REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Influenza Virus Infection PY-0893 11/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Molecular Diagnostic Testing for Influenza Virus Infection INDIANA MARKETPLACE PLANS PY-0893 Effective Date: 11/01/2019 2 A. Subject Molecular Diagnostic Testing for Influenza Virus Infection B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Molecular diagnostic testing for Influenza Virus can detect influenza viral RNA or nucleic acids in respiratory specimens with high sensitivity and specificity. The detection of influenza viral RNA or nucleic acids is not necessarily indicative of a viable or ongoing influenza viral replication. In cases where there is known active influenza virus and the clinical picture of the patient shows signs and symptoms of the influenza virus, molecular diagnostic testing is not needed. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy when the following criteria are met: Molecular Diagnostic Testing for Influenza Virus Infection INDIANA MARKETPLACE PLANS PY-0893 Effective Date: 11/01/2019 3 A. Conventional testing, such as a nasal swab has been performed with a negative result on the same date of service as the requested molecular diagnostic test, AND; B. The member presents with cardinal influenza virus infection symptoms to include but not limited to: 1. Fever over 100.4 F 2. Aching muscles 3. Chills and sweats 4. Headache 5. Dry, persistent cough 6. Fatigue and weakness 7. Nasal congestion 8. Sore throat II. CareSource considers Molecular Diagnostic Testing by PCR for Influenza Virus Infection appropriate as the first line testing only when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage in this policy. III. Conventional testing, such as nasal swabs and nasopharyngeal swabs, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types ICD-10 Code Description J09.X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia J10.08 Influenza due to other identified influenza virus with other specified pneumonia J10.1 Influenza due to other identified influenza virus with other respiratory manifestations Molecular Diagnostic Testing for Influenza Virus Infection INDIANA MARKETPLACE PLANS PY-0893 Effective Date: 11/01/2019 4 J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to other identified influenza virus with myocarditis J10.83 Influenza due to other identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations J11.81 Influenza due to unidentified influenza virus with encephalopathy J11.82 Influenza due to unidentified influenza virus with myocarditis J11.83 Influenza due to unidentified influenza virus with otitis media J11.89 Influenza due to unidentified influenza virus with other manifestations O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 11/01/2019 New Policy Date Revised Date Effective 11/01/2019 Date Archived H. References 1. Information on Rapid Molecular Assays, RT-PCR, and other Molecular Assays for Diagnosis of Influenza Virus Infection | Seasonal Influenza (Flu) | CDC. (2019, March 4). Retrieved 7/29/19 from www.cdc.gov/flu/professionals/diagnosis/molecular-assays.htm. 2. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 3. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Respiratory Virus PY-0883 11/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 5 G. Review/Revision History ……………………………………………………………………………………….. 5 H. References …………………………………………………………………………………………………………. 5 Molecular Diagnostic Testing for Respiratory Virus INDIANA MARKETPLACE PLANS PY-0883 Effective Date: 11/01/2019 2 A. Subject Molecular Diagnostic Testing for Respiratory Virus B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Molecular Diagnostic testing for the respiratory viruses known as Adenovirus, Influenza Virus, Coronavirus, Metapneumovirus, Parainfluenza Virus, Respiratory Syncytial Virus (RSV) and Rhinovirus can be utilized in the presence of symptoms such as cough, fever, headache, fatigue, rhinorrhea, pharyngitis and a general unwell feeling, that would create a clinical picture of a respiratory virus. Molecular Diagnostic testing for respiratory viruses is not indicated for every patient that presents with these signs and symptoms, as treatment is generally the same for all of the viruses and resolve with little to no pharmacological treatment, except in immunocompromised patients. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Molecular Diagnostic Testing for Respiratory Virus INDIANA MARKETPLACE PLANS PY-0883 Effective Date: 11/01/2019 3 D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy. II. CareSource considers Molecular Diagnostic Testing by PCR for Respiratory Virus medically necessary when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage in this policy. III. CareSource does not consider Molecular Diagnostic Testing by PCR for Respiratory Virus to be medically necessary when billed with any other ICD-10 diagnosis code and will not provide reimbursement for those services. IV. Conventional testing, such as rapid antigen direct tests, direct fluorescent antibody testing and cultures, are viewed as low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87631 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87632 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87633 Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets ICD-10 Code Description B30.2 Viral pharyngoconjunctivitis B34.0 Adenovirus infection, unspecified B34.2 Coronavirus infection, unspecified B97.0 Adenovirus as the cause of diseases classified elsewhere B97.21 SARS-associated coronavirus as the cause of diseases classified elsewhere B97.29 Other coronavirus as the cause of diseases classified elsewhere B97.4 Respiratory syncytial virus as the cause of diseases classified elsewhere B97.81 Human metapneumovirus as the cause of diseases classified elsewhere Molecular Diagnostic Testing for Respiratory Virus INDIANA MARKETPLACE PLANS PY-0883 Effective Date: 11/01/2019 4 B97.89 Other viral agents as the cause of diseases classified elsewhere J00 Acute nasopharyngitis [common cold] J05.0 Acute obstructive laryngitis [croup] J06.9 Acute upper respiratory infection, unspecified J09.X1 Influenza due to identified novel influenza A virus with pneumonia J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations J09.X3 Influenza due to identified novel influenza A virus with gastrointestinal manifestations J09.X9 Influenza due to identified novel influenza A virus with other manifestations J10.00 Influenza due to other identified influenza virus with unspecified type of pneumonia J10.01 Influenza due to other identified influenza virus with the same other identified influenza virus pneumonia J10.08 Influenza due to other identified influenza virus with other specified pneumonia J10.1 Influenza due to other identified influenza virus with other respiratory manifestations J10.2 Influenza due to other identified influenza virus with gastrointestinal manifestations J10.81 Influenza due to other identified influenza virus with encephalopathy J10.82 Influenza due to unidentified influenza virus with myocarditis J10.83 Influenza due to other identified influenza virus with otitis media J10.89 Influenza due to other identified influenza virus with other manifestations J11.00 Influenza due to unidentified influenza virus with unspecified type of pneumonia J11.08 Influenza due to unidentified influenza virus with