telephone support service to help people stop sm oking and stop the use of tobacco, 1-800-QUIT-NOW. Callers are routed through this service to their states specific resource, and may be able to obtain free support, advice, and counseling from experienced quit-line coaches, a personalized plan to quit, practical information on how to quit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking medications, free or discounted medications (available for at least some callers in most states), referrals to other resources, and/or mailed self-help materials. CareSource encourages all of its members to refrain from the use of tobacco, and if using it in any form , to make concerted and ongoing attempts to quit its use as soon as possible. C. DEFINITIONS Tobacco products means any product containing tobacco or nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, hookahs, kreteks, e-cigarettes, vaporized and other inhaled tobacco and nicotine products, smokeless tobacco (e.g., dip, chew, snuff , snus), dissolvable tobacco (e.g., strips, sticks, orbs, lozenges), or other ingestible tobacco products, and/or chewing tobacco. D. POLICY I. Prior authorizations are required for participating (contracted) providers only when the services they are providing for tobacco cessation exceed the limits of this policy. Archived Smoking & Tobacco Cessation GEORGIA MEDICAID PY-0378 Effective Date: 07/15/2018 3 II. Non-participating providers (not contracted with CareSource) should contact CareSource for prior authorization for these services. III. CareSource will reimburse its participating providers for the following tobacco use intervention and cessation care methods: A. An encounter for evaluation and management of the member on the same day as counseling to prevent or cease tobacco use; and, B. Screenings for tobacco use as needed for members 20 and younger; C. One screening for tobacco use per calendar year for members 21 and older; and, D. Three individual tobacco cessation counseling attempts per calendar year. 1. Each attempt will not exceed 12 weeks of treatment. 2. Face to face counseling sessions are required every 30 days during each 12 week treatment period. E. Nicotine replacement or non-nicotine medications prescribed and approved for use for tobacco cessation. IV. CareSource will not reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year, unless prior authorization has been obtained by the provider. V. The number of CPT, HCPCs, and diagnosis codes (ICD-10) potentially associated with the diagnosis and treatment of tobacco use and addiction is too great to list. As such, the specific tobacco cessation codes provided below are eligible to be reimbursed with any appropriate, associated code. VI. Evaluation and Management service for the member which is provided on the same day as counseling to prevent or cease tobacco use, should be reported with modifier-25 to indicate that the E&M service is separately identifiable from the counseling. 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 Georgia Medicaid fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODES DESCRIPTION 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes F. RELATED POLICIES/RUL ES N /A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 09/20/2017 New Policy. Date Revised Date Effective 07/15/2018 Archived Smoking & Tobacco Cessation GEORGIA MEDICAID PY-0378 Effective Date: 07/15/2018 4 H.REFERENCES 1. Physician Services Manual, 903.19, “Tobacco cessation services for Me dicaid eligible members.” Ibid.Appendix D, “Health check and adult preventive visit. (2017, July 1). 2. CDC-Fact Sheet-Quitting Smoking-Smoking & Tobacco Use. (n.d.). 3.Counseling to Prevent Tobacco Use. ( Transmittal 2058, 2010, September 30). Centers for Medicare & Medicaid Services, Department of Health & Human Services. 4. Treating Tobacco Use and Dependence. Clinical Practice Guideline. (n.d.). Fiore, Michael C (panel chair), Guideline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI) 5. U.S. Department of Health and Human Services. The Health Consequences of Smoking50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 6. National Institute on Drug Abuse. Research Report Series: Is Nicotine Addictiv e? Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2012. 7. American Society of Addiction Medicine. Public Policy Statement on Nicotine Addiction and Tobacco. Chevy Chase (MD): American Society of Addiction Medicine, 2008. 8. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 9. U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 10. Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guidelines . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008. 11. National Toxicology Program. Report on Carcinogens, Thirteenth Edition. Research Triangle Park (NC): U.S. Department of Health and Human Sciences, National Institute of Environmental Health Sciences, National Toxicology Program, 2014. 12. U.S. Department of Health and Human Services .The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 13. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. 14. Centers for Disease Control and Prevention. Quitting Smoking Among AdultsUnited States, 2000 2015. Morbidity and Mortality Weekly Report 2017: 65(52):1457-64. 15. Centers for Disease Control and Prevention. Youth Risk Behavior SurveillanceUnited States, 2015. Morbidity and Mortality Weekly Report [serial online] 2016:66 (SS 6):1 174. 16. Centers for Disease Control and Prevention. The Guide to Community Preventive Services: Reducing Tobacco Use and Secondhand Smoke Exposure. 17. U.S. Food and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation. FDA Consumer, 2006. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Da te Next Annual Review Effective Date 10/04/2017 05/15/2019 05/15/2018-08/31/2021 Policy Name Policy Number Br e as t Imaging PY-0398 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………………………………………………. 1 TABLE OF CONTE NTS …………………………………………………………………………………………….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 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billin g , coding a nd documentation guidelines. Co din g methodology, regulatory requirements, industry-s t a ndard cla ims 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 re f e rral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, but a re not limite d 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 lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medicall y necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rred 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 a nd applying t his Po licy to services provided in a particular case and may modify this Policy at any time.2 Breas t Imag i ng GEORGIA MEDICAIDPY-0398 Effec ti v e Date: 05/15/2018 A. SUBJECTBreast Imaging B. BACKGROUND Reimb urs ement policies are des igned to assist you when s ubmitting claims 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 g uarantee of payment. Reimb ursement f or claims may be subject to limitations a nd /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 rec eived for p ro cessing. 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. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c ode(s ) for the product or s ervice t h at is b eing prov ided. Th e inc lus ion of a code d o es not imply any rig ht to reimbursement or g uarantee c laims pay ment. CareSo urc e will reimburs e partic ipating p roviders for medically nec es sary and preventive s c reening tests for b reast c ancer as req uired b y federal statute through criteria based o n rec o mmendations f rom the U. S. Prev entive Serv ic es Ta s k Force (USPSTF) and American Co lleg e of Rad iology (ACR). Mammo graphy is the utilization of a lo w-dose x-ray imaging sy stem for the examination of the b reas ts and is c urrently c ons idered to be the best available method for early d etection of breast c anc er, p articularly in the c ase of small o r non-palpable lesions.This imag ing is often employed for s creening purpos es in an effort to red uce morbidity and mo rtality of uns uspected b reast canc er through earlier detection and treatment in asy mptomatic p atients . A Sc reening Mammogram typically includes t wo s tandard v iews of eac h breast (cranio-c aud al and medial lateral oblique) and d oes not require the pres ence of, o r monitoring by the interp reting rad iologist. When ab no rmalities are observed a d iagnostic t est is required to c o nf i r m the p res enc e of malignanc y.C. DEFINITIONS Technical Component (TC) services rend ered o uts ide the scope of the p hy s icians interpretation of the res ults of an ex amination. Professional Component (PC) p hysicians interpretation of the res ults of an ex amination. Global Component enc o mp as s es both the tec hni c al and p ro f es s i o nal c o mp o nents . See Breas t Imaging Medical Policy MM-0135 for further d efinitions D. POLICYI. CareS o urc e does no t req ui re prior autho ri zati o n for s c reeni ng and diagnostic mammo g rams . II. All o ther b reas t imaging, o ther than x-ray mammograms , req uire a prior authorization. III. CareSo urc e reimb urses f or s creening and d iagnostic mammograms ac cording to CareSource Med ic al policy MM-0135. Memb ers must meet the c riteria found in medic al p olic y MM-0135. IV. CareSo urc e c o nsiders d iagnos tic mammography medically nec ess ary for men and wo men with s ig ns and s ymptoms of breast disease o r a his tory of breast malignancy. 3 Breas t Imag i ng GEORGIA MEDICAIDPY-0398 Effec ti v e Date: 05/15/2018 V. When b illing f or mammography services, p roviders should us e the ap p ropriate CP T/ HCP CS c o d es and modifiers , if applicable.Note: Glo b al b illing is no t p ermitted for s ervices furnished in an o utpatient facility. Critical Access Hos pitals (CA Hs) may not us e global HCP CS c odes as the TC and PC c omponents are p aid und er d ifferent methodologies.E. CONDITIONS OF COVERAGE Reimb urs ement is dependent on, b ut not limited to, s ubmitting CMS appro ved HCPCS and CPT c o d es alo ng with appro priate modifiers. Pleas e ref er to the Georgia Medicaid fee s chedule-http s://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/AL L/ FEE %20SCHEDULES/ Sc hed ule%20of%20Max imum%20Allowable%20Payments%20Physic ian%20%202017092217440 5.p df 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 sources for the most current coding information. CP T Codes Code Description 76377 3D rend ering wit h interpretation and rep orting of c omputed tomography, mag netic res onance imaging, ultras ound, or o ther tomographic m o d ality; req uiring image p ost-proc essing on an ind ependent work station 76641 Ultras o und, b reast, unilateral, real time wit h image documentat ion, inc luding ax illa when p erf ormed; complete 76642 Ultras o und, b reast, unilateral, real time wit h image documentation, inc luding ax illa when p erf ormed; limited 77053 Mammary d uctogram or g alactogram, s ingle d uct, rad iological s upervision and interp retation 77054 Mammary d uctogram or g alactogram, multiple duc ts, radiological s uperv ision and interp retation 77058 Mag netic res onance imaging, b reast, without and /or wit h c ontras t mat erial(s ); unilateral 77059 Mag netic res onance imaging, b reast, without and /or wit h c ontrast material(s); b ilateral 77063 Sc reening d igital b reast tomosy nthesis, bilateral (Lis t s eparately in ad dition to c o d e for p rimary p rocedure) G0202 Sc reeni ng mammo g rap hy , producing d i rec t digital i mag e, b i l ateral , al l v i ews G0204 Di ag no s ti c mammo g rap hy , producing d i rec t digital i mag e, b i l ateral , al l v i ews G0206 Di ag no s ti c mammo g rap hy , producing d i rec t digital i mag e, uni l ateral , al l v i ews F. RELATED POLICIES/RULES Breas t Imag i ng Med i c al Policy, MM-0135 4 Breas t Imag i ng GEORGIA MEDICAIDPY-0398 Effec ti v e Date: 05/15/2018 G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 10/04/2017 New Po licy.Date Revised Date Effecti ve 05/15/2018 Date Archived 08/31/2021 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 CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . H. REFERENCES1. Americ an Canc er Soc iety. (2017, September). Retriev ed September 25, 2017, from http ://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/brea st-c ancer-early-detection-acs-r ec s2. U. S . Prev entiv e Services Ta s k Force; Breast Cancer: Screening. (2016, January ). Retrieved Sep tember 25, 2017, from http ://www.uspreventiveservicestaskforce.org/Page/Doc ument/UpdateSummaryFinal/br e as t-c anc er-s creening1?ds=1&s=mammography The Reimbursement Policy Statement detailed above has received due cons ideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Date Next Annual Review Effective Date 11/01/2017 03/01/2019 0 3/01/2018 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0 404 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies 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 o r 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 par t, 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 authorizati on 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 t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 2 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Screening and Surveillance for Colorectal Cancer GEORGIA MEDICAID PY-0404 Effective Date: 03/01/2018 2 A. SUBJECT Screening and Surveillance for Colorectal Cancer B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests for colorectal cancer as required by state requirements through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology (ACG). C. DEFINITIONS See Screening and Surveillance for Colorectal Cancer medical policy, MM-0192 D. POLICY I. CareSource does not require prior authorization for screening and diagnostic colonoscopies for participating providers. II.CareSource reimburses for screening and diagnostic colonoscopies according to CareSource Medical policy MM-0192. Members must meet the criteria found in medical policy MM-0192. III. When billing for screening and surveillance colorectal services, providers should use the appropriate CPT/HCPCS codes and modifiers, if applicable. