Modifier 59, XE, XP, XS, XU

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 59 , XE, XP, XS, XU B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide 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. Reimbursement modifiers are two-digit code s that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimburs ement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier ina ppropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that define when 2 Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situ ations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management ( E/M ) services, that are not usually reported together, but are appropriate under the patients specific circumstance. National Correct Coding Initiative (NCCI) guidelines state that providers should not use modifier 59 solely because 2 different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the 2 procedures/surger ies are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of service. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCSmodifiers to define specific subsets of modifier 59: XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT instructions state that m odifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review.A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59.VI. Modifier X {EPSU} (or 59 , when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available . Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 separate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. A. Modifier XS (or 59, when applicable) is for sur gical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed at different anatomic sites 2. are not ordinarily performed or encountered on the same day, and 3. cannot be described by 1 of the more specific anatomic NCCI Procedure to Procedure (PTP) -associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1 – T9, LC, LD, RC, LM, RI) B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that meet all the following: 1. are performed during different patient encounters 2. cannot be described by 1 of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91) C. Modifier XE (or 59, when applicable) may also be used when 2 timed procedures are performed during the same encounter but occur 1 after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are either 1. are performed at separate anatomic sites 2. are performed at separate patient encounters on the same date of service E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when all the following apply: 1. diagnostic procedure is the basis for performing the therapeutic procedure 2. occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires 3. provides clearly the information needed to decide whether to proceed with the therapeutic procedure 4. does not constitute a service that would have otherwise been required during the therapeutic intervention (If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately.) F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therapeutic procedure only when all the following apply: 1. diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure 2. occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires 3. does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post – procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately. Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules Modifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022Date Revised 08/02/2023 07/17/2024 07/ 16 /2025 Annual review: updated references. Approved at Committee. Review: updated references, approved at Committee Review: updated references, approved at Committee Date Effective 11/01/2025 Date Archived H. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 202 5. Accessed June 27, 2025 . www.cms.gov 2. Mechanized Claims Processing and Information Retrieval Systems; Operational, etc., Requirements, 42. U.S.C. 1396b(r) (2024). 3. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 202 4. Accessed June 27, 2025 . www.cms.gov 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated April 11, 2025 . Accessed June 27, 2025 . www.cms.gov 5. MLN1783722 – Proper Use of Modifiers 59 & -X{EPSU}. US Centers for Medicare & Medicaid Services; 202 4. June 27, 2025 . www.cms.gov 6. Transmittal R1422OTN – Publication 100-20 – MM8863 – Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014. Accessed June 27, 2025 . www.cms.gov Modifier 59, XE, XP, XS, XU-GA MCD-PY-1365Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 GA-MED-P-4248608 Issue Date 08/17/2022 Approved DCH 0 8/01/2025