specified pneumonia J11.1 Influenza due to unidentified influenza virus with other respiratory manifestations J11.2 Influenza due to unidentified influenza virus with gastrointestinal manifestations J11.81 Influenza due to unidentified influenza virus with encephalopathy J11.82 Influenza due to unidentified influenza virus with myocarditis J11.83 Influenza due to unidentified influenza virus with otitis media J11.89 Influenza due to unidentified influenza virus with other manifestations J12.0 Adenoviral pneumonia J12.1 Respiratory syncytial virus pneumonia J12.2 Parainfluenza virus pneumonia J12.3 Human metapneumovirus pneumonia J12.81 Pneumonia due to SARS-associated coronavirus J12.9 Viral pneumonia, unspecified J20.4 Acute bronchitis due to parainfluenza virus J20.5 Acute bronchitis due to respiratory syncytial virus J20.6 Acute bronchitis due to rhinovirus J20.9 Acute Bronchitis, unspecified J21.0 Acute bronchiolitis due to respiratory syncytial virus J21.9 Acute bronchiolitis, unspecified O98.511 Other viral diseases complicating pregnancy, first trimester Molecular Diagnostic Testing for Respiratory Virus INDIANA MARKETPLACE PLANS PY-0883 Effective Date: 11/01/2019 5 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 11/01/2019 New Policy Date Revised Date Effective 11/01/2019 Date Archived H. References 1. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip. 2. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. 3. NREVSS | Home | National Respiratory and Enteric Virus Surv System | CDC. (2019, July 24). Retrieved 7/29/19 from https://www.cdc.gov/surveillance/nrevss/index.html. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Molecular Diagnostic Testing for Streptococcus A and BInfection PY-0871 11/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 3 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Molecular Diagnostic Testing for Streptococcus A and BInfection INDIANA MARKETPLACE PLANS PY-0871 Effective Date: 11/01/2019 2 A. Subject Molecular Diagnostic Testing for Streptococcus A and BInfection B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Molecular testing, following a diagnosis or suspected diagnosis can help guide appropriate therapy by identifying specific therapeutic targets and appropriate pharmaceutical interventions. Molecular diagnostic testing utilizes Polymerase Chain Reaction (PCR), a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. Illnesses caused by Streptococcus A include Pharyngitis (strep throat), Scarlet Fever, Acute Rheumatic Fever and Post Streptococcal Glomerulonephritis. Illnesses caused by Streptococcus Binclude Bacteremia, Sepsis, Pneumonia, skin and soft tissue infections, bone and joint infections, meningitis (although this is a rare occurrence in adults). Screening for Streptococcus Bshould be done between 35 and 37 weeks in every pregnant women, as it is most commonly passed to newborns during the birthing process. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. CareSource may periodically require review of a providers office testing policies and procedures when performing CLIA-waived tests. C. Definitions Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT). Medically Necessary-Health care services or supplies needed to diagnosis or treat an illness, injury, condition, disease or its symptoms and that meet the accepted standards of medicine. Molecular Diagnostic Testing for Streptococcus A and BInfection INDIANA MARKETPLACE PLANS PY-0871 Effective Date: 11/01/2019 3 D. Policy I. No Prior Authorization is required for the Molecular Diagnostic Testing by PCR addressed in this policy when the following criteria are met: A. Conventional testing, such as the rapid strep test (throat culture), has been performed with a negative result on the same date of service as the requested molecular diagnostic test, AND; B. The member presents with cardinal streptococcus A and/or Bsymptoms to include but not limited to: 1. red, swollen tonsils 2. white or yellow coating or patches on the tonsils 3. sore throat 4. difficult or painful swallowing 5. fever 6. bad breath 7. stiff neck 8. enlarged, tender glands (lymph nodes) in the neck II. CareSource considers Molecular Diagnostic Testing by PCR for Streptococcus A and Streptococcus Binfection appropriate as the first line of testing only when submitted with any combination of the CPT and ICD-10 diagnosis codes listed in the Conditions of Coverage in this policy. III. Conventional testing, such as the rapid strep test (throat culture) for Streptococcus A; cultures of sterile body fluids and/ or vaginal and rectal cultures in pregnant women for Streptococcus B, are viewed as effective, low cost and should be utilized before the higher cost Molecular Diagnostic Testing by PCR. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 87651 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 87653 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique ICD-10 Code Description A38.0 Scarlet fever with otitis media A38.1 Scarlet fever with myocarditis A38.8 Scarlet fever with other complications A38.9 Scarlet fever, uncomplicated A40.0 Sepsis due to streptococcus, group A A40.1 Sepsis due to streptococcus, group BA40.3 Sepsis due to Streptococcus pneumoniae A40.8 Other streptococcal sepsis A40.9 Streptococcal sepsis, unspecified A41.9 Sepsis, unspecified organism Molecular Diagnostic Testing for Streptococcus A and BInfection INDIANA MARKETPLACE PLANS PY-0871 Effective Date: 11/01/2019 4 B95.0 Streptococcus, group A, as the cause of diseases classified elsewhere B95.1 Streptococcus, group B, as the cause of diseases classified elsewhere G00.2 Streptococcal meningitis I00 Rheumatic fever without heart involvement I01.0 Acute rheumatic pericarditis I01.1 Acute rheumatic endocarditis I01.2 Acute rheumatic myocarditis I01.8 Other acute rheumatic heart disease I01.9 Acute rheumatic heart disease, unspecified J02.0 Streptococcal pharyngitis J03.00 Acute streptococcal tonsillitis, unspecified J03.01 Acute recurrent streptococcal tonsillitis J13 Pneumonia due to Streptococcus pneumoniae J15.3 Pneumonia due to streptococcus, group BJ15.4 Pneumonia due to other streptococci J20.2 Acute bronchitis due to streptococcus M72.6 Necrotizing fasciitis N00.9 Acute nephritic syndrome with unspecified morphologic changes O99.511 Diseases of the respiratory system complicating pregnancy, first trimester O99.512 Diseases of the respiratory system complicating pregnancy, second trimester O99.513 Diseases of the respiratory system complicating pregnancy, third trimester O99.519 Diseases of the respiratory system complicating pregnancy, unspecified trimester O99.52 Diseases of the respiratory system complicating childbirth O99.53 Diseases of the respiratory system complicating the puerperium O99.820 Streptococcus Bcarrier state complicating pregnancy O99.824 Streptococcus Bcarrier state complicating childbirth O99.825 Streptococcus Bcarrier state complicating the puerperium P23.3 Congenital pneumonia due to streptococcus, group BP36.0 Sepsis of newborn due to streptococcus, group BZ05.1 Observation and evaluation of newborn for suspected infectious condition ruled out Z22.330 Carrier of Group Bstreptococcus F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 11/01/2019 New Policy Date Revised Date Effective 11/01/2019 Date Archived H. References 1. Group BStrep | GBS | Home | Streptococcus | CDC. (2019, June 25). Retrieved 7/29/19 from www.cdc.gov/groupbstrep. 