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting state Medicaid approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the state Medicaid fee schedules: https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FEE%20SCHEDULES/Lab%20Max%20Allowable%20%2020170908145522.pdf https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FEE%20SCHEDULES/Schedule%20of%20%20Maximum%20%20Allowable%20%20Payments%20%20Physician%2020170922174435.pdf The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information.Code Description 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple Archived Screening and Surveillance for Colorectal Cancer GEORGIA MEDICAID PY-0404 Effective Date: 03/01/2018 3 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45378 Colonoscopy, fle xible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, flexible; with transendoscopic balloon dilation 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound ex amination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (Cologuard) 82270 Blood, occult, by peroxidase activity ( e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening ( i.e., patient was provided 3 cards or single triple card for consecutive collection) 82272 Blood, occult, by peroxidase activity ( e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations Archived Screening and Surveillance for Colorectal Cancer GEORGIA MEDICAID PY-0404 Effective Date: 03/01/2018 4 F. RELATED POLICIES/RUL ES Screening and Surveillance for Colorectal Cancer, MM-0192 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/01/2017 New Policy. Date Revised Date Effective 0 3/01/2018 H. REFERENCES 1. Schedule of Maximum Allowable Payments Physician July 2017. (2017, July). Retrieved 10/9/2017 from https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FEE%20SCHEDULES/Schedule%20of%20%20Maximum%20%20Allowable%20%20Payments%20%20Physician%2020170922174435.pdf 2. Schedule of Maximum Allowable Payments Clinical Laboratory and Anatomical Pathology Services. (2017, October 1). Retrieved from https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/FEE%20SCHEDULES/Lab%20Max%20Allowable%20%2020170908145522.pdf The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Date Next Annual Review Effective Date 11/29/2017 03/01/2019 03/01/2018 Policy Name Policy Number Drug Testing PY-0156 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medical ly 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, inc reased 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 m ainly 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. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………….. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 6 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 8 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 8 H.REFERENCES ………………………………………………………………………………………… 8Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 2 A.SUBJECT Drug Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Monitoring for controlled substances is performed to detect the use of prescription medications and illegal substances of concern for the purpose of medical treatment. Monitoring for controlled substances plays a key role particularly in the care of persons undergoing medical treatment with chronic pain therapy and substance use disorder (SUD). Drug testing that is medically necessary for the management of members being treated with drugs that are potentially abusive or addictive such as opioids and related medications, or for members suspected of using illicit drugs solely or in combination with prescribed controlled substances is billable to CareSource . Qualitative/presumptive drug testing performed as part of routine, prenatal care for pregnant members is also billable to CareSource. Providers should have a working knowledge of analytic detection including primary agents, metabolites, lab threshold concentrations, and time periods involved in detection. The combination of a patient’s self-report and drug testing results serve as important tools in controlled substance monitoring, as well as a point of patient engagement. Qualitative/presumptive testing is a routine part of care, used when immediate results are needed, knowing results may be less accurate than quantitative/confirmatory tests. Quantitative/confirmatory testing is used when results may affect changes in medication, when patients dispute presumptive/qualitative results, or in treatment transitions. Anecdotal evidence to support testing for individual patients should be balanced with the limited population evidence for added value of multiple tests for chronic pain patients or SUD patients. For example, in a 2015 evaluation of 2,551,611 de-identified patients urine drug test results over four years in the U.S., Quest Diagnostics identified that the best achieved yearly inconsistency rate (when the results of a drug screen are not consistent with the patien ts history and prescribed medicines) in all urine drug tests was 53% (in 2014 vs 63% in 2011). C. DEFINITIONS Qualitative analysis-The testing of a substance or mixture to determine its chemical constituents, also known as presumptive testing. Quantitative test-A test that determines the amount of a substance per unit volume or weight, also known as confirmatory testing. Early and Periodic Screening, Diagnostic and Treatment ( EPSDT ) – this benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid. EPDST is key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, and developmental, and specialty services through early diagnosis and treatment. The program specifically covers c omprehensive health and developmental histor ies, immunizations, health education, vision services, dental Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 3 services, hearing services, and any additional health care diagnostic and treatment services for physical and mental illnesses that are coverable under the f ederal Medicaid program and found to be medically necessary to treat, correct or reduce illnesses and conditions discovered, regardless of whether the servic e is covered in a state’s Medicaid plan. Under the EPSDT program, a ny Medicaid provider can find a problem, make a referral or provide treatment. This includes doctors, nurses, dentists, physical therapists, occupational therapists, speech therapists, psyc hologists, psychiatrists and other health care professionals . Random alcohol and drug test a lab test administered at an irregular interval which is not announced in advance to the person being tested, and which detects the presence of alcohol, drugs or substances in the individual. Independent laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/Non-participating Participating means in-network and contracted with CareSource. Non-participating means out-of-network, not contracted by CareSource. D. POLICY I. Prior Authorization : Prior Authorization is required for drug testing as outlined in this policy. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care, or if they fall within the standards of care under EPDST guidelines. A. For all members, prior authorization for drug testing is not required in the emergency room (ER) setting when it is needed to evaluate acute overdose. B. For members age 6 and younger, prior authorizations are not required for drug testing , and there is no limit on the number of drug screening tests for a child in this age group. C. For members age 7 and older, prior authorization for drug testing is required for each drug test when: 1. The member reaches the limits imposed by this policy within the rolling 90-day time period (See Section D.IX below ); 2. The provider orders CPT code 80307, a test which requires a prior authorization each time; and/or, 3. The type of drug test or type of sample used for the drug testing is not covered by this policy. NOTE: Although the drug testing covered by this policy may or may not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II.General Criteria for Coverage : Clinical guidelines, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, posted here: https://www.caresource.com/providers/policies/ . Please refer to this policy for in-depth information on medical necessity for drug testing, documentation required for claims, and CareSource monitoring and review of drug testing claims. III. Individualized Testing : In all cases other than routine qualitative drug testing as part of prenatal care, medical necessity for submitted charges must be individualized and documented in the members medical record and included in the treatment plan of care. CareSource does not provide coverage for drug testing for forensic, legal, employment, transportation, school purposes or other third party requirement. IV. Non-Urine Testing : CareSource will reimburse blood testing without a prior authorization in emergency department settings only, to evaluate acute overdose. Drug testing with blood samples performed in any other setting outside of an ER requires the provider or lab to obtain prior authorization in order to be reimbursed. Hair, saliva, or other body fluid testing for Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 4 controlled substance monitoring has limited support in medical evidence and is not covered without prior authorization. Additionally, when non-urine drug testing is prior authorized, that non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing. NOTE : Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. V. Urine Testing : Urine for clinical drug testing is the specimen of choice because of its high drug concentrations and well-established testing procedures. Nevertheless, urine is one of the easiest specimens to adulterate. A. If the provider suspects such an occurrence, the provider may choose to evaluate specimen validity using validity tests. Specimen validity testing is considered to be a quality control issue and is included in the CPT code payment. Additional codes for specimen validity testing should not be separately billed to CareSource. Tests for creatinine, specific gravity, temperature or nitrates are not billable to and will not be reimbursed by CareSource when submitted simultaneously with a drug testing CPT code and ICD substance use disorder code. Failure to document customized tests with medical necessity information for each individual member and for each of the drug tests ordered will result in the denial of the claim for reimbursement, audit, and/or overpayment requests, and any other program means for enforcing this policy. B. Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse. C. Orders for custom profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or to conduct additional testing as needed, are not billable to and will not be reimbursed by CareSource. D. Testing on a routine basis is neither random nor individualized. Routine or reflex testing is not billable to and will not be reimbursed by CareSource unless a prior authorization has been obtained by the provider or lab. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random. E. CareSource does not provide coverage for testing as a requirement to stay in a facility, for example, in sober living or residential locations. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. F. Providers and laboratories must ensure specimen integrity appropriate for the stability of the drug agent being tested (for example, freezing the specimen) until the prior authorization process is completed. VI. Provider Orders : CareSource requires that the ordering provider s name appear in the appropriate lines of the claims forms; any claim that does not include this information is incomplete and therefore not billable to and will not be reimbursed by CareSource . A signed and dated provider order for drug testing is required. The provider s order must specifically match the number, level and complexity of the testing components performed. VII. Non-participating providers : Non-participating providers are not covered for drug testing laboratory services. Non-participating providers may use participating laboratories for drug testing services. VIII. Documentation Requirements : All documentation must be accurate, complete, maintained in the members medical record and available to CareSource upon request. The following documentation requirements apply: Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 5 A.Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering provider/treating provider must indicate the medical necessity for performing a qualitative drug test. B. Every page of the record must be legible and include appropriate member identification information (e.g., complete name, dates of service(s)). C. The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the member. D. The submitted medical record should support the use of the selected ICD-10-CM code(s) with appropriate indications for urine drug testing . E. The submitted CPT/HCPCS code should accurately describe the service performed. F. Copies of test results alone without the proper provider s order for the test are not sufficient documentation of medical necessity to support a claim. G. Drug testing records and related entries in a members medical record must be provided to CareSource upon request for auditing of medical necessity. Documentation must support medical necessity and specify why each test is ordered. Documentation must also support the number of analytes requested for testing, and what action the provider will take upon the findings. IX. Quantity Limitations A. CareSource will reimburse for up to 5 qualitative/presumptive tests in any rolling 90 day period for each member. B. CareSource will reimburse for up to 5 quantitative/confirmatory tests in any rolling 90 day period for each member. C. CareSource will cover a maximum of twenty-five multiple drug screens per member per fiscal year. For the State of Georgia, the fiscal year is defined as July 1 through June 30. D. Within these limits, only one multi-panel test, (i.e., testing for each category of a drug class, including metabolite(s), if performed, may be billed per day (same date of service) unless the ordering provider or providing lab has obtained prior authorization from CareSource. E. CareSource will cover only one qualitative/presumptive test per date of service. F. CareSource will cover only one quantitative/confirmatory test per date of service. G. Each CPT code is counted as a test toward these limits. H. Prior authorization must be obtained by the ordering/referring provider or lab for any drug testing performed exceeding these limits. CareSource will consider all such requests when they are medically necessary to the members line of treatment, or if they fall within the standards of care under EPDST guidelines. X. Confirmatory and Duplicative Testing A. Routine multi-drug quantitative/confirmatory testing is not billable to and will not be reimbursed by CareSource . Quantitative/confirmatory testing must be individualized and medically necessary. Routine confirmations (quantitative) of drug tests with negative results are not deemed medically necessary and are not covered by CareSource without a review and prior authorization . Quantitative/confirmatory testing is covered for a negative drug/drug class test when the negative finding is inconsistent with the members documented medical history and/or current documented chronic pain medication list. B. Routine nonspecific or wholesale orders for drug testing (qualitative), confirmation, and quantitative drugs of abuse testing are not billable. XI. Independent Laboratories A. Drug tests conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. CareSource may require documentation of FDA-approved complexity level for Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 6 instrumented equipment, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab. C. Both participating providers and non-participating providers may potentially order laboratory tests for CareSource members D. Only participating independent laboratories can bill for quantitative/confirmatory drug tests. E. Laboratories must have the appropriate level of CLIA certification for the testing perform ed and be contracted (participating) with CareSource. F. Claims are not billable to CareSource if submitted by laboratories that are non-participating (not contracted) with CareSource. G. The ordering/referring provider must include the clinical indication/medical necessity and any required prior authorizations in the order for the drug test as outlined above. H. The independent laboratory performing the drug testing must maintain hard copy documentation of the lab results, along with copies of the ordering/referring provider s order for the drug test and any required prior authorizations. I. Participating laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource . XII. Other Non-Billable Drug Testing A. Standing orders set up between a provider and laboratory which are prewritten and/or result in the same drugs and drug classes to be tested on a routine, repeat basis, are not billable to CareSource. B. Drug testing is not billable to and will not be reimbursed by CareSource if required by a third party such as: 1. For medico-legal purposes (e.g., court-ordered drug testing); 2. For employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment); 3. As a condition of: 3.1 Participation in school or community athletic activities or programs 3.2 Participation in school or community extra circular activities or programs 4. As a component of a routine physical/medical examination; e.g. (enrollment in school, enrollment in the military, etc.) EXCEPT for once yearly screening in EPSDT programs. 5. As a component of medical examination for any other administrative purposes not listed above (e.g., for purposes of marriage licensure, insurance eligibility, etc.). 6. As a requirement to live in sober housing or residential services. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. NOTE: Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits, recovery of overpayments identified, and provider prepay review. E. CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Georgia Medicaid fee schedule. https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Fee %20Schedul es/tabId/56/Default.aspx The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 7 NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. If covered, non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing.Codes Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes s ample validation when performed, per date of service. 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service. 80307 ( PRIOR AUTHORIZATION REQUIRED ) Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., u tilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample valida tion when performed, per date of service. G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limite d to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal s tandards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spe ctral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed. G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including me tabolite(s) if performed. G0482 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily ArchivedDrug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 8 stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qu alitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed. G0483 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs an d distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymati c methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibrati on and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) i f performed. F. RELATED POLICIES/RUL ES Drug Testing Medical Policy, MM-0127 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/29/2017 New Policy. Date Reviewed Date Revised 03/01/2018 H.REFERENCES 1.Provider Manuals, “Policies and Procedures for Physician Services.”(n.d.). Section 903.12 H, Laboratory Service: Drug Testing. Retrieved 6/7/2017 from https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manu als/tabId/54/Default.aspx 2. Provider Manuals, “Policies and Procedures for Independent Laboratory Services.”(n.d.). Section 903.7 H, Drug Testing. Retrieved 6/7/2017 from https://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manuals/tabId/54/Default.aspx 3. Physician Fee Schedule Search. (2017, January 1). Retrieved 2/6/2017 from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx 4.A. Barthwell, “Statement of Consensus on the Proper Utilization of Urine Testing in Identifying and Treating Substance Use Disorders,” 2015. [Online]. Available: http://farronline.org/wp-content/uploads/2015/11/Final-Report-Statement-of-Consensus-on-the-Proper-Utilization-of-Urine-Testing-in-Identifying-and-Treating-Substance-Abuse-Disorders.pdf 5. Pesce, C. West, K. Egan City and J. Strickland, “Interpretation of urine drug testing in pain patients,” Pain Medicine, vol. 13, no. 7, pp. 868-85, 2012. 6. Mayo Clinic, “Approximate detection times of drugs of abuse,” Oct 2016. [Online]. Available: http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html Archived Drug Testing GEORGIA MEDICAID PY-0156 Effective Date: 03/01/2018 9 7. K. E. Moeller, K. C. Lee and J. C. Kissack, “Urine drug screening: Practical guide for clinicians,” Mayo Clinic Proceedings, vol. 83, no. 1, pp. 66-76, Jan 2008. 8. S. Vakili, S. Currie and N. el-Guebaly, “Evaluating the utility of drug testing in an outpatient addiction program,” Addictive Disorders and their Treatment, vol. 8, no. 1, pp. 22-32, 2009. 9. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye, “Review and recommendations for drug testing in substance use treatment contexts,” Journal of Reward Deficiency Syndrome and Addiction Science, vol. 2, no. 1, pp. 28-45, 2016. 10. K. Dolan, D. Rouen and J. Kimber, “An overview of the use of urine, hair, sweat and saliva to detect drug use,” Drug and Alcohol Review, vol. 23, no. 2, pp. 213-217, 2004. 11. A. G. Verstraete, “Detection times of drugs of abuse in blood, urine, and oral fluid,” Therapeutic Drug Monitoring, vol. 26, no. 2, pp. 200-205, 2004. 12. ASAM, Principles of Addiction Medicine, 5th Edition ed., R. K. Ries, D. A. Fiellin, S. C. Miller and R. Saitz, Eds., Philadelphia, PA: Lippincott Williams & Wilkins, 2014. 13. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik, "Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study, “International Journal of Mental Health and Addiction, vol. 14, no. 1, pp. 64-80, 2016. 14. J. Dupouy, V. Macmier, H. Catala, M. Lavit, S. Oustric and M. Lapeyre-Mestre, “Does urine drug abuse screening help for managing patients? A systematic review,” Drug and Alcohol Dependence, vol. 136, pp. 11-20, 2014. 15. E. Y. Hilario, M. L. Griffin, R. K. McHugh, K. A. McDermott, H. S. Connery, G. M. Fitzmaurice and R. D. Weiss, “Denial of urinalysis-confirmed opioid use in prescription opioid dependence, “Journal of Substance Abuse Treatment, vol. 48, no. 1, pp. 85-90, 2015. 16. ASAM, “Drug Testing: A White Paper of the American Society of Addiction Medicine,” American Society of Addiction Medicine, Chevy Chase, MD, 2013. 17. Quest Diagnostics Health Trends Prescription Drug Monitoring Report 2015, Prescription Drug Misuse in America, Diagnostic Insights in the Continuing Drug Epidemic Battle. Accessed on December 8, 2016. Located at https://www.questdiagnostics.com/dms/Documents/health-trends/Health_Trends_27281_MI4854_V5_LG_082715_Small.pdf The Reimbursement Policy Statement detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY ST AT EMENT GEORGIA MEDICAID Original Issue Date Next Annual Review Effective Date 07/01/2017 07/01/2018 07/01/2017-0 3/ 31 /2 021 Policy Name Policy Number Global Obstetrical Services PY-0231 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ……………………………………………………………….1 TABLE OF CONTENTS ……………………………………………………………………………………………1 A. SUBJECT ………………………………………………………………………………………………………2 B. BACKGROUND ……………………………………………………………………………………………..2 C. DEFINITIONS ………………………………………………………………………………………………..2 D. POLICY ………………………………………………………………………………………………………..3 E. CONDITIONS OF COVERAGE ………………………………………………………………………..7 F. RELATED POLICIES /RULE S ……………………………………………………………………………9 G. REVIEW/REVISION HISTORY …………………………………………………………………………9 H. REFERENCES ……………………………………………………………………………………………….9 Reimbursement Po licie s prepared by CS MG Co . and its a ffilia te s (including CareSource) a re intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry – standard cla ims editing logic, benefitsdesign and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits a n d e lig ib ility on the date of service, m edical necessity, adherence to pla n p olicie s and procedures, cla ims editing logic, provider contractual agreement, and applicable referral, 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 wh ich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of funct ion, 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. 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 referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this 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. CSMG Co. and its a ffilia te s may use reasonable discretion in interpreting and ap ply in g t his Policy to services provided in a particular case and may modify this Policy at any time. G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 2 A. SUBJECTGlobal Obstetr ica l Services B. BACKGROUND Maternity c are or o b s tetrical s erv ices refers to the health c are treatment g iv en in relatio n to p reg nanc y and d eliv ery of a newb o rn c hild . Maternity c are s erv ices inc lude c are d uring the p renatal p erio d , lab or, birthing, and the p o stpartum p eriod. CareSo urc e c o vers o bstetrical services memb ers rec eiv e in a ho s p ital or b irthing c enter as well all as s o c iated o utp atient services. Th e services provided mus t be ap p ro priate to the sp ecific med ic al need s of the memb er. Determinatio n o f med ic al nec es s ity is the res p o ns ib ility o f the p hy s ic ian. Sub mis s ion of claims for reimb urs ement will serve as the providers c ertif ic ation of the med i c al nec es s i ty f o r thes e s erv i c es . Pro p er b i l l i ng and submission g ui d el i nes m ust be followed. This inc lud es the us e of indus try s tandard , c o mpliantc odes onall c laimss ubmissions . Serv ices s ho uld be b illed us ing Current Pro c ed ure Terminology (CPT) c o d es , Healthc are Common Pro c ed ure Coding Sy st em (HCP CS ) codes and /or rev enue codes. Th e codes d eno te services and /o r the procedure p erf o rmed. The b illed c o des are req uired to be f ully s upported in the med ic al rec o rd . Unles s o therwis e no ted , this p olic y ap plies to o nly p artic ipating p rov id ers and f acilities. C. DEFINITIONS Advanced practice nurse-Th e rec ently end o rs ed Co ns ens us Model for A PRN Reg ul ati o n: Li c ens u re , A c c red i tati o n , Certi f i c ati o n and Ed uc ati o n d ef i nes f o ur A PRN ro l es : c erti f i ed reg i s tered nurs e anes th eti s t (CRNA ), c ert i f i ed nurs e-mid wife (CNM), clinical nurs e sp ecialist (CNS ) and c ertified nurs e p rac titioner (CNP ). Thes e f o ur ro les are g iv en the title of ad v anc ed p rac tic e reg is tered nurs e (A PRN). Current Procedural Terminology (CP T) – The ans wer to most o b s tetric al b illing q ues ti o ns c an b e f o und i n the Phy s i c i an s Current Procedural Termi nology (CP T) manual or the CP TAssistant Arc hiv es (1990 p res ent). Maternity Care and Deliv ery is a subsection of the Surg ery section of the CP Tbook c od es . An und ers tand ing of the g lo bal p ac