Digital EEG Spike Analysis

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Digital EEG Spike Analysis-GA MCD-PY-1671 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Digital EEG Spike Analysis-GA MCD-PY-1671Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDigital EEG Spike Analysis B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide 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. Epilepsy is a chronic brain disorder that affects approximately 1.2% of the US populationor 3,700,000 people. Epileptic seizures are associated with a loss of awareness, fatigue,drowsiness, physical weakness, and confusion. Epilepsy s eizures can be triggered by stress, dehydration, alcohol, toxic exposure, hormonal changes, sleep deprivation, and visual stimulation. Epilepsy and seizures are diagnosed with a detailed medical history , blood tests, developmental, neurological, and behavioral tests, and scans and imaging techniques (eg, electroencephalography, computerized tomography, magnetic resonance imaging). Electroencephalography (EEG) is a diagnostic test that measures electrical activity in thebrain. EEG is a non-invasive procedure where small electrodes are attached to the patients scalp and the patient remains still or is instructed to perform specific tasks while brain wave patterns are recorded. Specific wave patterns are then used to help diagnos e medical conditions (eg, epilepsy), sleep disorders, evaluate brain function, and monitor brain activity. Advances in digital technology have led to software and hardware applications that expand the capability to record brain wave forms, graph out brain wave patterns, and automatically detect brain wave spikes that are indicative of abnormal brain activity. There are several approaches to EEG monitoring, with short-term and long-term optionsthat can be either inpatient or outpatient. Long-term EEG with video (video-EEG) is often used to assess patients with difficult diagnostic/management after clinical eval uation and routine EEG. This is generally an inpatient procedure through an epilepsy monitoring unit or as continuous EEG (cEEG) monitoring in the hospital or in special care units. Another option is ambulatory EEG (aEEG) , which can provide EEG recordings outside of the hospital or clinic. Long-term EEG helps to detect brain disturbances as they happen and can provide more information to adjust treatment. Abnormal EEG findings are often associated with epileptiform activity, such as epileptiform discharge. An epileptiform discharge represents a disrupt ion in brainfunction and is typically associated with spikes and sharp waves. Analy zing these spikes and sharps with the accompanying slow waves helps localize seizure onset. When combined with clinical observation, prolonged monitoring via ambulatory EEG , and the Digital EEG Spike Analysis-GA MCD-PY-1671Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 recorded clinical behavior provided by video-EEG, spike analysis helps to diagnose epilepsy and other health conditions . C. Definitions Ambulatory EEG (aEEG) Monitoring Portable recording of EEG outside of the hospital or clinic setting. Can be done with simultaneous video recording. Often uses computer software to detect seizures and interictal epileptiform discharges (IED) to aid in interpretation. Digital EEG Systems that allow for the recording, analysis, and storage of EEG data. These systems often include software tools that can detect spikes and other abnormal brain patterns and can help visualize, quantify, and interpret the data. Dipole Analysis Localization and quantification of the sources of electrical activity in the brain, which helps understand the origins of conditions such as epilepsy. Epileptiform Activity Indicates cortical hyperexcitability, which is associated with an increased risk of seizures and the presence of an epileptic network in the brain. Sharp Waves Single epileptiform discharge defined by its duration and disruption of the EEG background. Spikes Sharp, transient waveforms that are clearly distinguished from background activity and indicate abnormal electrical activity in the brain . Spikes are often associated with seizures. o Simple Spikes Short, sharp waveforms. o Spike-and-Wave Patterns A combination of spikes followed by a slower wave that are often seen in certain types of epilepsy. Video-EEG Monitoring Synchronous recording and display of EEG patterns and video-recorded behavior. Procedure can be done in the outpatient EEG laboratory, in the home, or in a hospital inpatient setting. D. PolicyI. CareSource considers digital EEG spike analysis (CPT code 95957 ) medically necessary and therefore reimbursable when performed in conjunction with EEG for topographic voltage and/or dipole analysis . This applies specifically for pre-surgical evaluation with video-EEG long-term monitoring in member s with intractable epilepsy , intracranial injuries, and concussions. II. All other indications for digital EEG spike analysis are not cov ered nor are reimbursable. III. The submitting provider is responsible for submitting accurate documentation tosubstantiate the coding of claims. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial.E. Conditions of CoverageNA Digital EEG Spike Analysis-GA MCD-PY-1671Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 06/18/2025 New policy. Approved at Committee.Date Revised Date Effective 11/01/2025 Date Archived H. References1. Baumgartner C, Pirker S. Video-EEG. Hanb Clin Neurol . 2019;160:171-183. doi:10.1016/B978-0-444-64032-1.00011-4 2. EEG, noninvasive. MCG Health, 28 th ed. Updated March 14, 2024. Accessed May 23, 2025. www.careweb.careguidelines.com 3. EEG, video monitoring. MCG Health, 28 th ed. Updated March 14, 2024. Accessed May 23, 2025. www.careweb.careguidelines.com 4. Eom TH. Electroencephalography source localization. Clin Exp Pediatr . 2022;66(5):201-209. doi:10.3345/cep.2022.00962 5. Epilepsy and seizures. National Institute of Neurological Disorders and Stroke. Accessed May 28, 2025. www.ninds.nih.gov 6. Feyissa AM, Tatum WO. Adult EEG. Handb Clin Neurol . 2019;160:103-124. doi:10.1016/B978-0-444-64032-1.00007-2 7. Guideline 8: guidelines for recording clinical EEG on digital media. American Clinical Neurophysiology Society. Accessed May 12, 2025. www.acns.org 8. Guideline 12 : guidelines for long-term monitoring for epilepsy. American Clinical Neurophysiology Society. Accessed May 23, 2025. www.acns.org 9. Haider HA, Hirsch LJ, Sutherland HW. Electroencephalography (EEG) in the diagnosis of seizures and epilepsy. UpToDate. Updated April 29, 2025. Accessed May 12, 2025. www.uptodate.com 10. Hirsch LJ, Fong MWWK, Leitinger M, et al. American Clinical Neurophysiology Societys standardized critical care EEG terminology: 2021 version. JClin Neurophysiol . 2021; 38:1-29. doi: 10.1097/WNP.0000000000000806 11. Kobau R, Luncheon C, Greenlund K. Active epilepsy prevalence among U.S. adults is 1.1% and differs by educational level National Health Interview Survey, United States, 2021. Epilepsy Behav . 2023;142:109180. doi:10.1016/j.yebeh.2023.109180 12. Moeller J, Haider HA, Hirsch LJ. Video and ambulatory EEG monitoring in the diagnosis of seizures and epilepsy. UpToDate. Updated May 6, 2025. Accessed May 23, 2025. www.uptodate.com 13. Tatum WO, Halford JJ, Olejniczak P, et al. Minimum technical requirements for performing ambulatory EEG. JClin Neurophysiol . 2022;39(6):435-440. doi:10.1097/WNP.0000000000000950 GA-MED-P-4186818 Issue date 11/ 01/2025 Approved 08/06/2025