2. Group A Strep | Home | Group A Streptococcus | GAS | CDC. (2018, November 1). Retrieved 7/29/19 from www.cdc.gov/groupAstrep. 3. License Agreement. (2019, January 15). Retrieved 7/29/19 from https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Downloads/19CLABQ1.zip.Molecular Diagnostic Testing for Streptococcus A and BInfection INDIANA MARKETPLACE PLANS PY-0871 Effective Date: 11/01/2019 5 4. Medically Necessary. (2019, July 29). Retrieved 7/29/19 from https://www.healthcare.gov/glossary/medically-necessary/. The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Vaccinations and Immunizations PY-0 413 09/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 6 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 6 H. References ………………………….. ………………………….. ………………………….. ……………………. 6 Archived Vaccinations and Immunizations INDIANA MARKETPLACE PLANS PY-0 413 Effective Date: 09/01/2019 2 A. Subject Vaccinations and Immunizations 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 sta ff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclus ion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. CareSource covers and rei mburses for vaccinations/immunizations based on the recommendations from the Centers for Disease Control and Prevention (CDC ) and the Advisory Committee on Immunization Practices (ACIP). The Vaccines for Children (VFC) program is a federally funded program that provides vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay. The Centers for Disease Control and Prevention ( CDC ) purchases vaccines at a discount and distributes them to state health departments which in turn distribute them at no charge to those private physicians offices and public health clinics registered as VFC provider s. The Vaccines for Children (VFC) p rogram helps provide vaccines to children whose parents or guardians may not be able to afford them. Th e VFC program helps ensure that children have a better chance of getting their recommended vaccinations on schedule . Vaccines available through the VFC p rogram are those recommended by the Advisory Committee on Immunization Practices (ACIP). C. Definitions Immunity-is protection from an infectious disease. Immunization-i s an inoculation against a vaccine preventable disease. Modifier-a reporting indicator used in conjunction with a CPT code to denote that a medical service or procedure that has been performed has been altered by a specific circumstance while remaining unchanged in its definition or CPT code. Program registered provider-a health care provider that is a licensed or otherwise authorized to administer pediatric vaccines and is enrolled in the Vaccines for Children Program (VFC). Recipient-a person age eighteen (18) or under who has been determined el igible to receive benefits. Vaccination-the act of introducing a vaccine into the body to produce immunity to a specific disease. Vaccine-a product that stimulates a persons immune system to produce immunity to a specific disease, protecting the pers on from that disease. Vaccines are usually administered through needle injections, but can also be administered by mouth or sprayed into the nose. Vaccines for Children Program (VFC) – the program for distribution of pediatric vaccines administered by the Department for Public Health. Archived Vaccinations and Immunizations INDIANA MARKETPLACE PLANS PY-0 413 Effective Date: 09/01/2019 3 D. Policy I. Vaccinations and Immunizations for CareSource members 18 years old or younger. A. Providers that participate in the VFC p rogram that administer vaccines: 1. CareSource may reimburse for the administration of a pediatric vaccine to a CareSource member 18 years old or younger . 2. CareSource may reimburse for the administration of a Flu vaccine to a CareSource member of any age. Note: Providers participat ing in the VFC program must use modifier SL on the claim line for the vaccine. Modifier SL indicates that the vaccine is state supplied vaccine and will not be reimbursed by CareSource. B. Providers that do not participate in the VFC program that ad minister vaccines. 1. If a provider is not a participating provider of the VFC program, they may submit a claim for both the administration and the vaccine for reimbursement. 2. Modifier SL is not used in this case, and CareSource may reimburse for bo th the administration and the vaccine. 3. CareSource may reimburse for the cost of a vaccine administration, to a CareSource member 18 years old or younger, in addition to administration of the vaccine. II. Vaccinations and Immunizations for CareSource members 19 years old or older. A. Adults do not qualify for the VFC program. B. CareSource may reimburse for vaccinations according to the CDC adult vaccination/immunization schedule. C. Provider may be reimbursed for the vaccine and administ ration provided to CareSource members. D. CareSource may reimburse for the administration of a Flu vaccine to a CareSource member of any age. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting The Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers , if applicable . Please refer to the individual CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered 90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) +90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) Archived Vaccinations and Immunizations INDIANA MARKETPLACE PLANS PY-0 413 Effective Date: 09/01/2019 4 +90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 90476 Adenovirus vaccine, type 4, live, for oral us e 90477 Adenovirus vaccine, type 7, live, for oral use 90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use 90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2 dose schedule, for intramuscular use 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use 90632 Hepatitis A vaccine (HepA), adult dosage, for intramuscular use 90633 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for intramuscular use 90634 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular use 90636 Hepatitis A and hepatitis Bvaccine (HepA-HepB), adult dosage, for intramuscular use 90644 Meningococcal conjugate vaccine, serogroups C & Yand Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use 90647 Haemophilus influenzae type b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, f or intramuscular use 90648 Haemophilus influenzae type b vaccine (Hib), PRP-Tconjugate, 4 dose schedule, for intramuscular use 90649 Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, for intramuscular use 90650 Human Papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use 90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use 90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use 90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for intradermal use 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use 90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use 90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use 90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use 90660 Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use 90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use 90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use 90666 Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use Archived Vaccinations and Immunizations INDIANA MARKETPLACE PLANS PY-0 413 Effective Date: 09/01/2019 5 90667 Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for intramuscular use 90668 Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use 90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use 90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use 90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use 90675 Rabies vaccine, for intramuscular use 90676 Rabies vaccine, for intradermal use 90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use 90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use 90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use 90685 Influenza virus vaccine, quadriva lent (IIV4), split virus, preservative free, 0.25 mL, for intramuscular use 90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use 90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use 90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use 90689 Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative fre e, 0.25 mL dosage, for intramuscular use 90690 Typhoid vaccine, live, oral 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use 90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use 90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatit is Bvaccine (DTaP-IPV-Hib-HepB), for intramuscular use 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use 90702 Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for intramuscular use 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use 90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use 9 0714 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 yea rs or older, for intramuscular use 90716 Varicella virus vaccine (VAR), live, for subcutaneous use Archived Vaccinations and Immunizations INDIANA MARKETPLACE PLANS PY-0 413 Effective Date: 09/01/2019 6 90717 Yellow fever vaccine, live, for subcutaneous use 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use 90732 Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use 90733 Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use 90734 Meningococcal conjugate vaccine, serogroups A, C, Yand W-135, quadrivalent (MCV4 or MenACW Y), for intramuscular use 90736 Zoster (shingles) vaccine (HZV), live, for subcutaneous injection 90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use 90739 Hepatitis Bvaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740 Hepatitis Bvaccine ( HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use 90743 Hepatitis Bvaccine (HepB), adolescent, 2 dose schedule, for intramuscular use 90744 Hepatitis Bvaccine (HepB), pediatric/adolescent dosage, 3 dose schedule , for intramuscular use 90746 Hepatitis Bvaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use 90747 Hepatitis Bvaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use 90748 Hepatitis Band Haemophilus influenzae type b vaccine (Hib-HepB), for intramuscular use 90749 Unlisted vaccine/toxoid 90750 Zoster (shingles) vaccine (HZV), recombinant, subunit, adjuvanted, for intramuscular use 90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use Modifier Description SL State supplied vaccine F. Related Policies/Rules G. Review/Revision History DATE ACTION Date Issued 0 9 / 0 1 /2019 New policy Date Revised Date Effective 09/01/2019 H. References 1. Adult Immunization Schedule by Vaccine and Age Group | CDC. (2019, February 5). Retrieved May 13, 2019, from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html 2. Birth-18 Years Immunization Schedule | CDC. (2019, February 5). Retrieved May 13, 2019, from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html 3. EncoderProForPayers. (2019). Retrieved May 13, 2019 from https://www.encoderprofp.com/epro4payers/ Archived Vaccinations and Immunizations INDIANA MARKETPLACE PLANS PY-0 413 Effective Date: 09/01/2019 7 4. Physician Fee Schedule Search. (2019, April 5). Retrieved May 13, 2019 from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE Policy Name Policy Number Date Effective Drug Test ing PY-0329 8/ 1/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health c are services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a bod y 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 neces sary 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 Cov erage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2D. POLICY ………………………….. ………………………….. ………………………….. …………….. 3 E. CONDITIONS OF COVERA GE ………………………….. ………………………….. …………. 5 F. RELATED POLICIES/RUL ES ………………………….. ………………………….. …………… 7 G. REVIEW/REVISION HIST ORY ………………………….. ………………………….. …………. 7 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 7 Archived Drug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 2 A. Subject Drug Testing B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for pro cessing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the pr oduct or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Drug testing is a part of medical care during the initial assessment, ongoing monitoring, and recovery phase for members with substance use disorder (SUD); for members who are at risk for abuse/misuse of drugs; or for other medical conditions. The drug test guides a provider in diagnosing and planning the members care when prescription medications or illegal drugs are of concern. Urine is the most common specimen to monitor drug use. There are two main types of urine drug testing (UDT): presumptive /qualitative and confirmatory /quantitative . Drug testing is sometimes also referred to as toxicology testing. C. Definitions Presumptive /Qualitative test-The testing of a substance or mixture to determine its chemical constituents, also known as qualitative testing. Confirmatory /Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as quantitative or definitive testing. Random drug test-A lab oratory drug test administered at a n ir regular interval that is not known in advance by the member. Independent laboratory-A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Participating/non-participating-Participating means in-network and contracted with CareSource. Non-participating, means out-of-network, not contracted with CareSourc e. Residential services-Per the Evidence of Coverage these health care services can include individual and group psychotherapy, family counseling, nursing services, and pharmacological therapy in a 24 hour community. NOTE : Clinical guidelines, definitions, standards, and scenarios for drug testing are outlined in detail within the CareSource Drug Testing Medical Policy, MM-0130 . Please refer to this policy for in-depth information on medical necessity ArchivedDrug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 3 for drug testing, d ocumentation requirements , and CareSource monitoring and review of drug testing claims. D. Policy I. General Criteria for Coverage A. Documentation must support medical necessity. B. Documentation must include the I CD-10 code demonstrating appropriate indication for UDT. C. The submitted CPT/HCPCS code must accurately describe the service performed. D. CareSource requires that the ordering providers name appear in the appropriate lines of the claims forms. II. Prior Authorization (PA) A. CareSource will consider all prior authorization requests when they are medically necessary to the members treatment and care. 1. CareSource will require a PA for confirmatory UDT greater than 14 drug classes (Codes G0482 & G0483) when number of tests exceed 4 per member per 12 month benefit year. These higher number drug panels are rarely indicated for routine urine drug testing as lower number panels are sufficient for modifying treatment plans in the majority of cases. 