k ag e services is need ed to code Maternity Care and Deliv ery Serv ic es correctly. Elective Delivery-is p erf o rmed for a no nmed ic al reas on. Some no nmed ical reas o ns inc lud e wanting to s c hed ule the b irt h of the b aby o n a specific d ate or living far away f rom the ho s p ital. Some wo men req ues t d eliv ery b ec aus e they are unc o mf o rtab le in the las t week s o f p reg nanc y . So me wo men req ues t a c es area n d el i v ery b ec aus e they f ear v ag i nal b irt h. (A meric an Congres s of Obs tetric ians and Gy nec ologis ts , 2015) Fetal death-means d eath prior to the complete ex p uls io n or ex trac tio n f ro m its m o t h er of a product of c onception, which af ter such ex pulsion or ex traction, does not breathe or s how any o ther ev id enc e of lif e such as b eating of the heart, p uls atio n of the umb ilical cord, or d ef inite mo v eme nt o f v o l untary mus c l es . "Fetal d eath" d o es no t i nc l ud e termi na ti o n of the p reg nanc y . (CareSourc e internal definition) Hi gh Ri sk Maternity-Maternity c are c o mp lic ated by a d o c umented c ond ition d uring the p ati ent s p reg nanc y req ui ri ng d i rec t f ac e-to-f ac e p rac ti ti o ner c are b ey o nd the us ual s erv i c e. Infert il i t y-i s d ef i ned as the condition of (i ) a p res umab l y heal thy wo man of c hi l d b eari ng ag e who has b een unab le to conceive o r (ii) a p res umab ly healthy man who has b een unab le to produce c o nc ep tion, in either c as e, af ter at leas t o ne y ear of t ry ing to do s o. (CareSourc e internal definition) Lactation consultant-means an ind iv idual who ho lds c redentials as an "International board c ertif ied lac tatio n c ons ultant." (CareSourc e internal definition) Materni ty Global-Serv ic es p ro v ided in unc o mp licated maternity c as es inc luding antep artum c are, d elivery and p ostpartum c are. This is reimbursed as a f ixe d amount after d eliv ery , and mus t meet g uid elines f or reimb urs ement o utlined b elow. Th e d ate of the d eliv ery is the d ate of service to be us ed when b illing the global p renatal codes. Glo b al services mus t enc o mp ass the Antep artum/Deliv ery /Postpartum p eriods as d efined in this G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 3 p o licy. Serv ic es c onsidered p art of the g lobal o bs tetric al p ack age will no t be reimb urs ed s ep aratel y . CareS o u rc e may rei mb u rs e mo re than o ne provider for antepartum care when the p atient trans f ers c are d uring the antep artum period. If that hap p ens , g lo bal b illing is d is allo wed , and the p ro viders then mus t us e sp lit g lob al or p artial g lobal billing.Mater ni t y Split Global or Partial Global-s ervic es provided by multiple providers d uri ng the Antep artum/D eliv ery /Postpartum p eriods of maternity c are as d efined in t his p olic y. CP Tcodes for antep artum c are o nly , d elivery o nly, deliv ery inc luding p ostpartum c are, and p o s tpartum c are o nly , sho uld be us ed when c rit eria is met f or sp litting the g lobal o bstetrical p ac k ag e. Rep o rt the s erv ic es p erfo rmed us ing the most ac c urate, mos t c omprehens iv e procedure code av ailab le. See circum stances that m eet criteria for split global billing noted on page 7, section Criteria for Splitting Global Obstetrical Services. o Split Global-d el i v ery o nl y or Med i c ai d antep art u m o Partial Global – d el i v ery and postpartum or Med i c ai d antep art u m Materni ty home-means a f acility f or p regnant g irls and wo men where ac c o mmo dations, med i c al c are, and social services are provided d uri ng the p renatal and postpartum periods. Maternity ho me does no t inc lude a p riv at e res id enc e where obstetric or newb o rn services are rec eiv ed by a res id ent of the ho me. (CareSourc e internal definition) Mater ni t y Period-Fo r billing purposes, the obstetrical period b eg i ns o n the d ate of the initial visit in whic h p reg nanc y was c o nf irmed and ex tend s thro ug h the end of the postpartum period (60 d ay s af ter v ag inal d eliv ery , 60 d ay s af ter C-s ec tio n). Medically Necessary Services (includes concepts of Medically Necessary and Medica l Neces si t y ) : Medically Necessary Services are b as ed upon g eneral l y ac c ep ted med ic al p rac tic es in lig ht of c o nd itions at the time of treatment, and whic h are: o Req ui red to c o rrec t or amel i o rat e a d ef ec t, physical or mental illness, or a condition o A p p ro p ri ate and c o ns i s tent wi th the diagnosis and the omission of whi c h c o ul d ad v ers el y af f ec t the elig ib le memb ers med ic al c o ndition o Compatible wi th the s tand ard s of ac c ep tab l e med i c al practice o Provided in a s af e, appropriate, and c ost-ef f ective s etting g iven the nature of the d iag no s is and the severity of the symptoms o Not provided solely f or the c o nv eni enc e of the memb e r or the c o nv eni enc e of the heal th provider o No t p rimarily c ustodial c are unles s c us todial c are is a c o vered s ervice or b enefit under the memb ers ev id enc e o f c o v erag e Provided when there is no o ther ef fec ti ve and mo re c onserv ative or s ubs tantially les s c ostly treatment, s erv ic e and s etting av ailab le Physician-means an ind ividual autho rized und er Chap ter 4731 of the Rev is ed Code to p rac ti c e med i c i ne and s urg ery or o s teo p athi c med i c i ne and s urg ery . (CareS o u rc e i nternal definition) Physician group, Physician group practice-means a clinic or an obstetric clinic e i t her wit h an elec tro nic health rec o rd (E HR), or where there is no EHR, b ut o ne memb er rec ord and eac h p hy s i c i an/nu r s e p rac ti ti o ner / n u rs e mi d wi f e s eei ng that memb e r has accessto the s ame memb e r rec o rd and mak es entri es i nto the rec o rd as services occur. Al l locations of a mul t i-location clinic with an EHR (o r o ne p ati ent rec o rd ) are c o ns i d ered the s ame physici angroup p rac tic e. Preconc e p ti o n care-means Med i c ai d-covered p rev enti v e med i c i ne services provided p ri o r to a p reg nanc y for the purpose of ac hiev ing o ptimal outcome of future p reg nanc ies . (CareSourc e internal definition) D. POLICYI. Pri o r Autho rizatio n Pri o r autho ri z ati o n i s no t req ui red for the g l o b al o b s tetri c al and mater ni ty services covered und er this p o lic y . G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 4 NOTE : Altho ug h the global o b s tetrical services c o v ered by this po licy do no t req uire a p rio r autho rizatio n, CareSo urc e may req ues t d o cumentation to s upp ort med ical necessity. Appropriate and complete d o c ument ati o n mus t be p res ent ed at the t i me of rev iew to v alid ate med ic al nec es s ity . I I. Mater ni ty Co v erag e-G e ne r alA. Maternity s erv ic es mus t b e furnis hed und er the s up erv is ion of a p hy s ician or c ertified ad v anc ed p ractice nurs e mid wife. Maternity s ervices enable b eneficiaries to v oluntarily choose a p ro v ider within the CareSo urc e netwo rk f o r maternity c are and post-partum c are. Fo r b illing purposes, the Maternity Ob s tetric al period b eg ins on the d ate of the initial visit in whic h p reg nanc y was c o nf irmed and ex tend s thro ug h the end of the postpartum period (60 d ay s af ter v ag inal d eliv ery and 60 d ay s af ter C-s ec tio n). 1. Co v ered services inc lud e o f fice visits f or a complete ex am, p harmac eutic als (inc lud ing some o v er the c o unter [ OTC] products wit h a p res c rip t io n), such as p renatal v i tami ns o r med i c ati o n rel ated to g es tati o nal d i ab etes , and f etal ul tras o und services are provided by or und er the supervision of a med ic al doctor, osteopath, or elig ib le Maternity provider. 2. Mater ni ty services may i nc l ud e the following: 2. 1 Preg nanc y tes ti ng /l ab o r ato r y tests. 2. 2 Office visits. 2. 3 Ultras o und s . 2. 4 Fetal d eliv ery . 2. 5 Post-P art u m visits. B. Maternity Global Perio d Th e CMS Physician Fee Sc hed ule as s ig ns maternity procedure codes a global d ay s ind ic ator of MMM, and d oes no t identify the numb er of d ays for a Maternity global period. CareSo urc e us es a Maternity Global Perio d of 56 d ay s after the d ate of v aginal d eliv ery and 60 d ay s af ter the d ate of C-section d eliv ery (d at e of deliv ery is d ay zero ). C. Coding Guid elines Th e d eliv ery d ate is us ed as the d ate of s ervice f or: 1. A ny o b s tetri c al global code. 2. Mo s t antep ar t u m c are codes. 3. A ny d el i v ery-o nl y code. 4. A ny d el i v ery + postpartum code. 5. A ny postpartum c are o nl y code. III. Cri t eri a for Global Billing and Summa ry of Bund l ed ServicesA. Th e global o b s tetric al p ac kag e c o de may o nly be c laimed when o ne p hy s ic ian, o ne c erti f i ed nurs e-midwife, or the s ame physician group practice provides all of the p ati ent s ro utine o b s tetric c are, inc luding the antep artum c are, d elivery , and p os tpartum c are. 1. Global services will be rei mb ur s ed o nl y when c are i nc l ud es al l p renatal visits p erf o rmed at med ically ap p ro priate interv als up to the d ate of d eliv ery , ro utine uri nal y s i s tes ti ng d uri ng the p renatal period, and c are for p reg nanc y rel ated conditions (e.g . naus ea, v o miting , c y s titis , vag initis). 2. A p rimary c are physician is responsible f or o v ers eeing p atient c are d uring the memb e r s p reg nanc y , d el i v ery , and postpartumc are. The group practice (o r clinic) s ho ul d bill globally for al l p renatal , d el i v ery , and postpartum c are services provided wit h the group practice (o r clinic) us ing the p rimary c are p hy s ic ians ind ivid ual Natio nal Pro v id er Id entifier (NP I) as t he p erf o rming p rov ider. B. On l y o ne p renatal c are code may be c l ai med p er p reg nanc y . C. Billing for global services c anno t be done unti l the d ate of d el i v ery D. Global Ob s tetri c al Package Stag es G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 5 1. Maternity c are and the global o b s tetric al p ac k age hav e three (3) d istinct s tag es : antep artum c are, d eliv ery , and postpartum c are. Th e global o b s tetric al p ac kag e inc lud es a larg e numb er of services whic h are c o ns id ered b und led into the global obstetrical code or the antep art u m c are, d el i v ery , and postpartum c are codes and are no t elig ib le to be rep o rt ed s ep arately . Th e b und led services are: 1. 1. Stag e I: A ntep art u m Care a. A ntep art u m c are b eg i ns wi th c o nc ep ti o n and end s wi th d el i v ery . A ntep art u m c are inc lud es the f o llo wing services whic h may no t be b illed s ep arately : ( 1) Ini ti al hi s to ry and physical, s ub s eq uent p hy s i c al ex am s , and ro uti ne urinaly s is . No te: Rep o rt the initial p renat al v i s i t wi th CP Tc o d e (c ateg o ry II code) 0500F (Initial p renatal c are visit) wit h a d ate of service of the initial p renatal v is it as a no-c harg e line item. ( 2) Mo nthl y visits up to 28 week s of g es tati o n. ( 3) Bi week l y visits to 36 week s g es tati o n. ( 4) Week l y visits f ro m 36 week s unti l d el i v ery . ( 5) Pap s mear at f i rs t p renat al visit. Thi s ap p l i es o nl y to the Pap s mear procedure. The l ab o rato ry p ro c es s i ng is s ep aratel y i d e nti f i ab l e an d p ay ab le. ( 6) Ed uc ati o n on b reas t f eed i ng , l ac tati o n and p reg nanc y (HCP CS l ev el II c o d es S9436 S9438, S9442 S9443) ( 7) Exercise c o ns ul tati o n or nutri ti o n c o uns el i ng d uri ng p reg nanc y (HCP CS lev el II codes S9449 S9452, S9470) b. At eac h of thes e visits, the rec o rd ing of weig ht, b lood p res s ures , fetal heart to nes , and ro uti ne c hemi c al urinalysis (code 81000 or 81002 ) are i nc l ud ed as p art of the global o b s tetric al p ac k ag e, and thes e services are no t reported s ep arately . c. The initial visit to es tab l i s h p reg nanc y is allowable und er the memb e r s med ic al b enef it. d. On c e the p reg nanc y has b een c o nf i rmed , the global mater ni t y period b eg i ns . e. On l y o ne antep ar t u m c are code may be billed p er p reg nanc y . 1. 2. Stag e II: Intrapartum Care or Del i v ery a. Del i v ery b eg i ns wi th the p as s ag e of the f etus and the p l ac enta f ro m the wo mb i nto the ex ternal world. b. Deliv ery c are inc ludes the following s erv ices whic h may no t be b illed s ep arately : ( 1) Admission to ho s p i tal . ( 2) Admission hi s t o ry and physical ex am. ( 3) Management of labor i nc l ud i ng f etal monitoring. ( 4) Pl ac emen t of i nternal f etal and /o r uteri ne monitors. ( 5) Cathet e ri z ati o n or c athete r i ns erti o n. ( 6) Preparation of the p eri neu m wi th anti s ep ti c s o l uti o n. ( 7) Del i v ery , any metho d : i. Vag i nal d el i v ery wi th or wi tho ut forceps or v ac uum ex trac ti o n. ii. Ces are a n d eliv ery . ( 8) Deliv ery of the p lac enta, any method. ( 9) Inj ec ti o n of l o c al anes thes i a. ( 1 0) Ind uc ti o n of labor with pitocin or oxytocin. Thi s i s c o ns i d ered an inherent p art of the d eliv ery service, and there is no s ep arate p ro c ed ure c o d e as s ig nment. (AMA1, 6) ( 1 1) Artificial rup tur e of membranes (A RO M ) before d el i v ery . Th i s is an G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 6 inclusive c o mp o nent of the d el i v ery code reported. Ther ef o r e , it wo ul d no t be appropriate to rep o rt a s ep arate c o de f or this service. ( A MA1, 9) 1. 