Cosmetic and Reconstructive Services

REIMBURSEMENT POLICY STATEMENT Georgia Medicaid Policy Name & Number Date Effective Cosmetic and Reconstructive Services-GA MCD-PY-1674 11/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable r eferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Table of Contents 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 Cosmetic and Reconstructive Services-GA MCD-PY-1674 Effective Dat e: 11/01/2025 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. 2 A. SubjectCosmetic and Reconstructive ServicesB. BackgroundCosmetic treatments are services that are performed solely to alter a patient s appearance and are typically not covered by health insurance plans. There are certain procedures, however, that may be considered either cosmetic or reconstructive. Areconstructive service is differentiated from a cosmetic treatment by the patients condition and the purpose and intent of the procedure.C. DefinitionsCosmetic Procedure Is p erformed for aesthetic purposes and is not medically necessary .Reconstructive Procedures Is both medically necessary and primarily to restore or improve function or to correct deformity resulting from congenital or developmental anomaly, disease, trauma, or previous therapeutic or surgical process.D. PolicyI. Cosmetic procedures are NOT medically necessary and are NOT reimbursable .II. Reconstructive procedures are reimbursable when medical necessity is met. The following services outline general requirements for reimbursement. CareSource may request additional documentation.A. Chemical PeelsChemical peels are considered cosmetic procedures and are NOT reimbursable.B. Vascular Lesions1. Treatment is reimbursable when documentation shows significant functional impairment, such as bleeding or lesion interfering with vision, and the procedure is reasonably expected to improve the functional impairment.2. Treatment is performed to correct a significant variation from normal human anatomy due to a congenital defect.C. Dermabrasion1. Treatment for actinic keratoses, pre-malignant skin lesions, and localized non-melanoma malignant skin lesions is reimbursable .2. Treatment is considered NOT reimbursable when there is no significant functional impairment and is intended to change a physical appearance within normal human anatomic variation, such as acne scars and uneven pigmentation.D. Hair Procedures1. Permanent hair removal is reimbursable when performed for a. pilonidal cyst b. pilonidal sinus c. pilar cyst d. trichodermal cyst Cosmetic and Reconstructive Services-GA MCD-PY-1674Effective Dat e: 11/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 e. follicular disorder2. All other hair removal and h air transplantation are considered a cosmetic procedure and are NOT reimbursable. E. Laser and Surgical Treatment of Rosacea and Telangiectasia 1. Treatment for rosacea is reimbursable when: a. Rosacea is severe. b. Refractory to standard medical therapy. c. Preoperative photos document clinical skin changes requiring treatment. 2. Telangiectasia must not be isolated, including spider veins, and cause significant functional impairment to be reimbursable . 3. All other indications for laser skin resurfacing, such as acne scars and facial wrinkles, are considered NOT reimbursable and are cosmetic. F. Tattoos 1. Skin tattooing is reimbursable when performed as part of a medically necessary therapeutic treatment, such as radiation therapy. 2. Skin tattooing is reimbursable when performed as part of a covered breast reconstruction. 3. Tattoo removal or excision is NOT reimbursable and is considered cosmetic. E. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource and are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a re view of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and office staff are encouraged to use self-service channels to verify a members eligibility. Reimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes.Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource polic ies apply to both participating and nonparticipating providers and facilities. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 07/30/2025 Approved at Committee.Date Revised Date Effective 11/01/2025 Cosmetic and Reconstructive Services-GA MCD-PY-1674 Effective Dat e: 11/01/2025 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. 4 Date Archived H. References1. Aedo G, Chahun M, Gatica E, et al. Managing a burning face: clinical manifestations and therapeutic approaches for neurogenic rosacea. Int JMol Sci .2025;26(5):2366. doi: 10.3390/ijms260523662. Bennoun I. Areola and nipple reconstruction in breast cancer and other conditions.Curr Probl Dermatol . 2022;56:169-180. doi: 10.1159/0005261953. Cerrati EW, Arch M, Binetter D, et al. Surgical treatment of head and neck port-wine stains by means of a staged zonal approach. Plast Reconstr Surg .2014;134(5):1003-1012. doi: 10.1097/PRS.00000000000006294. Colletti G, Negrello S, Rozell-Shannon L, et al. Surgery for port-wine stains: a systematic review. JPerson Med . 2023;13(7):1058. doi: 10.3390/jpm130710585. Dianzani C, Conforti C, Giuffrida R, et al. Current therapies for actinic keratosis. Int JDermatol . 2020;59(6):645-759. doi: 10.1111/ijd.147676. Dingenen E, Segers D, De Mawseneer H, et al. Sturge-Weber syndrome: an update for the pediatrician. World JPediatr . 2024;20(5):435-443. doi: 10.1007/s12519-024-00809-y7. Fuchs A, Marmur E. The kinetics of skin cancer: progression of actinic keratosis to squamous cell carcinoma. Dermatol Surg . 2007;33(9):1099-1101. doi: 10.1111/j.1524-4725.2007.33224.x8. Georgia Medicaid State Plan. Updated February 24, 2025. Accessed July 30, 2025. www.medicaid.georgia.gov9. Goldstein AO. Overview of benign lesions of the skin. UpToDate. Updated April 12,2024. Accessed July 30, 2025.10. Hardy-Abeloos C, Gorovets D, Lewis A, et al. Prospective evaluation of patient-reported outcomes of invisible ink tattoos for the delivery of external beam radiation therapy: the PREFER trial. Front Oncol . 2024;14:1374258. doi: 10.3389/fonc.2024.137425811. Hua NJ, Chen J, Geng RSQ, et al. Efficacy of treatments in reducing facial erythema in rosacea: a systematic review. 2025;29(1):43-50. doi: 10.1177/1203475424128754612. Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local anesthesia in office-based dermatologic surgery. Am Acad Dermatol . 2016;74:1201-1219. doi:10.1016/j.jaad.2016.01.02213. Landeg SJ, Kirby AM, Lee SF, et al. A randomized control trial evaluating fluorescent ink versus dark ink tattoos for breast radiotherapy. Br JRadiol .2016;89(1068):20160288. doi: 10.1259/bjr.2016028814. Lee JW, Chung HY. Capillary malformations (portwine stains) of the head and neck:natural history, investigations, laser, and surgical management. Otolaryngol Clin NAm . 2018;51(1):197-211. doi:10.1016/j.otc.2017.09.00415. Lee KC, Wambier CG, Soon SL, et al. Basic chemical peeling: superficial and medium-depth peels. JAm Acad Dermatol . 2019;81(2):313-324. doi: 10.1016/j.jaad.2018.10.079 Cosmetic and Reconstructive Services-GA MCD-PY-1674 Effective Dat e: 11/01/2025 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. 5 16. Nakano LC, Cacione DG, Baptista-Silva JCC, et al. Treatment for telangiectasias and reticular veins. Cochrane Database Syst Rev . 2021;10(10): CD012723 .doi: 10.1002/14651858.CD012723.pub217. Nasser MM, Ghoneim BM, Eldaly W, et al. A comparative study between cryo-laser cryo-sclerotherapy and sclerotherapy in the treatment of telangiectasia and reticular veins: a randomized controlled trial. JVasc Surg Venous Lymphat Disord .2024;12(4):101874. doi: 10.1016/j.jvsv.202418. Patel ND, Chong AT, Kolla AM, et al. Venous malformations. Semin Intervent Radiol .2022;39(5):498-507. doi: 10.1055/s-0042-175794019. Piccolo D, Fusco I, Zingoni T, et al. Effective treatment of rosacea and other vascular lesions using intense pulsed light system emitting vasculara chromophore-specific wavelengths: a clinical and dermoscopical analysis. JClin Med . 2024;13(6):1646. doi: 10.3390/jcm1306164620. Regno LD, Catapano S, Di Stefani A, et al. A review of existing therapies for actinic keratosis: current status and future directions. Am JClin Dermatol . 2022;23:339-352. doi: 10.1007/s40257-022-00674-321. Rendon MI, Berson DS, Cohen JL, et al. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. JClinAesthet Dermatol . 2010;3(7):32-43. Accessed July 30, 2025. www.pmc.ncbi.nlm.nih.gov22. Rose L, Mallela T, Waters M, et al. Cosmetic considerations after breast cancer treatment. 2024;316(6):223. doi: 10.1007/s00403-024-02898-123. Sabeti S, Ball KL, Burkhart C, et al. Consensus statement for the management and treatment of port-wine birthmarks in Sturge-Weber syndrome. JAMA Dermatol .2021;157(1):98-104. doi: 10.1001/jamadermatol.2020.422624. Sarnoff DS. Therapeutic update on actinic keratosis. JDrugs Dermatol .2014;13(7):785. Accessed July 30, 2025. www.jddonline.com25. Thiboutot D, Anderson R, Cook-Bolden F, et al. Standard management options for rosacea: the 2019 update by the National Rosacea Society Expert Committee. JAmAcad Dermatol . 2020;82(6):1501-1510. doi: 10.1016/j.jaad.2020.01.07726. Uhlenhake EE. Optimal treatment of actinic keratoses. Clin Interv Aging . 2013;8:29-35. doi: 10.2147/CIA.S3193027. Urban MJ, Williams EF III. Vascular lesions. Facial Plas t Surg Clin NAm .2024;32(1):13-25. doi : 10.1016/j.fsc.2023.09.00328. van Zuuren EJ, Arents BWM, van der Linden MMD, et al. Rosacea: new concepts in classification and treatment. Am JClin Dermatol . 2021;22(4):457-465. doi: 10.1007/s40257-021-00595-729. Wladis EJ, Adam AP. Treatment of ocular rosacea. Surv Opthalmol . 2018;63(3):340-346. doi: 10.1016/j.survophthal.2017.07.005GA-MED-P – 4284804 07/30/2025 Approved DCH 08/19/2025