2. PA is required for any non-particip ating provider with CareSource for non-emergency room setting . 3. PA is required for any non-participating lab/ facility with CareSource for non-emergency room setting. 4. PA is not required in an emergency room setting . UDT utilization will be monitored by CareSource. 5. PA needs to make a clear case for medical necessity for the level of testing being requested . B. Providers and laboratories will need to ensure specimen integrity appropriate for the stability of the drug agent being tested until the PA process i s complete i.e. freezing specimen. C. Must submit appropriate clinical documentation with PA request to determine appropriate medical necessity. D. If needed, the licensed practitioner that is operating in his/her scope of practice must obtain the prior authoriz ation. III. Quantity Limitations A. CareSource will cover up to 4 confirmatory UDT greater than 14 drug classes (Codes G0482 & G0483) per member per 12 month benefit year B. When individual analytes are ordered, CareSource allows for a maximum of 7 analytes CPT codes per date of service and it will count as one urine drug test. C. Benefit is limited to 25 urine drug test per year which includes 1. A combination of individual analytes and multi-class drug tests AND 2. Both presumptive and confirmatory tests D. Each panel of multi-class CPT code is counted as one test Archived Drug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 4 IV. Laboratory A. CareSource laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which include s services ordered by that provider, but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. V. Non-Urine Testing A. CareSource will reimburse blood testing in e mergency room settings . B. Drug testing with blood samples performed in any other setting outside of an e mergency room is a non-covered benefit. C. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered VI. Confirmatory Testing A. Routine multi-drug confirmatory testing is not billable and will not be reimbursed by CareSource . B. Confirmatory testing must be individualized for the member and medically necessary. Routine confirmatory drug tests with negative presumptive results are not covered by CareSource. C. Confirmatory testing is billable when documentation supports 1. How the test results will guide plan of care i.e. modification of treatment plan, consultation with specialist AND ONE of the following: a. Presumptive testing was negative for prescription medications AND provider was expecting the test to be positive for p rescribed medication AND member reports taking medication as prescribed OR b. Presumptive testing was positive for prescription drug with abuse potential that was not prescribed by provider AND the member disputes the presumptive testing results OR c. Presumptive testing was positive for illegal drug AND the member disputes the presumptive testing results OR d. A substance or metabolite is needed to be identified that cannot be identified by presumptive testing . (e.g. semi-synthetic and synthetic opioids, certain benzodiazepines). VII. Non-Billable Drug Testing A. Testing that is not individualized such as 1. Reflexive testing. 2. Routine orders. 3. Standard orders. 4. Preprinted orders. 5. Requesting a broad spectrum of tests that a machine is capable of doing solely because a result may be positive. 6. Large arbitrary panels. 7. Universal testing. 8. Conduct additional testing as needed. B. Testing re quired by third parties such as 1. Testing ordered by a court or other medico-legal purpose such as child custody. Archived Drug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 5 2. Testing for pre-employment or random testing that is a requirement of employment. 3. Physicians health programs (recovery for physicians, dentists, veterinarians, pharmacists, etc.). 4. School entry or testing for athletics. 5. Testing required for military service. 6. Testing required by any th ird party. 7. Testing in residential facility, partial hospital, or sober living as a condition to remain in that community. 8. Testing with another pay source that is primary such as a county, state or federal agency. 9. Testing for marriage license. 10. Forensic. 11. Testing for other admin purposes. 12. Routine physical/medical examination. C. Testing for validity of specimen It is included in the payment for the test and will not be reimbursed separately. D. Blood drug testing when completed outside of the emergency room. E. Hair , saliva, or other body fluid testing for controlled substance monitoring. F. Any type of drug testing not addressed in this policy. G. Routine nonspecific or wholesale orders including routine drug panels. H. Routine use of confirmatory testing following a negati ve presumptive expected result. I. Custom Profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or conduct additional testing as needed orders. J. A confirmatory test prior to discussing results of presumptive test with membe r. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis , subsequent medical review audits , recovery of overpayments identified, and provider prepay review . E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Indiana Marketplace approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes . Please refer to the CMS fee schedule . The following list(s) of cod es is provided as a refe rence. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Codes Qualitative/Presumptive Tests-Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of serv ice Archived Drug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 6 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Codes Quantitative/Confirmatory Tests-Description G0480 Drug Test definitive/Quantitative 1-7 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC /MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral dr ift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug Test definitive/Quantitative 8-14 drug classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding i mmunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, pe r day; 8-14 drug class(es), including metabolite(s) if performed G0482 Drug testing definitive/Quantitative 15-21 classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structu ral isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehy drogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed G0483 Drug testing definitive/Quantitative 22+ classes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limit ed to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass sp ectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed ArchivedDrug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 7 G0659 Drug testing definitive/Quantitative non-specified number of drug classes Drug tes t(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase), performed without method or drug-specific calibration, without matrix-matched quality control material, or without use of stab le isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes 80320 alcohols 80321 alcohol biomarkers 1 or 2 80322 alcohol biomarkers 3 or more 80323 alkaloids, not otherwise specified 80324 amphetamines 1 or 2 80325 amphetamines 3 or 4 80326 amphetamines 5 or more 