3. Stag e III: Po s tp artum Care a. Postpartum care b eg i ns af ter delivery. Postpartum c are i nc l ud es the f o llo wing services which may no t be b illed s ep arately : ( 1) Exploration of uterus . ( 2) Episiotomy and rep ai r. ( 3) Rep ai r of cervical, v ag i nal or p eri neal l ac erati o ns . (AMA1, 4, 5) ( 4) Pl ac emen t of a hemo s ta ti c p ac k or ag ent. ( 5) Rec o v ery room visit. ( 6) Hospital visits. ( 7) Office visits or ho me v i s i ts (e. g . midwife c are) d uri ng the Mater ni ty Global Period. ( 8) Ed uc ati o n and assistance wi th l ac tati o n, b reas t and nipple c are, and b reas t f eed ing . b. CareS o u r c e will rei mb urs e: ( 1) One p ro v ider for d elivery . ( 2) One p ro v ider for p os tpartum c are. ( 3) On e as s i s tants u rg eo n for a c es are a n d el i v ery , if d o c umented . c. Th e p o s tp artum v i s i t s ho ul d be rep o rt ed as a no-c harg e line i tem wi th the d ate o f s erv ic e. I V. Cri t eri a for Splitting the Global Ob s tetri c al Services:A. Maternity c are and d eliv ery may be b illed as a sing le c ode ex c ept when the f o llowing c irc ums tanc es o c cur whic h req uire the p ac k ag e to be broken into c o mponents : 1. Th e memb e r has a c hang e of i ns urer d uri ng her p reg nanc y 2. Th e memb er has rec eiv ed p art of her antenatal c are els ewhere, e.g. f rom ano ther group practice 3. Th e memb e r l eav es her c are wi th y o ur group practice before the global obstetrical c are is c o mp lete 4. Th e memb er mus t b e ref erred to a p ro vider f rom ano ther group p ractice or a d ifferent lic ens ure (e.g . mid wif e to MD) for a c es arean d eliv ery 5. Th e memb e r has an unatte nd ed , precipitous d el i v ery 6. Termi n ati o n of p reg nanc y wi tho ut d el i v ery (e. g . mi s c arri ag e, ectopic p reg nanc y ) B. Billing a Split Ob s tetri c al Package 1. CP Tcodes f or antep artum c are o nly , d eliv ery only , d eliv ery inc luding p os tpartum c are, and /o r postpartum c are o nl y , s ho ul d be us ed when c ri t eri a is met f o r splitting the global o b s tetric al p ac k ag e. Report the services p erf o rmed us ing the most ac c urate, most c o mp rehens iv e procedure code av ailab le. V. Deliv ery of Multiple Ges tations A. Global b illing for multiple g es tations s hould inc lud e o ne g lobal p roc edure c o de and a d eliv ery o nly code for eac h s ub s equent d eliv ery. Th e sp ecific co des d epend on the metho d of d elivery and numb er of infants d eliv ered . Fo r d eliv eries of more than o ne newb o rn, s ub mit all d elivery c harges , any global services, and any additional s urgical services f rom the d ate of d eliv ery on the s ame claim, with the ap p ro priate d iagno sis c o d e f o r the multip le g es tatio ns .B. Multip le s urg ery f ee red uc tio ns apply to multiple d eliv ery services for multip le g es tati o ns . Th e code for the s ec o nd d el i v ery and any s ub s eq uent d el i v eri es s ho ul d inc lud e a mo d if ier 51 and a mo d if ier 59 to ind ic ate s ep arate newb o rn. C. In mo s t c as es the d el i v ery of the f i rs t newb o rn is c o ns i d ered p ri mary and al l o wed at G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 7 100% and the d eliv ery of all s ub s eq uent newb o rns are c o ns id ered s ec o nd ary and rei mb urs ed at 50% o f the c o ntrac ted allowable amo unt. A n ex c ep ti o n to thi s rul e may occur if the global o b s tetrical service c anno t be b illed for the f irs t newb o rn and the s ub s eq uent newb o rn is d eliv ered b y c es arean. VI. Li mi tati o ns on Elective Ob stetri c Del i v eri es A. Reimb urs ement f or any c es arean s ection, lab or induc tion, or any deliv ery following labor ind uc tio n is subject to the f ollowing c rit eria: 1. Ges tati o n al ag e of the f etus mus t be d etermi n ed to be at l eas t thi rty-ni n e week s ; o r, 2. If a d el i v ery occurs prior to thi rty-ni n e week s g es tati o n, mater n al and /o r f etal conditions mus t i nd i c ate med i c al nec es s i ty for the d el i v ery . B. A ny l ab o r i nd uc ti o ns or c es are an sections prior to 39 week s g es tati o n that are no t properly d o cumented as med ically nec es s ary are no t elig ib le for reimb urs ement. VI I. Mater ni ty Services No t Rei mb ur s ed to ProviderA. Ho me p reg nanc y tests B. Ultras o und s p erformed o nly for d etermination of s ex of the fetus or to p rovide a k eep s ak e p ic t ure C. Three and f o ur d imens io nal ultrasounds D. Paterni ty tes ting E. Lamaz e classes F. Bi rthi ng classes G. Parenti ng classes H. Ho me to co l yti c i nf us i o n therap y E. CONDITIONS OF COVERAGEReim bursem ent is dependent on, but not limited to, submitting Georgia Medicaid approved HCP CS and CP Tcodes along wi th appropriate m odifiers. Please refer to the Georgia Medicaid fee schedule. https://www.mmis.georgia.gov/portal/PubAccess.Provider%20In f orm ation/ Fee%20Sched ul es/tabId/ 5 6/ De f au l t. a sp x The following l i st(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 m ost current coding information.I. CareSo urc e req uires that all d eliv ery c harg es, antep artum c are, p ostp artum c are, and any ad d itional s urgical s erv ices f rom the d ate of d elivery (e.g ., 58611 tub al at time of c es arean d eliv ery ) b e s ub mitted o n the s ame claim.I I. Fo r antep artum c are o nly (1 to 3 visits) us e the appropriate Ev aluatio n and Manag ement (E / M) c o d es . Sel ec t l ev el b as ed upon the hi s to ry , ex ami na ti o n , and medical decision mak i ng d o c umented in the record for that visit. III. Pro v id ers are to indicate Maternity as a d iagnosis when b illing any of the s erv ic es listed in this p o licy that relate to Maternity . Pro v id ers are to complete the diagnosis c ode or the appropriate narrativ e, where ap p lic able. In addition, p rov iders s hould id entify services related to the treatment of c o mplic atio ns of Maternity . Fo r ex amp le: A. Surg i c al procedure such emerg e nc y C-Section d ue to f etal distress B. Atypical office visits and laboratorytests need ed d ue to memb er or f etal ano mal i es C. Other services (such as hospital, radiology, p harmac e uti c al , blood and blood d eriv ativ es ). G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 8 I V. Deliv ery Lab o r and d el i v ery services are b as ed on the need of eac h i nd i v i d ual p ati ent and c an includ e the f o llo wing ty p es o f s erv ic es , f etal mo nito ring o f any ty p e o f metho d , rup ture of memb ranes , amnio inf us ion, fo rcep s and /or v ac uum-as s isted d elivery , ep isiotomy and/or lac eratio n rep air, as well as f etal and maternal tes ting , and ind uc tio n of lab or servic es . A. Vag i nal Del i v ery Rep o rti ng1. Pri mary d el i v ery service code: 59400 or 59610 1. 1. Each ad d i ti o nal d el i v ery code: 59409-51 or 59612-51 1. 2. If the ad d i ti o nal service b ec o mes a c es are a n d el i v ery , then rep o rt the primary d eliv ery service as a c es arean d eliv ery : 59510 or 59618 B. Ces are a n Del i v ery Rep o rti ng 1. Pri mary d el i v ery service code: 59510 or 59618 1. 1. No additional procedural delivery code s ho ul d be us ed ; o nl y a single cesarea n d eliv ery service is to be rep o rt ed no matter ho w many live b irt hs . 1. 2. Modifier 22 s ho ul d be ad d ed to support s ub s tanti al ad d i ti o nal wo rk C. Postpartum Care Po s tp artum c are inc lud es ho s p ital and office visits fo llowing any type of d eliv ery , and c an i nc l ud e any numb er of visits (usually ex tend s o v er a six-week p eri o d ). It i s ex p ec t e d that the memb er wi l l hav e p o s tp artum c are rel ated to thei r med i c al need s , wi th the f i nal p o s tpartum visit at the conclusion of the p o stpartum p eriod. Eac h of thes e visits c an be rep o rted with p ro c ed ure c o d e 0503F. D. Mater ni ty Manag e m e nt Services Claims for materni ty management services s ho ul d rec o rd a valid CP Tor HCP CS procedure code f or eac h service p ro v ided and an appropriate ICD-10 diagnosis code to ind ic ate an enc o unter for maternity manag ement Codes Description 58611 Li g ati o n o r trans ec ti o n o f f al l o p i an tub e(s ) when d o ne at the ti me of c es area n d el i v ery or int ra-ab d o minal s urg ery (no t a s ep arate p roced ure) (Lis t s ep aratelyin ad dition to code for p ri mary p ro c ed ure) 59400 Ro uti ne o b stetri c c are i nc l ud i ng antep ar tu m c are, v ag i nal d el i v ery (wi t h or wi tho ut episiotomy, and /o r f orceps) and postpartum c are 59409 Vag i nal d el i v ery o nl y (wi t h or wi tho ut episiotomy and /o r f orceps) 59410 Vag i nal d el i v ery o nl y (wi t h o r without episiotomy and /o r f o rc ep s ); i nc l ud i ng p o s tp artum c are 59412 Ex ternal c ep hal i c v ers i o n, wi th or wi tho ut tocolysis 59414 Del i v ery o f p l ac enta (s ep arat e procedure) may not be s ep arat el y c o d ed in addition to the code for the delivery service). ( AMA1, 3 ) 59425 A ntep art u m c are o nl y ; 4-6 visits (Uni t s = 1) 59426 A ntep art u m c are o nl y ; 7 or mo re visits (Uni t s = 1) 59430 Postpartum c are o nl y (s ep ar a t e p ro c ed ure) 59510 Ro uti ne o b stetri c c are i nc l ud i ng antep ar t u mc a r e , c es are a n d el i v ery , and postpartum c are 59514 Ces are a n d el i v ery o nl y 59515 Ces are a n d el i v ery o nl y ; i nc l ud i ng postpartum c are 59525 Sub to tal or total hys terec tomy after c esarean d eliv ery (Lis tsep arately in addition to code for primary procedure) 59610 Ro uti ne o b stetri c c are i nc l ud i ng antep ar t u mc a r e , v ag i nal d el i v ery (wi t h or wi tho ut episiotomy, and /o r f orceps) and postpartumc are, af ter p rev i o us c es area n d el i v ery 59612 Vag i nal d el i v ery o nl y , af ter p rev i o us c es area n d el i v ery (wi t h or wi tho ut episiotomy and /o r f orceps) 59614 Vag i nal d el i v ery o nl y , af ter p rev i o us c es are an d el i v ery (wi t h or wi tho ut episiotomy and /o r f o rc ep s ); inc lud ing p os tpartum c are G l o bal Obs tetric al Serv i c es Georgia Med ic aid PY-0231 Effec ti v e Date: 07/01/2017 9 59618 Ro uti ne o b stetri c c are i nc l ud i ng antep ar t u mc a r e , c es are a n d el i v ery , and postpartum c are, following attemp t ed v ag i nal d el i v ery af ter p rev i o us c es area n d el i v ery59620 Ces are a n d el i v ery only, following attemp ted v ag i nal d el i v ery af ter p rev i o us c es area n d eliv ery 59622 Ces are a n d el i v ery only, following attemp ted v ag i nal d el i v ery af ter p rev i o us c es area n d eliv ery ; inc lud ing p o s tpartum c are 0500F Ini ti al p renatal c are visit (rep o rt at f i rs t p renatal enc o unt e r wi th heal th c are p ro f es s i o nal providing o b s tetri c al c are, rep o rt al s o d ate of visit and in a s ep arat e field, the l as t d ate of mens t ru al period LMP ) 0501F Prenatal f lo w s heet d o c umented in med ic al rec o rd by f irs t p renatal visit (d o c umen t ati o n i nc l ud es at minimum blood pressure, wei g ht, uri ne p ro tei n, uteri n e s ize, f etal heart tones , and es timated d ate of delivery). Rep ort als o: date of v isit and, in a s ep arate f ield , the d ate of the las t mens trual period-LMP (No t e: If reporting 0501F p renatal f lo w s heet, it is no t nec es s ary to rep ort 0500F initial p renatal c are visit) 0502F Sub s eq uent p renatal c are visit (ex c lud es : p atients who are s een for a condition unrel at ed to p reg nanc y or p renatal c are [e.g ., an up p er res p i rat o ry i nf ec ti o n; p ati ents s een for c o ns ul tati o n o nl y , no t for c o nti nui ng c are]) 0503F Postpartum c are visit AUTHOR IZ A TI ON PERIODF. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 07/01/2017Date Revised Date Effecti ve 07/01/2017 Archiv ed Date 03/3 1/2021 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 CareSo urc e res erv es the right to follow CMS/State/NCCI g uidelines without a f ormal d o c umented Policy . H. REFERENCES 1. Po l i c i es and Pro c ed ures f o r Phy s i c i an Serv i c es , Pro v i d er Manual s . (n. d . ). Retri ev ed Marc h 9, 2017 f ro m https://www. m mis. geor gia. gov / port al/ Pu b Ac c e s s . Pr ov ider %20Inf or mat ion/ Pro v i d er % 20Manu als /tab Id /54/Default.as px 2. Current Pro c ed ural Termino logy. (2015, June 1). Retriev ed June 11, 2015, f ro m http ://www.ama-as s n.o rg /ama/p ub /p hy s i c ian-r es o urc es/sol uti o ns-manag i ng-y o ur – p rac tic e/c oding-b illing-ins uranc e/cpt.page 3. Gui d el i ne Sug g es ti o ns for Elective Lab o r Ind uc ti o n. (2012 ). Retri ev ed June 11, 2015, f ro m http://www.acog.org/ -/media/Districts/District-I/20120120 – Elec tiv eIOLGuid eline.p df?d mc=1&ts=20150611T0857437601 4. American Association of Critical Care Nurs es Co ns ens us Model for APRN Reg ul ati o n: Li c ens ur e, A c c red i tati o n, Certification and Ed uc ati o n, 2015. 5. Americ an Ac ad emy of Ped iatrics , Americ an Co lleg e of Ob st et rics and Gy nec ologists. Guid elines for p erinatal c are. 7 th ed . Elk Grove Village (IL): AAP; Was hington, DC: American Co lleg e of Obstetrics and Gy nec o lo gis ts ; 2012.