Single Dose Vial – Claims Modifiers

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name Policy Number Effective Date Single Dose Vial Claims Modifiers PY-PHARM-0104 01-01-2025 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Table of ContentsReimbursement Policy Statement …………………………………………………………………………………… 1 A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ……………………………………………………………………………………………………… 4 F. Related Policies/Rules …………………………………………………………………………………………… 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 4 Reimbursement Policy Statement: Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-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. 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. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy. Single Dose Vial Claims Modifiers Georgia Medicaid PY-PHARM-0104 Effective Date: 01-01-202 5 2 A. SubjectThis policy provides guidance for claims billing documentation and reimbursement of single dose injectable vials. 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/ICD-10 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. This policy describes documentation requirements and reimbursement guidelines for billing of the administered and discarded portion(s) of drugs and biologicals. Providers shall bill and receive reimbursement for both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manufactured and supplied only in single dose or single use format. The JW modifier is required to be reported on a claim to report the amount of drug that is discarded and eligible for payment and should be used only for claims that bill single-dose container drugs. The discarded portion of single use or single dose vials must be identified with the JW Modifier as a separate line item from the dose or administered portion. Providers may be reimbursed for the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers are required to report the JZ modifier on all claims that bill for drugs from single-dose containers when there are no discarded amounts. The JZ modifier is reported on a claim to attest that no amount of drug was discarded and should only be used for claims that bill for single-dose container drugs. Claims containing drug administered from multi-dose vials are not subject to this requirement. Under this policy, all claims for separately payable single dose format injectable drugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Single Dose Vial Claims Modifiers Georgia Medicaid PY-PHARM-0104 Effective Date: 01-01-202 5 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discarded portion of drug not administered Drug amount discarded/not administered to any patient JZ All drug administered none discarded Zero drug amount discarded/not administered to any patient C. DefinitionsModifier JW refers to the drug amount discarded (wasted)/not administered to any patient. Modifer JZrefers to zero drug amount discarded/not administered to any patient.Discarded Wastage or Unused Portion is defined as the amount of a single use/dose vial or other single use/dose package that remains after administering a dose/quantity of a drug or biological. Single Dose Vial i s defined as a vial of medication intended for administration by injection or infusion that is meant for use in a single patient for a sing le procedure. These vials are labeled as single-dose or single-vial by the manufacturer and typically do not contain a preservative. Multi-Dose Vial is defined as a vial of medication intended for administration by injection or infusion that contains more than one dose of medication. These vials are labeled as multi-dose by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria.D. Policy Modifier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modifier JW. Both details are reimbursable. CareSource will consider reimbursement for: I. A single-dose or single-use vial drug that is wasted, when Modifier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimbursement for: I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modifier is required when there are no discarded amounts of a single-dose container drug for which the JW modifier would be required if there were discarded Single Dose Vial Claims Modifiers Georgia Medicaid PY-PHARM-0104 Effective Date: 01-01-202 5 4 amounts. The JZ modifier is required to attest that there were no discarded amounts, and no JW modifier amount is reported.E. Conditions of Coverage Providers must not use the JW modifier for medications manufactured in a multi-dose vial format. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered for reimbursement must not exceed the package size of the vial used for preparation of the dose. Providers must not bill for vial contents overfill. Providers must not use the JW modifier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modifer is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modifier. 1. Claim Line #1 HCPCS code for drug administered and the amount admistered to the patient. 2. Claim Line #2 HCPCS code for drug discarded (wasted) with JW modifier appended to indicate waste and the amount discarded (wasted). The JZ Modifier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapter 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original effective dateDate Revised 08-25-2023 Updated policy to include JZ modifier. Updated policy name and references. 10-11-2024 Annual review. No changes.Date Effective 01-01-202 5Date Archived H. References1. Billing and Coding: JW and JZ Modifier Billing Guidelines Article-Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932) (cms.gov)2. New JZ Claims Modifer for Certain Medicare Part BDrugs https://www.cms.gov/files/document/mm13056-new-jz-claims-modifier-certain-medicare-part-b- drugs.pdf3. Discarded Drugs and Biologicals JW Modifier and JZ Modifier Policy FAQs. jw-modifier-faqs.pdf (cms.gov) The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.