80327 anabolic steroids, 1 or 2 80328 anabolic steroid, 3 or more 80332 antidepressants, serotonergic class 1 or 2 80333 antidepressants, serotonergic class 3-5 80334 antidepressants, serotonergic class 6 or more 80335 antidepressants, tricyclic and other cyclicals 1 or 2 80336 antidepressants, tricyclic and other cyclicals 3-5 80337 antidepressants, tricyclic and other cyclicals 6 or more 80338 antidepressants not otherwise specified 80339 antiepileptic, not otherwise specified 1-3 80340 antiepileptic, not otherwise specified 4-6 80341 antiepileptic, not otherwise specified 7 or more 80342 antipsychotics, not otherwise specified 1-3 80343 antipsychotics, not otherwise specified 4-6 80344 antipsychotics, not otherwise specified 7 or more 80345 barbiturates 80346 benzodiazepines, 1-12 80347 benzodiazepines, 13 or more 80348 buprenorphine 80349 cannabinoids, natural 80350 cannabinoids, synthetic 1-3 80351 cannabinoids, synthetic 4-6 80352 cannabinoids, synthetic 7 or more 80353 cocaine 80354 fentanyl 80355 gabapentin, non-blood 80356 heroin metabolite 80357 ketamine and norketamine 80358 methadone 80359 MDA, MDEA, MDMA 80360 methylphenidate 80361 opiates, 1 or more 80362 opioids and opiate analogs, 1 or 2 80363 opioids and opiate analogs, 3 or 4 80364 opioids and opiate analogs, 5 or more 80365 oxycodone Archived Drug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 8 80366 pregabalin 80368 sedative hypnotics (non benzodiazepines) 80369 skeletal muscle relaxants 1 or 2 80370 skeletal muscle relaxants 3 or more 80371 stimulants, synthetic 80372 tapentadol 80373 tramadol 80374 stereoisomer (enantiomer) analysis, single drug class 80375 drug, or substance definitive, quali ta tive or quanti ta tive, not otherwise specified 1-3 80376 drug, or substance definitive, quali ta tive or quanti ta tive, not otherwise specified 4-6 80377 drug, or substance definitive, quali ta tive or quanti ta tive, not otherwise specified 7 or more 83992 phencyclidine (PCP) F. RELATED POLICIES/RULES CareSource Drug Testing Medical Policy MM-0130 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/1/2017 Date Revised 11/29/2017 2/16/2018 5/1/2019 Date Effective 8 /1/2019 Updated clinical indications, quantity limits , and PA requirements H. REFERENCES 1. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye. (2016). Review and recommendations for drug testing in substance use treatment contexts. Journal of Reward Deficiency Syndrome and Addiction Science . Retrieved on 12/11 /20iction Science18 from https://blumsrewarddeficiencysyndrome.com/ets/articles/v1n1/jrdsas-025-adi-jaffe.pdf 2. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik. (2016) Counselors clinical use of definitive drug testing results in their work with substance-use patients: A qualitative study. International Journal of Mental Health and Addiction. Retrieved on 12/13/2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710647/pdf/11469_2015_Article_9569.pdf 3. American Society of Addict ion Medicine (Revised 2010). Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in other Clinical Settings. Retrieved on 12/11/2018 from https://www.asam.org/docs/default-source/public-policy-statemen ts/1drug-testing — clinical-10-10.pdf?sfvrsn=1b11ac97_0#search=”urine drug testing 4. Jarvis, M, Williams, J, Hurford, M, Lindsay, D, Lincoln, P, Giles, L, Luongo, P, Safarian, T. (2017) Journal of Addiction Medicine . Retrieved on 12/13/2018 from https://journals.lww.com/journaladdictionmedicine/Fulltext/2017/06000/Appropriate_Use_of_Drug_Testing_in_Clinical.1.aspx 5. Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR. Re commendations and Reports Retrieved on 12/11/2018 from http://dx.doi.org/10.15585/mmwr.rr6501e1 6. eCFR Code of Federal Regulations. (n.d.). Retrieved on 12/11/2018 from https://www.ecfr.gov/cgi-Archived Drug Testing INDIANA MARKETPLACE PY-032 9 Effective Date: 8 /1/2019 9 bin/retrieveECFR?gp=3&SID=7282616ac574225f795d5849935efc45&ty= HTML&h=L&n=pt42.1.8&r=PART#se42.1.8_12 7. CareSource Evidence of Coverage and Health Insurance Contract. (201 9 ). Retrie ve d on 4/29/2019 from https://www.caresource.com/in/plans/marketplace/plan-documents/ 8. Owen, G, Burton, A, Schade, C, Passik, S. (2012) Urine Drug Testing: Current Recommendations and Best Practices. Pain Physician Journal . Retrieved 12/13/2018 from http://www.painphysicianjournal.com/current/pdf?article=MTcxMA%3D%3D&journal=68 9. U.S. Departm ent of Veterans Affairs (2014) Pain Management Opioid Safety VA Educational Guide. Retrieved on 12/11/2018 from https://www.va.gov/PAINMANAGEMENT/docs/OSI_1_Tookit_Provider_AD_Educational_Gui de_7_17.pdf 10. Washington State Interagency Guideline on Opioid Dos ing for Chronic Non-cancer Pain. (2017) Retrieved on 12/11/2018 from https://kbml.ky.gov/prescribing-substance-abuse/Documents/Resources%20SAWashington%20State%20Interagency%20Guideline%20on%20Opioid%20Dosing%20for%20Chronic%20Non-Cancer%20Pain%20Urine%20D rug%20Testing%20Guidance.pdf The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Reimbursement Modifiers PY-0 7 1 3 0 8 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding method ology, regulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibil ity on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidity, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenience of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modif y this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. …….. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……… 10 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……….. 10 G. Review/Revision History ………………………….. ………………………….. ………………………….. …….. 10 H. References ………………………….. ………………………….. ………………………….. ……………………….. 1 0 Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 2 A. Subject Re imburse me nt Modifie rs 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 w ill 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 ac curate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Modifiers can be used to further describe a produc t or service rendered. Some modifiers are for informational purposes only , while other modifiers are used to report additional information, to the code description, of the product or service. Although CareSource accepts the use of modifiers specific to th is policy, not all modifiers are included within this policy. The modifiers included within this policy are those modifiers that affect the reimbursement of a service. Using a modifier inappropriately can result in the denial of a claim or an incorrect r eimbursement for a product or service. CareSource may verify the use of any modifier through post-payment audit. All information regarding the use of these modifiers must be made available upon CareSources request. In the e ve nt of a ny conflict be tw e e n this policy a nd a provide rs contra ct w ith Ca re Source , the provide rs contra ct w ill be the gove rning docume nt. C. Definitions Curre nt Proce dura l Te rminology (CPT) – codes that are issued, updated and maintained by the American Medical Association (AMA) tha t provides a standard language for coding and billing medical services and procedures. He a lthca re Common Proce dure Coding Syste m (HCPCS) – codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard lang uage for coding and billing of products, supplies, and services not included in the CPT codes. Modifie r-t