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Date Next Annual Review Effective Date 08/04/2017 08/04/2018 02/01/2018-11/30/2021 Policy Name Policy Number Allergy Testing an d Allergen Immunotherapy PY-0334 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT……………………………………………………………… 1 TABLE OF CONTENTS …………………………………………………………………………………………. 1 A. SUBJECT …………………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………………. 2 C. DEFINITIONS ………………………………………………………………………………………………. 2 D. POLICY ……………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ……………………………………………………………………… 4 F. RELATED POLICIES/RULES ………………………………………………………………………… 4 G. REVIEW/REVISION HISTORY ……………………………………………………………………… 4 H. REFERENCES …………………………………………………………………………………………….. 5 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding b illin g, coding an d documentation guidelines. Coding methodology, regulatory requirements, industry-s t a ndard cla ims editing logic, benefits design and other factors a re 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, a nd applicable r e f e rral, authorization, n o tifica tion a nd utiliza tion management guidelines. Me d ica lly necessary services include, b ut a re not limite d to, t h ose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury a nd 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. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Po licy Statements, Provider Manuals, Member Handbooks, and/or other p o licie s 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 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 a nd applying th is Po licy to services provided in a particular case and ma y modify th is Po licy at any t ime . 2 Allergy Tes ti n g an d Al l ergen Immun o th erapy GEORGIA MEDICAID PY-0334 Effec ti v e Date: 02/01/2018A. SUBJECT Allergy Testing and Allergen Immunotherapy B. BACKGROUND Reimb urs ement p olicies are d es igned to as sist y ou when s ubmitting c laims to CareSourc e. They are ro utinely updated to p romote acc urate c oding and policy c larification. Thes e proprietary p o lic ies are no t a g uarantee of p ayment. Reim bursement for c laims may be s ubject 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. It is the res p o nsibility of the submitting p rovider to submit the most ac curate and ap propriate CP T/ HCP CS c o de(s) for the product or s ervice that is being pro vided. Th e inc lusion of a c ode does not imply any right to reimbursement or g uarantee claims payment. CareSo urc e c onsiders s pecific allerg y tes ti ng and allergy immunotherapy medically necess ary for memb ers with c linically s ignificant allergic s ymptoms. Based on a rev iew of the medic al literature and the p o sition s tatements of sc ientific o rganizations in the field of allergy and immunology, CareSo urc e c ons iders the specific allergy testing and treatment desc ribed below medically nec es s ary in ac cordance wit h the selection c riteria no ted. C. DEFINITIONS Allergen im munotherapy: (D esens itization, Hy po-sens itization) is parenteral administration of allergenic ex trac ts as antigens at periodic intervals, us ually on an inc reasing dosage scale to a d o sage maintained as maintenanc e therapy. Allergy: Ref ers to an ac quired p otential for developing ad verse reac tions that are mediated b y the immune s ystem (v ia Ig Eantibodies). Allergic d isease rep resents the c linic al manif es tations of thes e advers e i mm u ne res ponses . Allergy testing: Id entifying the offending antigen(s) for a p atient by in-v i v o t es ting p erc utaneo us, intradermal, and less commonly, p atch and photo patch t est s. Dose: A 1c c aliq uot of medicine or s erum tak en fro m a s ingle, m u lt i-dose v ial. Te n d oses are ty p ic ally o btained from s uch a v ial. In ac c ordance with CMS g uidelines, diluted doses will not b e reimb urs ed; ins tead, if the medication o r serum is d iluted, o nly thos e doses d esignated f ro m the maintenance v ial (a max imum of ten) will be reimbursed. D. POLICY I. CareSo urc e d oes not require an authorization for immunotherapy serv ic es administered by a p artic ipating p rovider within the limitation o utlined in this policy. II. CareSo urc e will reimburse p roviders of phys ic ian s ervices for the performance and ev aluatio n of allergy sensitivity tests when the following c onditions are met: A. A c o mplete medical and allergic/immunologic history and physic al ex amination m us t be d o ne p rior to p erforming d iagnos tic testing and be made av ailable to CareSourc e upon req ues t. B. The tes ting must b e performed b ased on the medical and allergic/immunologic history and p hy s ical ex amination that documents that the antigen being us ed for the tes ti ng ex is ts within a reas o nable p robability of ex posure in the p atients env ironment and be d o c umented in the patients medical rec ord. C. Bas ed o n the information in the medical record, the testing must be limited to the minimal numb er of nec essary tes ts to reac h a d iagnos is . 3 Allergy Tes ti n g an d Al l ergen Immun o th erapy GEORGIA MEDICAID PY-0334 Effec ti v e Date: 02/01/2018III. Perc utaneo us tests, intra-c utaneous/ intradermal tes ts, photo patch tests , and p atc h tes ts, photo t est s, or application tests are reimbursed on a p er t est basis. When s ubmitting cl a ims the p ro v ider must s pecify the number of tests performed. IV. Quantitativ e or s emi-quantitative in-v itro allergen s pecific Ig Etes ts (f ormerly referred to as RAST tes ts ) are c o vered if sk in testing is not pos sible o r not reliable and they are p erformed by p rov iders certified under t he Clinical Laboratory Imp rovement Amendment of 1988 (CLIA 88) to p erf orm t es ts. V. Op hthalmic mucous membrane tests and d irec t nas al mucous membrane tes ts are allowed o nly when skin testing c annot t est allergens . VI. If an ing es tion c hallenge test is c ompleted in les s than 61 minutes, ac cording to CPT/ RUC rules an E/M c o de should be us ed instead of 95076, if appropriate. A. The ad d-o n c ode [95079] is intended to be us ed for c hallenges lasting b eyond the two ho ur b as e c ode. CPT rules req uire that an ad d-on must last at least for 1 min. more than 50% of the total duration of the code, which means physic ians s hould not us e 95079 until the ad d itional time eq ualed at leas t 31 minutes beyond the first two hour o ral food c halleng e. VII. Allerg en immunotherapy A. Pro v iders may b e reimburs ed for the p rofes sional s ervices nec ess ary for a l l er g en immuno therapy. B. An o f fic e visit may be reimbursed in ad dition to the allergen immunotherapy c odes (95115, 95117, 95144-95180) o nly if other identifiable serv ices are p rovided at that t im e. If an o f fic e visit code is submitted with an allerg en immunotherapy s ervice, the modifier 25 mus t be us ed. C. Allerg en immunotherapy will not be c overed for the f ollowing antigens : news print, to b ac co s moke, dandelion, orris ro ot, phenol, formalin, alcohol, s ugar, yeas t, g rain mill d us t, goldenrod, p yret hrum, marigold, s oybean dust, honeys uckle, wo o l, fiberglass , green tea or c halk s ince they are no t considered medically necess ary . D. CareSo urc e rec ognizes two components of allergen immunotherapy , one b eing the ad minis tration (injection) of the antigen, whic h includes all professional s erv ices as s o c iated with the ad ministration of the antigen, and the o ther b eing the antigen itself. Th e se two c o mponents m ust be separate on the claim, regardless of whether or not the p ro v ider who presc ribes and pro vides the antigen is the s ame as the pro vider who ad minis ters the antigen. VIII . Injec tio ns A. Fo r reimb urs ement for the administration (injection) of allergenic ext ract of stinging insec t v eno m, the provider m ust use CP Tc ode 95115 o r 95117. 1. The allerg enic ex tract may be adminis tered by the physician o r by a p roperly ins truc ted employee under the general superv is ion of the physician in an office s etting .2. Thes e codes may no t be used with CPT c ode 95144 [Professional serv ices for the s up erv is ion of p reparation and p rovision of antigens for allergen immunotherapy; sing le d ose vials] B. Antig ens (exc luding s tinging ins ect v enoms) 1. When the p ro v ider p rescribes and provides s ingle o r multiple antigens for allergen immuno therapy in multiple-dose v ials (i.e., v ials c ontaining two o r more doses of antig ens ), the prov ider must us e CPT c o de 95165 [Professional serv ic es for the s up erv is ion o r preparation and prov is ion of antigens for allergen immunotherapy ; s ing le o r multiple antigens ] in the pro cedure/ s ervice c ode block and the number of doses c ontained in the v i al in the unit(s) b loc k on the inv oic e. 4 2. 3. Allergy Tes ti n g an d Al l ergen Immun o th erapy GEORGIA MEDICAID PY-0334 Effec ti v e Date: 02/01/2018If the p ro v ider d ispenses two o r more multiple-d ose v ials of antigen, for eac h v ial d is p ensed CPT c ode 95165 must be listed on a s eparate line along with the c o rres p onding number of dos es. Fo r ex amp le, if a p atient c annot b e treated with immunotherapy b y placing all antig ens in o ne v ial and two multi-dose v ials c ontaining ten d oses eac h mus t b e d is p ensed, the CP Tc ode 95165 m us t be listed on t wo separate lines and a 10 (f or ten d o s es) m ust be entered for the corres ponding units. 4. CPT c o d e 95144, the s ingle d ose v ial antigen preparation c ode, must not be us ed as o ne of the components of a c omplete s ervice p erformed by a p rovider. The c ode mus t b e us ed only if the pro vider p roviding the antigen is providing it to be injected by some o ther entity. The numb er of v ia l s p repared m ust be indic ated. 5. CareSo urc e d oes no t rec ognize CPT c odes 95120 through 95134 b ecause they rep res ent c omplete services, i . e., serv ic es that include the injection service as well as the antig en and its p reparation. Only component billing will b e allowed. Providers p ro v iding both components of the s ervice must d o c omponent b illing. The p ro vider mus t, as ap propriate, us e one of the injection CPT c o des (95115 o r 95117) and o ne o f the antigen/ antigen preparation CPT c o des (95145 through 95149, 95165, o r 95170). Th e numb er o f dos es must be spec ified. IX. Ins ec t v eno ms in s ingle d ose vials or p reparations A. If the p ro vider adminis ters the v enom(s ), CPT c ode 95115 or 95117 m us t be u s ed f or the injec tio n(s) of the antigen(s). B. When a p ro v ider pres cribes and/or prov ides s tinging insec t v enom antigens in s i ng le d o s e v ials or prep arations, CPT c o des 95145 to 95149 m ust be used. 1. When a p ro v ider pres cribes and p rovides s ingle or multiple s tinging insect v eno m(s ) in multiple dose v ials, CPT c odes 95145 to 95149 must be us ed. The numb er rep o rted as the unit of s erv ic e mus t rep resent the total number of doses c o ntained in the vial. 2. Reg ard les s of the number of d oses, the d ate of s ervice reported should be: 2. 1 Th e d ate the v ial is dispensed to the patient, if the p atient t a k es the vial ho me to be ad ministered at a d ifferent off i ce OR 2. 2 Th e d ate the f irs t d ose is ad ministered to the patient, if the vial is k ept in the p hy s icians office. 3. If the p ro vider als o administers the venom, CP Tc ode 95115 or 95117 m us t be us ed f or the multiple injection(s). Th e c orrec t quantity is o ne for either c ode. E. CONDITIONS OF COVERAGE CPT CODE DESCRIPT ION 95004-95071 Allergy Tests 95076-95079 Challenge Ingestion Te s t ing 95115-95199 Allergy Immunotherapy F. RELATED POLICIES/RULES5 G. REVIEW/REVION HISTORY N/ A Allergy Tes ti n g an d Al l ergen Immun o th erapy GEORGIA MEDICAID PY-0334 Effec ti v e Date: 02/01/2018TH. Ref erenc es N/A he Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Date Issued 08/04/2017 New Policy Date Revised Date Effective 02/01/2018 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 fo r mal documen ted Policy.
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAIDOriginal Issue Date Next Annual Review Effective Date 09/05/2017 09/05/2018 02/01/2018 Policy Name Policy Number Genetic Testing-Polymerase Chain Reaction PY-0307 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies 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 o r 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 par t, 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 authorizati on 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 t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………………………………………. …………. 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Genetic Testing-Polymerase Chain Reaction Georgia Medicaid PY-0307 Effective Date: 02/01/2018 2 A. SUBJECT Genetic Testing-Polymerase Chain Reaction B. BACKGROUND Polymerase Chain Reaction (PCR) is a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time period. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. PCR plays a diagnostic role when selected pathogens pose difficulties for specimen collection or culture characteristics (time, environment, or substrate constraints). For example, evaluating viral load by PCR technique for HIV helps gauge response to therapies. However, the technique is also so sensitive that amplified contaminant DNA is problematic to achieving valid test results. False positive results may also occur if DNA from one specimen contaminates another. The technique cannot distinguish DNA from colonizing organisms, or even DNA from dead microbes in a specimen, from those causing clinically significant infections. In fact, for many types of microbes the test sensitivities, specificities, and predictive values of PCR gene testing are not reported for large patient groups. Repeated cycles of synthesizing complementary strands of DNA are performed in a stepwise manner up to 30 times to achieve adequate gene amplification for diagnosis. Cycles involve 1) denaturing DNA with heat to create single strands, 2) annealing PCR primers of oligonucleotides (short pieces of DNA of 20-30 base pairs each) to the DNA to be amplified, and 3) enzymatic synthesis of complementary DNA with Taq polymerase or Pfu polymerase. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. Errors can occur anywhere in the testing process, particularly when the manufacturer’s instructions are not followed and when testing personnel are not familiar with all aspects of the test system. Some waived tests have potential for serious health impacts and unintended consequences if performed incorrectly. To decrease the risk of erroneous results, the test needs to be performed correctly, by trained personnel and in an environment where good laboratory practices are followed. CareSource may periodically require rev iew of a providers office testing policies and procedures when performing CLIA-waived tests. CareSource will cover influenza testing with the CPT 87502 only when a CLIA-waived manufacturer testing system performs gene amplification by polymerase chain reaction (PCR) or nucleic acid amplification technology (NAT) testing. Appropriate indications must be documented in the members medical record and available for review by CareSource upon request. