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

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

Drug Testing

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

Readmission

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

Avastin for use in Ophthalmology Billing Guideline

REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Policy Name Policy Number Effective Date Avastin for use in Ophthalmology Billing Guideline PY-0734 08/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Avastin for use in Ophthalmology Billing Guideline GEORGIA MEDICAID PY-0734 Effective Date: 08/01/2019 2 A. Subject Avastin for use in Ophthalmology Billing Guideline B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Avastin is a drug used in the treatment of wet age-related macular degeneration, diabetic eye disease and other problems of the retina. Avastin is injected into the eye and helps to slow down disease related vision loss. The use of Avastin to treat eye disease is considered off-label, which is allowed by the FDA when doctors are well informed regarding the drug and there are studies that prove its an effective treatment option. There is no cure for macular degeneration, treatment is aimed at slowing down the progression of the disease and preventing vision loss. C. Definitions Macular Degeneration a progressive vision impairment resulting from deterioration of the central part of the retina, known as macula. D. Policy I. CareSource does not require a Prior Authorization for the use of Avastin in Ophthalmology, when billed with the following codes: A. J3490 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. B. J3590 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. E. Conditions of Coverage HCPCS J3490, J3590 NDC 50242-0061-01 or 50242-0060-01: F. Related Policies/Rules N/A Avastin for use in Ophthalmology Billing Guideline GEORGIA MEDICAID PY-0734 Effective Date: 08/01/2019 3 G. Review/Revision History DATE ACTION Date Issued 06/01/2019 New policy Date Revised Date Effective 08/01/2019 H. References 1. Boyd, K. (2018, May 22). What Is Avastin? Retrieved October 29, 2018, from https://www.aao.org/eye-health/drugs/avastin 2. “Off-Label” and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices-Information Sheet. (2018, July 12). Retrieved October 29, 2018, from https://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0669 DCH Approved: 05/08/2019

Medical Drug Reimbursement Rates

REIMBURSEMENT POLICY STATEMENTGEORGIA MEDICAID Policy Name Policy Number Effective Date Medical Drug Reimbursement Rates PY-0796 08/01/2019-12/3 1/2022 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Stat ement ………………………….. ………………………….. ……………………….. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. ……………………. 2 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ….. 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 2 G. Review/Revision History ………………………….. ………………………….. ………………………….. …. 2 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 3 Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherencet o plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly for the convenience of the member or provid er. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict betw eenthis Policy and the plan contr act (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SubjectMedical Drug Reimbursement Rates Med ical Drug Reimbursemen t Rates GEORGIA MEDICAIDPY-0796 Effective Date: 08/01/2019 B. BackgroundReim bursem ent policies are designed to assist you when subm itting claim s to CareSource. They are routinely updated to prom ote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of paym ent. Reim bursement f or claim s m ay be subject to lim itations and/or qualif ications. Reim bursem ent will be established based upon a review of the actual services provided to a m em ber and will be determined when the claim is received f or processing. Health care providers and their of f ice staf f are encourag ed to use self-service channels to verif y m em bers eligibility. It is the responsibility of the subm itting provider to subm it the m ost accurate and appropriateCPT/HCPCS code(s) f or the product or service that is being provided. The inclus ion of a code in this policy does not im ply any right to reim bursem ent or guarantee claim s paym ent. C. Def initions Average Wholesale Price (AWP) – is the m anuf acturer’s list price of the drug when sold to the wholesaler. Average Sales Price (ASP) a rate that is calculated by the m anuf acture on a quarterly basis and subm itted to Medicare. Medicare then places these rates in a f ile and uploads to the Medicare Part BDrug Average Sales Price Drug Pricing Files tab on cm s.gov. D. PolicyI. This is a reim bursem ent policy that outlines reim bursem ent rates f or drugs that are billed and adm inistered in the f ollowing places of service under the m em bers m edical benef it only when drug reim bursem ent rates are not specif ically called out in the provider contr act or the drug code is not listed on the Georgia Medicaid Fee Schedule: A. Place of Service 11 Of f ice 1. Medicares ASP (Average Sales Price) plus 6% B. Place of Service 12 Hom e 1. Manuf actures AWP (Average Wholesale Price) m inus 15% C. Place of Service 22 On Cam pus-Outpatient Hospital 1. Manuf actures AWP (Average Wholesale Price) m inus 15% E. Conditions of CoverageReim bursem ent is dependent on, but not lim ited to, subm itting Georgia Medicaid approved HCPCS and CPT codes along with appropriate m odif iers. Please ref er to the individual Georgia Medicaid f ee schedule f or appropriate codes. F. Related Policies/RulesG. Review/Revision HistoryDATE ACTIONDate Issued 06/01/20193 Med ical Drug Reimbursemen t Rates GEORGIA MEDICAIDPY-0796 Effective Date: 08/01/2019 Date Revised Date Effective 8/01/2019 Date Archived 12/3 1/2022 This Po licy is no lo nger active and has been archived . Please no te that there could be o ther Po licies that may have some of the same rules inco rp orated and CareSource reserves the rig ht to f ollow CMS/State/NCCI g uidelines without a f o rmal documented P olicy H. Ref erencesThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. GA-P-0705 DCH Approved: 04/30/2019

Provider Home Visits

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

Drug Testing

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

Smoking & Tobacco Cessation

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

Breast Imaging

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.

Screening and Surveillance for Colorectal Cancer

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

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