wo-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. D. Policy I. Modifi e r 22-Increased Procedural Services A. Modifier 22 is used to report services (surgical or nonsurgical) when the work required to provide a service is substantially greater than typically required. The extra work may be identified by appending modifier 22 to the usual procedure code. B. Procedure codes with modifier 22 appended ma y be reimbursed up to 120% of the fee schedule amount. Note : This modifier is not appended to E/M services (99201-99499). Claims for 99201-99499 with modifier 22 will be denied. Medical records ARE required with the ArchivedReim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 3 claim and must support the use of this modifier. Claims with procedures including 22 and no supporting documentation will be denied . II. Modifie r 50-Bilateral Procedures A. Professional Claims Only A ppend modifier 50 to the appropriate unilateral code on a single claim line and indicate 1 unit in the unit field of that claim line. B. Modifier 50 applies to surgical procedures (CPT codes 10040-69990 ) and to radiology proce dures performed bilaterally. C. Applies to any bilateral procedure performed on both sides at the same session . D. The use of modifier 50 is NOT appropriate in the following situations: 1. Using modifier 50 on a bilateral procedure performed on different areas of the right and left sides of the body. 2. Appending modifier 50 to a procedure code that is defined by CPT as primarily bilateral or a bilateral service. 3. Appending modifier 50 to a surgical CPT code, the description of which contains the words one or both. E. Do not report two line items to indicate a bilateral procedure. F. Procedure code with modifier 50 appended will reimburse 1 unit at 150% of the fee schedule amount. III. Modifie r 51-Multiple Procedures A. Modifier 51 is used to report multiple procedures, other than E/M services, are performed at the same session by the same individual, the primary procedure or service is reported as listed. B. The additional procedure(s) or service(s) may be identi fied by appending modifier 51 to the additional procedure or service code(s). C. Modifier 51 should not be appended to des ignated “add-on” codes. D . Procedure code with modifier 51 appended will reimburse 50% of the fee listed on the Medicaid Physician Fee Schedule for the service. IV . Modifie r 52-Reduced services A. Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. 1. Mo difier 52 is used for reporting reduced services when the procedure was terminated a fte r the patient was prepped and brought to the room where the service was to be performed. B. Modifier 52 may be used to report reduced radiology procedures. 1. The correct reporting is to assign the CPT code to the extent of the procedure performed. 2. This modifier is used only to report a radiology procedure that has been reduced when no other code exists to report what has been done. 3. Report the intended code with modifier 52. i. Example, if the planned procedure is a two-view chest x-ray and only one view of the chest is performed, do not report CPT code 71020-52 (for x-ray chest, two views-reduced service). Instead, report CPT code 71010 (x-ray chest, single view). ii. Example, i f a barium swallow is not completed because the patient cannot handle the barium, report CPT code ( 74270-52) . C. Modifier 52 does not provide for reimbursement of an ineligible service. D. For hospital outpatient reporting of a previously scheduled p rocedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74. E. Procedure code with modifier 52 appended will reimburse at 50% of the fee schedule amount. Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 4 Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier. The extenuating circumstances preventing the completion of the procedure must also be documented V. Modifie r 53-Discontinued Procedure A . Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. 1. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedur e was started but discontinued a fte r anesthesia is administered to the patient. 2. Modifier 53 is used to indicate that the physician terminated a surgical/diagnostic procedure due to the patients well-bein g. B. This modifier is not used to report an elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. C. Modifier 53 ca nnot be used when a laparoscopic or endoscopic procedure is converted to an open procedure. D. Modifier 53 doe s not provide for reimbursement of an ineligible service. E. Modifier 53 ca nnot be appended to E/M codes. F. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or a fter administration of anesthesia, see modifiers 73 and 74. G. Procedure code with modifier 53 appended will reimburse at 25% of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources re quest. Clinical information documented in the patient’s records must support to use of this modifier. Documentation must include a statement indicating at what point the procedure was discontinued. The extenuating circumstances preventing the completion of the procedure must also be documented . VI . Modifie r 54-Surgical Care Only A. Modifier 54 is reported when one physician performed a surgical procedure only; another physician provides the preoperative and/or postoperative management. B. Modifier 54 must only be appended to the surgical procedure code. C. Procedure code with modifier 54 appended will reimbursed at 70% of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s reco rds must support to use of this modifier. VI I. Modifie r 55-Postoperative Management Only A. Modifier 55 is reported w hen 1 physician or other qualified health care professio nal performed the postoperative management and another performed the surgical procedure, the postoperative component may be identified by appending modifier 55 to the procedure code. B. Modifiers 55 must only be appended to the surgical procedure code. C. Procedure code with modifier 55 appended will reimburse at 15% of the fee schedule amount. Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 5 Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patien t’s reco rds must support to use of this modifier. VI II. Modifie r 56-Preoperative Management Only A. Modifier 56 is reported when 1 physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the s urgic al c ode. B. Modifiers 56 must only be appended to the surgical procedure code. C. Procedure code with modifier 56 appended will reimburse at 15% of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s reco rds must support to use of this modifier. I X . Modifie r 62-Two Surgeons A. Modifier 62 is reported when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure. 1. Each surgeon must report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as lo ng as both surgeons continue to work together as primary surgeons. 2. Each surgeon must report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported without the modifier 62 added. 3. If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) w ith the modifier 80 or 82 added, as appropriate. B. Procedure code with modifier 62 appended will be reimbursed at 6 2.5 % of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s reco rds must support to use of this modifier. X. Modifie r 66-Surgical Team A. Modifier 66 is reported when three or more surgeons work together during a highly complex procedure are carried out under the “surgical team” concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure code used for reporting services. B. Claims submitted by team surgeons are identified with modifier 66. C. The Centers for Medicare & Medicaid Services (CMS) established a Team Surgery Indicator (TEAM SURG) found in the CMS National Physician Fee Schedule Relative Value File. Values are: 1. 