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) Archived Genetic Testing-Polymerase Chain Reaction Georgia Medicaid PY-0307 Effective Date: 02/01/2018 3 D.POLICY I. A Prior Authorization is not required for selected PCR testing. II. CareSource considers nucleic acid amplification testing (NAAT) by polymerase chain reaction (PCR) to be medically necessary for the following indications in oncology and heritable conditions: A. Chronic Lymphocytic Leukemia (CLL) [1] B. BCR-ABL testing for Chronic Myelogenous Leukemia (CML) [2] [3] [4] C. Mucosa-Associated Lymphoid Tissue (MALT) [5] D. Lynch syndrome [6] [7] E. BRAF mutation which is seen in colorectal carcinoma, gliomas, hepatobiliary carcinomas, melanoma, papillary thyroid carcinoma, ovarian teratomas and serous tumors, and hairy-cell leukemia (HCL). [8,9] F. The use of PCR gene testing for persons who meet criteria has been demonstrated in a variety of heritable conditions and is supported by published literature or endorsed by consensus professional societies. These conditions include certain primary thrombophilias[10], Tay-Sachs and Canavan diseases[11], Fabry disease[12], Gaucher disease[13], Niemann-pick disease[14], Hemochromatosis[15], Rett syndrome[16], Huntington’s disease[17], Celiac disease[18], Ankylosing spondylitis[19], Prader-Willi or Angelman syndrome, and other sho rt-stature syndromes[20], Fragile Xsyndrome[21], and sickle-cell disease[22]. Applications of selected PCR techniques are also part of the workup and management for candidates donating organs and tissues. [23, 24] The first-line screening test for Tay-Sachs remains an enzyme activity test rather than genotyping. Genotyping is used for preimplantation diagnosis and confirmatory testing. In contrast, DNA-based testing is used for Canavan screening and diagnosis. G. Methylenetetrahydrofolate reductase (MTHFR) polymorphism testing has little clinical utility and does not meet medical necessity criteria as meta-analyses have disproven an association between elevated homocysteine and risk for coronary artery disease and between MTHFR polymorphisms and risk for venous thromboembolism.[25] III. CareSource considers NAAT by PCR to be medically necessary for the following indications in infectious disease management: A. Shiga toxin –producing Escherichia coli (STEC) [26] B. C. difficile enterocolitis [27-29] C. Entamoeba species [30,31] D. Tuberculosis[32] E. Staphylococcus aureus[33] F. Actinomyces species may be identified in tissue specimens with a 16s rRNA sequencing and PCR assay.[34, 35] G. Dengue is a mosquito-borne febrile illness and diagnosis requires laboratory confirmation by culture, NAAT or testing for dengue specific antibodies.[37] For other mosquito-borne illnesses such as West Nile virus and Zika, PCR also has diagnostic utility, including in saliva tests.[38] Ebola may be diagnosed by PCR techniques on plasma.[39] IV. CareSource considers viral PCR testing in conjunction with a Clinical Laboratory Improvement Amendments (CLIA)-approved reference lab as medically necessary for indications endorsed in a primary or supplemental diagnostic approach as described by the Infectious Diseases Society of America (IDSA) . [ 40] Many molecular diagnostic tests for viral pathogens include PCR techniques, offered by CLIA-certified reference laboratories. Viral syndrome testing is considered based on the patient’s age, history, immune status, and other variables. According to the IDSA, diagnostic samples are obtained and tested for the most likely agents.[40] Samples are commonly held frozen in the microbiology laboratory for Archived Genetic Testing-Polymerase Chain Reaction Georgia Medicaid PY-0307 Effective Date: 02/01/2018 4 additional testing if necessary, given that it is not cost-effective to test initial samples broadly for multiple viruses.[40]These viral pathogens include: A. Herpes virus infections [41, 42], Varicella and Zoster[43], Measles[44], Mumps[45], Cytomegalovirus [40], Adenovirus [40], Enterovirus [42], and Parvovirus [40]. B. For persons with positive HIV, antigen/antibody combination immunoassays and either HIV-1 negative or indeterminate HIV-2 differentiation immunoassay, PCR testing is indicated.[40, 46, 47] C. The diagnosis of hepatitis B (HBV) or C (HCV) typically begins with an antibody test for screening or in the presence of acute hepatitis. For hepatitis B, PCR viral genetic assays may be applied to determine viral genotype, detecting genotypic drug resistance mutations, and identifying core promoter/precore mutations.[48] For hepatitis C, persons with positive screening test results should undergo confirmatory or supplemental testing for HCV RNA by molecular test methods. V. PCR techniques have been developed for a variety of respiratory pathogens and may be included in diagnostic algorithms for affected persons in the pediatric and adult populations. The Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) consensus guidelines on the management of community-acquired pneumonia in adults report that testing is optional for persons who are not hospitalized [49]. However, patients who require hospitalization should have pretreatment blood cultures, culture and Gram stain of good-quality samples of expectorated sputum and, if disease is severe, urinary antigen tests for S. pneumoniae and Legionella pneumophila, when available . [49] Evaluation of bronchoscopically obtained samples and/or thoracentesis-obtained samples of pleural fluid may be necessary for diagnosis in hospitalized persons unable to produce a sputum sample. PCR testing may be applied in selected cases where microorganisms are suspected based upon age, history, immune status, and other variables. PCR testing is available for Mycoplasma. [ 49] VI. CareSource considers PCR testing for pathogens of other types or in other anatomic sites medically necessary as described by the IDSA and the American Society for Microbiology (ASM) in A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). [40] Guidelines were developed by both laboratory and clinical experts and provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions.[40] VII. For many pathogens, while a PCR test is available, the clinical utility is not clearly defined by available evidence, evidence is insufficient or inconclusive, or there is no support for quantification PCR testing. For Bartonella henselae and quintona species, immunofluorescent antibody assay serology is sensitive and specific, and there is no inconclusive evidence of an indication for quantification . [50, 51]. For many pathogens, such as Chlamydia pneumoniae, Hepatitis G, herpes simplex virus (HSV), Herpes virus-6, Legionella pneumophilia, Mycobacteria avium-intracellulare, Mycoplasma pneumoniae, Neisseria gonorrhoeae, and Streptococcus, group A guidelines from the IDSA do not hav e a recommendation for quantification.[40] VIII. For sexually transmitted infections including Chlamydia, Gonorrhea, Syphilis, and other pathogens, refer to the CareSource Sexually Transmitted Infection (STI) policy. E. CONDITIONS OF COVERAGE F. RELATED POLICIES/RULES 1. Genetic Testing, Genetic Screening and Genetic Counseling (MM-0003) 2. Sexually Transmitted Infections (PY-0037) Archived Genetic Testing-Polymerase Chain Reaction Georgia Medicaid PY-0307 Effective Date: 02/01/2018 5 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 09/05/2017 New policy. Date Revised Date Effective 02/01/2018 H. REFERENCES [1] D. Kienle, A. Benner, C. Laufle, D. Winkler, C. Schneider, A. Buhler , et al., “Gene expression factors as predictors of genetic risk and survival in chronic lymphocytic leukemia,” Haematologica, vol. 95, pp. 102-9, Jan 2010. [2] F. Notta, C. G. Mullighan, J. C. Wang, A. Poeppl, S. Doulatov, L. A. Phillips , et al., “Evolution of human BCR-ABL1 lymphoblastic leukaemia-initiating cells,” Nature, vol. 469, pp. 362-367, 2011. [3] A. A. Darji and P. D. Bharadia, “CHRONIC MYELOGENOUS LEUKEMIA: A REVIEW AND UPDATE OF CURRENT AND FUTURE THERAPY,” International Journal of Pharmacy and Pharmaceutical Sciences, vol. 8, 2016. [4] M. W. Deininger, “Molecular monitoring in CML and the prospects for treatment-free remissions,” Hematology Am Soc Hematol Educ Program, vol. 2015, pp. 257-63, 2015. [5] A. D. Zelenetz, J. S. Abramson, R. H. Advani, C. B. Andreadis, J. C. Byrd, M. S. Czuczman , et al. , “NCCN Clinical Practice Guidelines in Oncology: non-Hodgkin’s lymphomas,” JNatl Compr Canc Netw, vol. 8, pp. 288-334, Mar 2010. [6] H. Hampel, “NCCN increases the emphasis on genetic/familial high-risk assessment in [7] K. M. Chin, B. Wessler, P. Chew, and J. Lau, “Genetic Tests for Cancer,” in Genetic Tests for Cancer , ed Rockville (MD), 2006. [8] P. G. Febbo, M. Ladanyi, K. D. Aldape, A. M. De Marzo, M. E. Hammond, D. F. Hayes , et al., “NCCN Task Force report: Evaluating the clinical utility of tumor markers in oncology,” Journal of the National Comprehensive Cancer Network, vol. 9, pp. S-1-S-32, 2011. [9] S. Pakneshan, A. Salajegheh, R. A. Smith, and A. K. Lam, “Clinicopathological relevance of BRAF mutations in human cancer,” Pathology, vol. 45, pp. 346-56, Jun 2013. [10] S. Moll, “W ho should be tested for thrombophilia?,” Genet Med, vol. 13, pp. 19-20, 01//print 2011. [11] A. Colaianni, S. Chandrasekharan, and R. Cook-Deegan, “Impact of gene patents and licensing practices on access to genetic testing and carrier screening for Tay-Sachs and Canavan disease,” Genet Med, vol. 12, pp. S5-S14, 04//print 2010. [12] R. Schiffmann, M. Fuller, L. A. Clarke, and J. M. F. G. Aerts, “Is it Fabry disease?,” Genet Med, 05/19/online 2016. [13] C. R. Scott, G. Pastores, H. Andersson, J. Charrow, P. Kaplan, E. Kolodny , et al., “The clinical expression of Gaucher disease correlates with genotype: Data from 570 patients,” Genet Med, vol. 2, pp. 65-65, 01//print 2000. [14] R. Y. Wang, O. A. Bodamer, M. S. Watson, and W. R. Wilcox, “Lysosomal storage diseases: Diagnostic confirmation and management of presymptomatic individuals,” Genet Med, vol. 13, pp. 457-484, 05//print 2011. [15] C. Mura, O. Raguenes, V. Scotet, S. Jacolot, A.-Y. Mercier, and C. Ferec, “A 6-year survey of HFE gene test for hemochromatosis diagnosis,” Genet Med, vol. 7, pp. 68-73, 01//print 2005. [16] T. Bienvenu and J. Chelly, “Molecular genetics of Rett syndrome: when DNA methylation goes unrecognized,” Nat Rev Genet, vol. 7, pp. 415-426, 06//print 2006. [17] W. H. Rogowski, S. D. Grosse, and M. J. Khoury, “Challenges of translating genetic tests into clinical and public health practice,” Nat Rev Genet, vol. 10, pp. 489-495, 07//print 2009. [18] G. J. Tack, W. H. M. Verbeek, M. W. J. Schreurs, and C. J. J. Mulder, “The spectrum of celiac disease: epidemiology, clinical aspects and treatment,” Nat Rev Gastroenterol Hepatol, vol. 7, pp. 204-213, 04//print 2010. Archived Genetic Testing-Polymerase Chain Reaction Georgia Medicaid PY-0307 Effective Date: 02/01/2018 6 [19] L. -S. Tam, J. Gu, and D. Yu, “Pathogenesis of ankylosing spondylitis,” Nat Rev Rheumatol, vol. 6, pp. 399-405, 07//print 2010. [20] S. B. Cassidy, S. Schwartz, J. L. Miller, and D. J. Driscoll, “Prader-Willi syndrome,” Genet Med, vol. 14, pp. 10-26, 01//print 2012. [21] D. C. Crawford, J. M. Acuna, and S. L. Sherman, “FMR1 and the fragile Xsyndrome: Human genome epidemiology review,” Genet Med, vol. 3, pp. 359-371, 09//print 2001. [22] M. Bender and G. D. Seibel, “Sickle cell disease,” 2014. [23] N. Kamani, S. Spellman, C. K. Hurley, J. N. Barker, F. O. Smith, M. Oudshoorn , et al., “State of the art review: HLA matching and outcome of unrelated donor umbilical cord blood transplants,” Biol Blood Marrow Transplant, vol. 14, pp. 1-6, Jan 2008. [24] L. D’Orsogna, S. Fidler, A. Irish, B. Saker, H. Moody, and F. T. Christiansen, “HLA donor-specific antibody detected by solid phase assay identifies high-risk transplantation pairs irrespective of CDC crossmatch results: case reports and literature review,” Clin Transpl, pp. 497-501, 2006. [25] S. E. Hickey, C. J. Curry, and H. V. Toriello, “ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing,” Genet Med, vol. 15, pp. 153-6, Feb 2013. [26] L. H. Gould, C. Bopp, N. Strockbine, R. Atkinson, V. Baselski, B. Body , et al., “Recommendations for diagnosis of shiga toxin –producing Escherichia coli infections by clinical laboratories,” MMWR Recomm Rep, vol. 58, pp. 1-14, Oct 16 2009. [27] S. H. Cohen, D. N. Gerding, S. Johnson, C. P. Kelly, V. G. Loo, L. C. McDonald , et al., “Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA),” Infect Control Hosp Epidemiol, vol. 31, pp. 431-55, May 2010. [28] S. B. Selvaraju, M. Gripka, K. Estes, A. Nguyen, M. A. Jackson, and R. Selvarangan, “Detection of toxigenic Clostridium difficile in pediatric stool samples: an evaluation of Quik Check Complete Antigen assay, BD GeneOhm Cdiff PCR, and ProGastro Cd PCR assays,” Diagnostic Microbiology and Infectious Disease, vol. 71, pp. 224-229, 11// 2011. [29] M. H. Wilcox, T. Planche, F. C. Fang, and P. Gilligan, “What is the current role of algorithmic approaches for diagnosis of Clostridium difficile infection?,” JClin Microbiol, vol. 48, pp. 4347-53, Dec 2010. [30] S. Roy, M. Kabir, D. Mondal, I. K. M. Ali, W. A. Petri, and R. Haque, “Real-time-PCR assay for diagnosis of Entamoeba histolytica infection,” Journal of clinical microbiology, vol. 43, pp. 2168-2172, 2005. [31] S. Solaymani-Mohammadi, C. M. Coyle, S. M. Factor, and W. A. Petri Jr, “Amebic colitis in an antigenically and serologically negative patient: usefulness of a small-subunit ribosomal RNA gene-based polymerase chain reaction in diagnosis,” Diagnostic Microbiology and Infectious Disease, vol. 62, pp. 333-335, 11// 