Modifier 25

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modifier 25-GA MCD-PY-1361 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Modifier 25-GA MCD-PY-1361Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifier 25 B. BackgroundReimbursement policies are designed to assist physicians when submitting claims to CareSource and are routinely updated to promote accurate coding and provide 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. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-character code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifier 25 is used to report an Evaluation andManagement (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CP T) book defines modifier 25 as a 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. There must be documentation that substantiates the use of mo difier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a medically necessary,significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies th e relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to rep ort an E/M service that resulted in a decision to perform surgery. See modifier 57 for a surgical decision . For significant, separately identifiable non-E/M services, see modifier 59. Although CareSource accepts the use of modifiers, their use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. CareSource uses published guidelines from Modifier 25-GA MCD-PY-1361Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly. C. Definitions American Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT ) Codes that are issue d, updated, and maintained by the AMA that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier A 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 25 may be flagged for either a prepayment clinical validation or prepayment medical record coding review .A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims s ubmission, this will also result in a claims denial.IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. VI. Appending modifier 25 to an E/M service is considered inappropriate in the followingcircumstances:Modifier 25-GA MCD-PY-1361Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post – operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preve ntative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation. J. CareSource will not reimburse CPT 99211 when billed with modifier 25. E. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy app lies to bothparticipating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract withCareSource, the providers contract will be the governing document.F. Related Policies/RulesModifiers G. Review/Revision HistoryDATE ACTIONDate Issued 08/17/2022 New PolicyDate Revised 08/02/2023 07/17/2024 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Modifier 25-GA MCD-PY-1361Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 06/04 /2025 Review: added 99211 statement, updated references,approved at Committe e. Date Effective 09/01/2025 Date Archived H. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed May 13, 2025 . www.ama.assn.org 2. Appropriate use of Modifier 25. American College of Cardiology. Accessed May 13, 2025 . www.acc.org 3. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed May 13, 2025 . www.aapc.com 4. Chapter 1 General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services . Centers for Medicare and Medicaid Services; 202 5. Accessed May 13, 2025 . www.cms.gov 5. Felger TA, Felger M. Understanding when to use modifier -25. Fam Pract Manag. 2004;11(9):21-22. Accessed May 13, 2025 . www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 202 5. Accessed May 13, 2025 . www.cms.gov GA-MED-P-4051450 Issue Date 08/17/2022 Approved DCH 07/14/2025

Neonatal Intensive Care Unit (NICU) Level of Care

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 10/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, 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 no t limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 6 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of Care B. BackgroundThis policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification.The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of care that a newborn with specified diagnoses and symptoms require. All four levels of care are represented by a uniquerevenue code . Any inpatient revenue codes not billed as levels 2-4 will be recognized as level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions , such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy are not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Intensity of Care (IOC) The complexity of care that a newborn with specified diagnoses and symptoms require s. Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Newborn CareServices Services performed from birth to 4 weeks. Neonatal Intensive Care Services (NICU) Critical care services for a newborn. Well Baby Care Services A basic level of care to neonates who are low risk. D. PolicyI. Per federal mandate, newborn members are covered at an inpatient facility for a 2 – day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with revenue codes 0170/0171 and a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174) , authorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to submit documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn require s a NICU admission or a higher IOC service, anauthorization is required.IV. If a complication develops with the mother or baby that necessitates additionalhospital days, NICU admission, or non-well-baby service, an authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed during transitional time.VI. Clinical review will determine appropriate IOC utilizing MCG standards. Care Source will adjust IOC reimbursement if clinical documentation does not support the IOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria , as well as CareSource policy.VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to reference MCG guidelines as well as the clarifications and specific details below . Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 NICU LevelRevenue Code Description MCG NICU Intensity of Care Level 1 0171: Newborn Level I Intensity of Care Criteria 1 Routine Care ( LOC-010 ) Neonatal care may be indicated for the p hysiologically stable infant (eg, no apnea, bradycardia, or unstable temperature) requiring care consisting of 1 or more of the following: Routine newborn care Evaluation and care of neonates with conditions that require inpatient services available at Level I Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues (eg , sustained weight gain, poor PO feeding ), or establishment of safe discharge destination and plan Uncomplicated jaundice treated only with phototherapy and requiring infrequent bilirubin checks Absence of parenteral medications Evaluation and management of glucose levels without IV fluids , d iagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level IIIntensity of Care Criteria 2 Continuing Care (LOC-011 )Neonatal care may be indicated for 1 or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen ( 2L/min), with other co – morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation ( 2 L/minute of blended oxygen , continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation ( NIPPV ) o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes Umbilical arterial catheter (UAC) for blood draws Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia requiring > 5 mg/kg/min of IV treatment or hypoglycemia not responsive to 1 IV dextrose bolus (200 mg/kg or 2 ml/kg of D10W ) Total parenteral nutrition or IV fluids to supplement inadequate oral intake (NG or PO) > 50% total nutrition NAS requiring initiation/escalation of medication or inability to wean Hyperbilirubinemia with evidence of hemolysis requiring IVIG or blood transfusion Acute encephalopathy that is moderate to severe and under active investigation or has been investigated and does not meet criteria for therapeutic hypothermia Surgical conditions requiring general anesthesia up to 2 days post-op , if indicated Surgical/Therapies for retinopathy of prematurity (ROP) Seizure activity requiring initiation, supplementation , or changing of seizure medications Transfusion of blood products in absence of severe acute etiology or manifestations (eg, transfusion needed for anemia of prematurity, iatrogenic anemia) Hypotension requiring IV fluid bolus Level 4 0174: Newborn Level IV Intensity of Care Criteria 4 Intensive Care (LOC-013 ) Includes Level 3 requirements and 1 or more of the following: Perioperative care following surgical repair of severe neonatal conditions, for example: o bowel resection for necrotizing enterocolitis (NEC) o tracheoesophageal fistula or esophageal atresia repair o cardiac surgery excluding PDA ligation o myelomeningocele closure (up to 48 hours post-op) o organ transplant Medically necessary inhaled nitric oxide (iNO) Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.6 Extracorporeal membrane oxygenation (ECMO) High frequency oscillatory or jet ventilation (initial week) Therapeutic cooling Exchange transfusion (day of procedure) Uncontrolled active seizures despite medications Ongoing cardiovascular support (inotropes, chronotropes, antiarrhythmics) Severe hemodynamic instability requiring ongoing IV fluid/medication support o dialysis o IV sedation that includes paralysis o prostaglandin infusion CPR in the last 24 hours (not inclusive of delivery room resuscitation) Transfusion of blood products in setting of severe acute etiology or manifestation (eg, hemolytic anemia, disseminated intravascular coagulation, hemorrhage) E. Conditions of CoverageI. Reimbursement is independent of the location of care and corresponds to the medical treatment provided and level of service the neonate requires. To ensure accurate reimbursement, submitted claims will be reviewed to align with authorized levels of care and/or clinically validate diagnoses, procedures , and other claim information that impact payment. Based on review, the following may occur: Down-code revenue codes to authorized levels of care Issue a base DRG payment Adjust claim diagnoses/procedures that are not substantiated in the medical information provided and apply DRG regrouping, A request for complete medical records and/or itemized statements to support the services on the claim may be made II. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 03/12/2025 New policy. Approved at Committee.Date Revised Date Effective 10/01/2025 Date Archived H. References1. About preterm labor and birth. National Institutes of Health (NIH). Reviewed May 9, 2023. Accessed January 30, 2025 . www.nichd.nih.gov Neonatal Intensive Care Unit (NICU) Level of Care-GA MCD-PY-1431 Effective Dat e: 10/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.7 2. Admission to NICU. Specification Manual for Joint Commission National QualityMeasures . The Joint Commission; 2024. Version 2024B1. www.manual.jointcommission.org 3. Intensity of Care Criteria 1 – Routine Care. LOC-010 (ISC GRG). MCG Health. 2 8th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 4. Intensity of Care Criteria 2 – Continuing Care. LOC-011 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 5. Intensity of Care Criteria 3 – Intermediate Care. LOC-012 (ISC GRG). MCG Health. 28th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 6. Intensity of Care Criteria 4 – Intensive Care. LOC-013 (ISC GRG). MCG Health. 2 8th ed. Accessed January 30, 2025 . www.careweb.careguidelines.com 7. Stark AR, Pursley DM, Papile L, et al. Standards for levels of neonatal care: II, III, and IV. Pediatrics . 2023;151(6):e2023061957. doi:10.1542/peds.2023-061957 GA-MED-P-3769851 Issue Date 03/12/2025 Approved DCH 07/02/2025