2008. [32] P. Nahid, S. E. Dorman, N. Alipanah, P. M. Barry, J. L. Brozek, A. Cattamanchi , et al., “Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis,” Clinical Infectious Diseases, p. ciw376, 2016. [33] D. L. Stevens, A. L. Bisno, H. F. Chambers, E. P. Dellinger, E. J. Goldstein, S. L. Gorbach , et al. , “Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America,” Clinical Infectious Diseases, vol. 59, pp. e10-e52, 2014. [34] M. J. Belmont, P. M. Behar, and M. K. Wax, “Atypical presentations of actinomycosis,” Head & neck, vol. 21, pp. 264-268, 1999. [35] T. Hansen, M. Kunkel, E. Springer, C. Walter, A. Weber, E. Siegel , et al., “Actinomycosis of the jaws –histopathological study of 45 patients shows significant involvement in bisphosphonate-associated osteonecrosis and infected osteoradionecrosis,” Virchows Arch, vol. 451, pp. 1009-17, Dec 2007. [36] C. L. Schroeder, H. P. Narra, M. Rojas, A. Sahni, J. Patel, K. Khanipov , et al., “Bacterial small RNAs in the Genus Rickettsia,” BMC Genomics, vol. 16, p. 1075, 2015. ArchivedGenetic Testing-Polymerase Chain Reaction Georgia Medicaid PY-0307 Effective Date: 02/01/2018 7 [37] M. G. Teixeira and M. L. Barreto, “Diagnosis and management of dengue,” BMJ, vol. 339, 2009. [38] D. Musso, C. Roche, T. X. Nhan, E. Robin, A. Teissier, and V. M. Cao-Lormeau, “Detection of Zika virus in saliva,” JClin Virol, vol. 68, pp. 53-5, Jul 2015. [39] J. R. Spengler, A. K. McElroy, J. R. Harmon, U. Stroher, S. T. Nichol, and C. F. Spiropoulou, “Relationship Between Ebola Virus Real-Time Quantitative Polymerase Chain Reaction-Based Threshold Cycle Value and Virus Isolation From Human Plasma,” JInfect Dis, vol. 212 Suppl 2, pp. S346-9, Oct 1 2015. [40] E. J. Baron, J. M. Miller, M. P. Weinstein, S. S. Richter, P. H. Gilligan, R. B. Thomson , et al., “A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM) a,” Clinical Infectious Diseases, vol. 57, pp. e22-e121, August 15, 2013 2013. [41] D. W . Kimberlin, “Diagnosis of herpes simplex virus in the era of polymerase chain reaction,” The Pediatric infectious disease journal, vol. 25, pp. 841-842, 2006. [42] R. L. DeBiasi and K. L. Tyler, “Molecular methods for diagnosis of viral encephalitis,” Clinical microbiology reviews, vol. 17, pp. 903-925, 2004. [43] P. A. Thomas and P. Geraldine, “Infectious keratitis,” Current opinion in infectious diseases, vol. 20, pp. 129-141, 2007. [44] R. S. van Binnendijk, S. van den Hof, H. van den Kerkhof, R. H. G. Kohl, F. Woonink, G. A. M. Berbers , et al., “Evaluation of Serological and Virological Tests in the Diagnosis of Clinical and Subclinical Measles Virus Infections during an Outbreak of Measles in The Netherlands,” Journal of Infectious Diseases, vol. 188, pp. 898-903, September 15, 2003 2003. [45] C. H. Krause, K. Eastick, and M. M. Ogilvie, “Real-time PCR for mumps diagnosis on clinical specimens comparison with results of conventional methods of virus detection and nested PCR,” Journal of clinical virology, vol. 37, pp. 184-189, 2006. [46] CDC. (2014, Quick reference guide-Laboratory testing for the diagnosis of HIV infection : updated recommendations. CDC Stacks. Available: https://stacks.cdc.gov/view/cdc/23446 [47] G. Murphy and C. Aitken, “HIV testing the perspective from across the pond,” Journal of Clinical Virology, vol. 52, pp. S71-S76, 2011. [48] A. Valsamakis, “Molecular testing in the diagnosis and management of chronic hepatitis B,” Clinical microbiology reviews, vol. 20, pp. 426-439, 2007. [49] L. A. Mandell, R. G. Wunderink, A. Anzueto, J. G. Bartlett, G. D. Campbell, N. C. Dean , et al. , “Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults,” Clinical Infectious Diseases, vol. 44, pp. S27-S72, March 1, 2007 2007. [50] P. E. Fournier, J. L. Mainardi, and D. Raoult, “Value of microimmunofluorescence for diagnosis and follow-up of Bartonella endocarditis,” Clin Diagn Lab Immunol, vol. 9, pp. 795-801, Jul 2002. [51] L. M. Mofenson, M. T. Brady, S. P. Danner, K. L. Dominguez, R. Hazra, E. Handelsman , et al., “Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics,” MMWR Recomm Rep, vol. 58, pp. 1-166, Sep 4 2009. [52] K. A. Workowski, S. Berman, C. Centers for Disease, and Prevention, “Sexually transmitted diseases treatment guidelines, 2010,” MMWR Recomm Rep, vol. 59, pp. 1-110, Dec 17 2010. [53] ACOG, “ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis,” Obstet Gynecol, vol. 107, pp. 1195-1206, May 2006. The Reimbursement Policy Statement detailed a bove has r eceived due consi deration as defined in the Reimbursement Po li cy Stateme nt Po li cy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Dat e Next Annual Review Effective Da te 06/07/2017 06/07/2018 02/01/2018-10/31/2022 Policy Name Policy Number Nursing Facility Services PY-0321 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Contents of PolicyREIMBURSEMENT PO LI CY STATEMENT ……………………………………………………………… 1 TABLE OF CONTENTS ………………………………………………………………………………………….. 1 A. SUBJECT …………………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………………. 2 C. DEFINITIONS ………………………………………………………………………………………………. 2 D. POLICY ……………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ……………………………………………………………………… 4 F. RELATED POLICIES/RULES ………………………………………………………………………… 4 G. REVIEW/REVISION HISTORY………………………………………………………………………. 4 H. REFERENCES ……………………………………………………………………………………………… 4 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billin g , coding a nd documentation guidelines. Co din g methodology, regulatory requirements, industry-s t a ndard 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 edica l necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re 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 limit e 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, dysfunction 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 document s, 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 Co ve rage) 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. SUBJECTNursing Facility Services B. BACKGROUND Skilled Nurs i n g Facility Serv ic es Georgia Med i c ai d PY-0321 Las t Rev i s ed 02/01/2018Nurs ing Facilities are ins titutions that prov ide nurs ing and medical care to p atients who no longer req uire ac ute c are s ettings, but do req uire lic ensed nurs ing s ervices , rehabilitation s ervices , o r o ther health-related s ervic es on a reg ular bas is , that c annot b e prov ided in the ho me. C. DEFINITIONS RUG (Res o urc e Utilization Group) is the sy stem of c lassif ying nursing facility res idents i nto c as e mix g roups. D. POLICY I. Prio r Autho rization is req uired f or all admissions to a Nurs ing Facility. II. Ad mission Criteria A. Prio r to nurs ing facility admis sion, all patients mus t have a Pre-Admiss ion Screening and Res id ent Rev iew (PASRR) c ompleted. B. In c as es where the p atients primary diagnosis is psy chiatric o r there is p syc hiatric c are inv o lv ed, the p atient is not considered a c andidate for intermediate care s ervices . The ind iv idual m ust als o have medic al c are needs that meet the crit eria for intermediate c are f ac ility placement. C. Intermed iate c are services may be p rovided to a p atient with a s table medical condition req uiring intermittent skilled nurs ing serv ic es under the d irec tion of a lic ensed physician when the f o llowing c riteria is met. 1. Med ic al Status a. Req uires mo nitoring and overall management of a medical condition(s) und er the d irec tion of a lic ensed phy sician . In addition to this criteria, the patients specific m edical condition m ust requi re any of the following (b-h) plus one item from 2 or 3. b. Nutritio nal management; which may inc lude therapeutic diets or maintenance of hy d ration s tatus. c. Maintenanc e and preventiv e skin care and treatment of s kin conditions such as c uts , ab rasions or healing d ecubiti. d. Catheter c are such as catheter c hange and irrigation. e. Therap y services such as o xygen therapy, phy sical therapy, speech therapy, o c c upational therapy (les s than five (5) times week ly ). f. Res to rative nurs ing s ervices s uch as rang e of motion exerc is es and bowel and b lad d er training. g. Mo nito ring of vi tal s igns and laboratory s tudies or weights. h. Manag ement and administration of med ic ations inc luding injections. 2. Mental Status ( m us t be such tha t the cognitive lo ss is m or e than occasional forgetfulness ). a. Do c umented short or long-t er m memory d e f ic it s wit h etiologic diagnosis Co g nitive los s addres sed on MDS/ care p lan for continued p lacement. b. Do c umented moderately o r sev erely impaired c ognitive s kills wi th etiologic diagnosis f or d a il y d ecision making. Co gnitive loss addres sed on MDS/ c are plan f o r c ontinued p lac ement. c. Problem behavior, i . e., wandering, v erbal abus e, phys ic ally and /or soc ially d is rup tiv e o r inappropriate behavior requiring appropriate superv ision o r interv ention. 3 Skilled Nurs i n g Facility Serv ic es Georgia Med i c ai d PY-0321 Las t Rev i s ed 02/01/2018d. Und etermined cognitive patterns whic h cannot be asses sed by a mental s tatus ex am, f or ex ample, d ue to aphasia. Func tio nal Status a. Trans f er and loc omotion performance of res ident requires limited ex tensive as s is tance by staff through help or o ne-person p hy sical ass is t. b. Assistance wit h feeding. Continuous stand-by s upervision, encouragement or c ueing req uired and s et-up help of meals . c. Req uires d irec t as sistanc e of another person to maintain c ontinence. d. Do c umented c ommunication d eficits in making s elf-understood or unders tanding o thers . Deficits m ust be addres sed in the medical rec ord with etiologic d i ag no s is ad d res s o n MDS/ care p lan for c ontinued p lac ement. e. Direc t s tand-by s upervision o r c ueing with one-pers on p hy sical as sistance f ro m s taf f to complete dres sing and personal hy giene. (If thi s is the only evaluation of care identified, another deficit in functional status is required ). III. Reimb ursement A. Reimb urs ement rates are neg otiated at the t i me of authorization request, upon approv al o f s erv ic es and bas ed on an ag reed perc entage of the RUG sc ore. B. Fo r memb ers admitted to a Nurs ing Facility prior to b ecoming effective wi th CareSource the f o llowing will ap ply : 1. If the memb er is already admitted to o ngoing no n acute treatment that has b een p rev io usly c ov ered prior to the patients effective date wi th CareSource, serv ic es will b e c o v ered for at least 30 c alendar d ays to allow time for a c linical rev iew and , if nec es s ary , Trans ition of Care. 2. CareSo urc e will no t be obligated to cov er serv ic es beyond 30 c alendar days, ev en if ano ther c arriers authorization was for a p eriod greater than 30 c alendar days, if the c linic al rev iew d etermines c ontinued authorization is not medically nec essary . C. The numb er o f d ays of c are c harg ed for nurs ing facility s ervices is always in units of full days, beginning at midnight and ends twenty-four hours later. Any p ar t of a day, including the d ay o f admis sion counts as a full day. However, the day of d is charge or d eath is not c o unted as a b illable day . If ad miss ion and discharge o r death occ ur o n the s ame day , the d ay is c onsidered a d ay of admission and c ounts as o ne b illable day . D. Mec hanic al Ventilation is reimbursed at a p er diem rate and is all inc lus iv e for the p atients c are; no o ther medical billing is allowed for nurs ing s ervices . E. Nurs ing Fac ilities that find, after as sessment, that a p atient req uires a s pecialized or custom wheelc hair in o rder to maxi mi ze independence, are responsible for the expens e of that specialized or c ustom wheelchair and my not b i ll s eparately or ins truc t a Durable Med ic al Provider to bill CareSource for pay ment. F. Th e reimb urs ement rat e established is an inclusive payment that cov ers the cost of the f o llowing: 1. Patients ro om and board 2. Sp ec ial d ietary needs 3. Dietary s up plements us ed for tube or oral feedings, when p res cribed by a p hysician. 4. Laund ry 5. Nurs ing and ro utine serv ic es, including the following (t his is not an exhaustiv e l is t ): nurs ing c are (ex c luding p rivate d uty nurs e), medic al s ocial serv ices, ac tiv ities p ro g ram, Physical therapy, Speec h therapy , Oc cupational therap y, s pecialized rehab ilitation s ervices, res torativ e nurs ing c are, hand feedings, ass is tance in p ers o nal c are and gro oming, nurs ing supplies, inc ontinence c are items, routine p ers o nal c are items and Ov er the Counter medic ations. G. If the p atient is b e i ng d is charged fro m the fac il i ty wi th no ex pec tation of return, a d is c harge s tatus c ode should be us ed on the c lai m f orm. 3. 4 Skilled Nurs i n g Facility Serv ic es Georgia Med i c ai d PY-0321 Las t Rev i s ed 02/01/2018H. Ap p ropriate revenue c odes must be us ed when billing p atient leav e days , whether p lanned or due to hospitalizations. Providers m ust o nl y b il l the d ays the patient is in the f acility. IV. In the case that a member will be s taying in a Nurs ing Facility for l o ng t erm c are and does no t p lan o n returning to the community, CareSource will initiate disenrollment b ack to Medicaid Fee f o r Serv ice, after 3 months . E. CONDITIONS OF COVERAGE HCP CS CP TAUTHORI ZATION PER I OD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 06/07/2017 New policy.Date Revised Date Effective 02/01/2018 Date Archived 10/31/2022 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f ormal documented Policy. H. REFERENCES1. Pro v ider Manuals, Nurs ing Facility Services . (n.d.). Retrieved May 30, 2017, from http s://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manu als /tabId/54/Default.aspxThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
© Copyright CareSource 2025. All rights reserved.
System Details