Influenza Testing

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Influenza Testing-GA MCD-PY-1543 10/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Influenza Testing-GA MCD-PY-1543Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectInfluenza Testing B. BackgroundInfluenza (flu) is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs. Rapid influenza diagnostic tests (RIDTs) are immunoassays that identify the presence of influenza A and Bviral nucleoprotein antigens in respiratory specimens and display the result in a qualitative way (positive vs. negative) . The best way to reduce the risk of flu and potentially serious complications is by getting vaccinated each year. Having clinical signs and symptoms consistent with influenza increases, which increases the reliability of a positive RIDT result. A positive result is most likely a true positive result if the respiratory specimen was collected within 3-4 days of illness during periods of high influenza activity (eg , winter). A n egative result of RIDTs do not exclude influenza virus infection and influenza should still be considered in a patient if clinical suspicion is high based upon history, signs, symptoms and clinical examination. C. Definitions Influenza (Flu) Season The time in which influenza spikes in the population, typically starting in October and peaking between December and February, although significant activity can last as late as May. Rapid Influenza Diagnostic Tests (RIDTs) Testing that detect s the parts of the virus (antigens) that stimulate an immune response. These tests can provide results within approximately 10-15 minutes. D. PolicyI. CareSource considers conventional testing, such as rapid influenza diagnostic tests (RIDTs) , as lowe st cost and should be utilized before any further testing or higher cost tests are performed . II. Influenza can cause mild to severe illness and , at times , can lead to death. Flu symptoms usually come on suddenly. P atients who have flu often feel some or all of these signs and symptoms: fever of 100.4 or higher feeling feverish/chills cough sore throat runny or stuffy nose muscle or body aches headaches fatigue (tiredness) vomiting and diarrhea (more common in children ) Influenza Testing-GA MCD-PY-1543Effective Dat e: 10/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 A. RIDT CPT code must be billed first when testing for influenza : 87804 – Infectious agent antigen detection by immunoassay with direct optical observation; influenza VI. If conventional testing is:A. Positive no further testing is medically necessary. B. Negative if the members presenting symptoms support the diagnosis, then molecular diagnostic test (MDT) may be medically necessary to confirm the diagnosis. VII. CareSource may request documentation to support medical necessity .B. Only 1 RIDT per member per day is reimbursable. C. Only 1 MDT per member per day is reimbursable if medically necessary. C. Duplicate tests will not be reimbursed. VIII. Documentation must support medical necessity, and testing during or outside of the defined influenza season may result in recoupment if documentation does not support medical necessity.E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 09/25/2024 New policyDate Revised 03 /12 /2025 Revision. Removed flu season timeframe. VII. Clarified duplicate testing. Added documentation language and updated references. Approved at Committee. Date Effective 10/ 01/2025 Date Archived H. References1. Diagnosis for flu. Centers for Disease Control. October 3, 2022. Accessed January 24, 2025. www.cdc.gov 2. Flu season. Centers for Disease Control. Updated October 28,2024. Accessed January 24, 2025. www.cdc.gov 3. Rapid influenza diagnostic tests. Centers for Disease Control. Updated September 17, 2024. Accessed January 24, 2025. www.cdc.gov GA-MED-P-3769851 Issue Date 09/2 5/202 4 Approved DCH 07/02/2025

Urinalysis and Evaluation and Management Services

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Urinalysis and Evaluation and Management Services-GA MCD-PY-1605 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 2 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Urinalysis and Evaluation and Management Services-GA MCD-PY-1605Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectUrinalysis and Evaluation and Management Services B. BackgroundThis policy provides guidance when billing urinalysis laboratory tests in conjunction with Evaluation and Management (E/M) services, on the same day, for the same member, by the same provider. Urinalysis laboratory tests are used to evaluate health and diagnose medical conditions using the physical, chemical, and microscopic properties of an individuals urine sample. The urine sample is visually examined for color, clarity, and odor. A dipstick is used to examine the chemical properties of the urine sample for its pH, specific gravity, prot ein, glucose, ketones, bilirubin, urobilinogen, nitrites, and leukocyte esterase. A microscopic exam of urine measures the presence of red blood cells, white blood cells, epithelial cells, casts, crystals, and bacteria. The results of a urinalysis can help assess kidney function, monitor diabetes mellitus (DM) status, evaluate liver disease, for routine health screening, or alert the health care provider to the possible presence of a urinary tract infection (UTI), proteinuria, or hematuria. C. Definitions Evaluation and Management ( E/M) Service An interaction with a patient that involves a health care professional evaluating or managing a patients health, which may include office and other outpatient services, hospital inpatient services, consultations, ER visits, nursing facility services, a nd home care services. Outpatient Visit Physicians private office or group practice where members can be evaluated and treated by their provider. Routine Procedures Common procedure (eg, diagnostic test or screen) that is performed in connection with another procedure (eg, collection of a clean-catch urine sample or a throat swab) or is included in a treatment protocol for which a composite payment amount has been esta blished (eg, specific laboratory test performed for an individual receiving dialysis). D. PolicyI. Urinalysis tests (81002, 81003) are considered routine procedures when performed during an E/M visit in the outpatient setting. When urinalysis tests are conducted in conjunction with an E/M service on the same day, for the same member, by the same provide r, the provider will not be reimbursed for the urinalysis tests. Only the E/M service will be reimbursed. II. CareSource does not reimburse providers for the collection and forwarding of urinalysis tests (81002, 81003) when those tests are performed by independent or public laboratories. E. Conditions of CoverageNA Urinalysis and Evaluation and Management Services-GA MCD-PY-1605Effective Dat e: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 05/07/2025 New policy. Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived H. References1. Part II Policies and procedures for diagnostic screening and preventive services. Georgia Department of Community Health. Updated April 1, 2025. Accessed April 7, 2025. www.mmis.georgia.gov 2. Part II Policies and procedures for physician services. Georgia Department of Community Health. Updated April 1, 2025. Accessed April 7, 2025. www.mmis.georgia.gov GA-MED-P-3973709 Issue Date 05/07/2025 Approved DCH 6/18/2025

Modifiers

REIMBURSEMENT POLICY STATEMENTGeorgia Medicaid Policy Name & Number Date Effective Modifiers-GA MCD-PY-1353 09/ 01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. …………….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………….. ……… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. ………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. ……………….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ………………… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………………. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………………. 3 H. References ………………………….. ………………………….. ………………………….. ………………………….. ………. 3 Modifiers-GA MCD-PY-1353Effective Date: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement modifiers are two-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both CPT and HCPCS manuals. Use of a modifier does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure. To indicate that a procedure was performed on the left side, right side, or bilaterally. To report multiple procedures performed during the same session by the same health care provider. To indicate multiple health care professionals participated in the procedure. To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of anymodifier through post-payment audit. Inappropriate use of a modifier can result in a claim denial or incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes , used along with a CPT or HCPCS code , to provide additional information about the service or supply rendered. D. PolicyIt is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided according to the following industry standard guidelines (may not be all-inclusive): National Correct Coding Initiative (NCCI) editing guidelines American Medical Association (AMA) guidelines American Hospital Association (AHA) billing rules Current Procedural Terminology (CPT) Modifiers-GA MCD-PY-1353Effective Date: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Healthcare Common Procedure Coding System (HCPCS) ICD-10 CM and PCS National Drug Codes (NDC) Diagnosis Related Group (DRG) guidelines CCI table edits. The inclusion of a code in a policy does not imply any right to reimbursement or guarantee claims payment. E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting Georgia Medicaid approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual Georgia Medicaid fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSource policies applyto both participating and nonparticipating providers and facilities.In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.F. Related Policies/Rules NA G. Review/Revision HistoryDATE ACTIONDate Issued 01/20/2022 New PolicyDate Revised 10/12/2022 09/27/2023 05/07/2025 No changes. Update references. Updated references. Approved at Committee. Periodic review. Updated background and references. Approved at Committee. Date Effective 09/01/2025 Date Archived H. References1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS). US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed March 26, 2025. www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed March 26, 2025. www.ama-assn.org 3. Medicare Claims Processing Manual, XII: Physicians/Nonphysician Practitioners. US Centers for Medicare and Medicaid Services. Issued December 19, 2024. Accessed March 26, 2025. www.cms.gov Modifiers-GA MCD-PY-1353Effective Date: 09/01/2025The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers. US Centers for Medicare and Medicaid Services. March 24, 2023. Accessed March 26, 2025. www. cms .govGA-MED-P-3973709 issue date 01/20/2022 Approved DCH 6/18/2025

Facility Charges for Hospital-Based Outpatient Clinics

REIMBURSEMENT POLICY STATEMENTMedicaid Policy Name & Number Date Effective Facility Charges for Hospital-Based Outpatient Clinics – GA MCD-PY-1619 09/01/2025 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, 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 con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Facility Charges for Hospital-Based Outpatient Clinics-GA MCD-PY-1619 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectFacility Charges for Hospital-Based Outpatient Clinics B. BackgroundThis policy outlines the guidelines for facility charges associated with services provided in hospital-based outpatient clinics. Patients receiving care in these settings may notice a facility charge on their bill , which is distinct from the fees for the specific procedures or treatments. These charges are typically billed using a UB-04 institutional claim form. C. Definitions CMS-1500 A standard claim form that professional providers and medical billing professionals use to bill insurance companies for health care services. Facility Charges A charge that is part of the overhead cost of a hospital, which supports the location and other services the hospital must provide and are not directly related to the care a patient receives. Also known as a facility fee. Hospital-Based Outpatient Clinics An outpatient facility that may or may not be on the hospital grounds, is operating under the ownership or administrative control of the hospital and offers the same or similar services as the hospital. Network Provider Healthcare professionals in good standing who have successfully passed a CareSource credentialing or recredentialing program. Participation Agreement An agreement between a health plan and providers or hospitals, which includes terms, such as information about compensation, billing, payment, network participation, provider licensing and insurance, provider credentialing, maintenance of records, termi nation, and state contracting and filing requirements. Health plans compensate providers for covered services rendered to members and compensate hospitals through facility charges under the terms of the agreement. Revenue Code A 4-digit number that is used on hospital bills to inform insurance companies either where the patient was when they received treatment, or what type of item a patient may have received as a patient. UB-04 Claim f orm used by hospitals and other providers to bill for institutional services. A valid procedure code must accompany a revenue code for it to be accepted by the insurance provider. D. PolicyI. CareSource does not provide reimbursement for facility charges associated with clinic services rendered by a network provider for any hospital-based outpatient clinics when billed using the UB-04 form. Specifically, facility charges billed with revenue cod e 510 are not reimbursed, as these charges are not considered covered services under the health plan participation agreements. II. CareSource will only reimburse for clinic services provided for a member that are rendered on the same day in which the treatment is rendered at the hospital-basedoutpatient clinic when billed on a CMS-1500 professional claim form.Facility Charges for Hospital-Based Outpatient Clinics-GA MCD-PY-1619 Effective Dat e: 09/01/2025 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 III. Hospitals are prohibited from seek ing reimbursement for facility charges at hospital-based outpatient clinics from CareSource, CareSource members, or CareSource subsidiaries when billed using revenue code 510. E. State-Specific InformationNA F. Conditions of CoverageReimbursement policies are designed to assist providers when submitting claims to CareSource. These policies are routinely updated to promote accurate coding and policy clarification. There 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 o ffice staff are encouraged to use self-service channels to verify members eligibility. Reimbursement id dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individu al fee schedule for appropriate codes. The following list of revenue codes are provided as a reference and are not reimbursable.Revenue Code Description0510 General G. Related Policies/RulesN/A H. Review/Revision HistoryDATE ACTIONDate Issued 04/23/2025 New polic y. Approved at Committee.Date Revised Date Effective 09/01/2025 Date Archived I. References1. Brocks J. Health plan network provider agreement essentials. LexisNexis. Published April 20, 2019. Accessed April 8 , 202 5. www.lexisnexis.com 2. Facility fees and how they affect health care prices. Health Care Cost Institute. Accessed April 8, 202 5. www.healthcostinstitute.org 3. Professional paper claim form (CMS-1500). Centers for Medicare & Medicaid Services. Accessed April 8 , 202 5. www.cms.gov 4. What is outpatient facility coding and reimbursement. AAPC. Reviewed January 27, 2025. Accessed April 8, 2025. www.aapc.com GA-MED-P-3973709 issue date 04/23/2025 Approved DCH 6/18/2025

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