0-Team surgeons not permitted for this procedure. 2. 1-Team surgeons may be paid; supporting documentation is required to establish medical necessity. 3. 2-Team surgeons permitted. 4. 9-Team surgeon concept does not apply. D. Codes with CMS Team Surgery Indicators of 0 and 9 should not be billed with modifier 66. E. Modifier 66 should not be used if a surgeon acts as an assistant surgeon on a separate procedure not included in the team surgery. Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 6 F. Only one surgeon maybe be considered the primary surgeon. CareSource will n ot reimburse procedures when two surgeons each bill one side of bilateral surgery as the primary surgeon. G. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. H. Procedure code with modifier 66 appended will reimburse at 150% of the established fee, divided equally between the team surgeons. I. For team surgery with three surgeons, each surgeon will be reimbursed at 50% of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s reco rds must support to use of this modifier. XI . Modifie r 73-Discontinued Outpatient Hospital/Ambulator y Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia A. Modifier 73 is reported to a service to indicate that due to extenuating circumstances or those that threaten the well-being of the patient, a surgical or diagnostic procedure at an outpatient hospital or ambulatory surgical center (ASC) was discontinued prior to the administrat ion of anesthesia. B. Modifier 73 is only appropriate for use by an ASC. C. Modifier 53 should not be used for any ASC service as the modifier is used exclusively on a professional claim. D. Procedure code with Modifier 73 appended will reimburse a t 50% of the ASCs fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient’s reco rds must support to use of this modifier. XI I. Modifie r 74-Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Afte r Administration of Anesthesia A . Modifier 74 is reported when d ue to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure a fte r the administration of anesthesia or after the procedure was started (incision made, intubation started, scope inserted.) B. Modifier 74 is not appropriate for the elective cancellation or postponement of a procedure based on the physician or patients choice. C. Modifier 74 is not appropriate when the termination of the procedure occurs prior to the beginning of the procedure or the administration of anesthesia. D . Modifier 74 is not for physician use. It is only appropriate for the ASC. E. Procedure code with modifier 74 appended will be reimburs ed at 10 0% of the fee schedule amount. Note : Medical records are not required with the claim, but must be availa ble upon CareSources request. Clinical information documented in the patient’s reco rds must support to use of this modifier. XI I I. Modifie r 78-Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period A. Modifier 78 is reported to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure fol lowing initial procedure). Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 7 1. When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. 2. Modifier 78 should be appended when: i. The return to the operating room is unplanned. ii. The service is performed by same physician who performed the initial procedure. iii. The service is related to the initial procedure. iv. The service is performed during the postoperative period of the initial proce dure (10-90 days) B. Procedure code with modifier 78 appended will be reimbursed at 70% of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information do cumented in the patient’s records must support to use of this modifier. XI V . Modifie r 80-Assistant Surgeon A. Modifier 80 is reported to indicate surgical assistant services by a physician and is applied to the surgical procedure code(s). B. Assistant Surgeon provides full assistance to the primary surgeon and is capable of taking over the surgery should the primary surgeon become incapacitated. C. Modifier 80 will not be accepted from non-physicians. Modifier AS should be used. D . Procedure code with modifier 80 a ppended will be reimburs ed at 16 % of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's rec ords must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. If there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XV. Modifie r 81-Minimum Assistant Surgeon A. Modifier 8 1 is reported to indicate m inimum surgical assistant services and is applied to the surgical procedure code(s). B. Minimum Assistant Surgeon is a n assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon. C. Modifier 81 will not be acce pted from non-physicians. Modifier AS should be used. D. Procedure code with modifier 81 a ppended will be reimburs ed at 16 % of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support to use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. I f there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XV I . Modifie r 82-Assistant Surgeon (when qualified resident surgeon not available) A. Modifier 82 is reported to indicate when surgical assistance is needed, but a qualified resident was not available. B. Modifier 82 is u sed primarily in teaching hospitals to indicat e that a qualified resident surgeon is unavailable . Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 8 C. The unavailability of a qualified resident surgeon is a prerequisite for the use of this modifier. The assistant must provide documentation (certification) stating that a qualified resident was not a vailable for this procedure and why the resident was not available. D. Procedure code with modifier 82 a ppended will be reimburs ed at 16 % of the fee schedule amount. Note : Medical records are not required with the claim, but must be available upon Ca reSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery and why a qualified resi dent was not available. I f there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XV I I . Modifie r AA-Anesthesia services performed personally by an anesthesiologist A . Modifier AA is used to report when the anesthesia services are personally performed by an Anesthesiologist. B. Procedure code with modifier AA appended will be reimbursed at 100% of the fee schedule amount. XV I II. Modifie r AD-Anesthesia services supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. A . Modifier AD is used to report when the anesthesia services are supervised by an anesthesiologist: more than 4 concurrent anesthesia procedures. B. Procedure code with modifier AD appended will be reimbursed at 100% of the fee schedule amount. XI X . Modifie r QK-Medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. A . Modifier QK is used to repor t when medical direction of 2, 3 or 4 concurrent anesthesia services involving qualified individuals. B. Procedure code with modifier QK appended will be reimbursed at 50% of the fee schedule amount. XX. Modifie r QX-Anesthesia services performed by a CRNA with medical direction by an anesthesiologist. A . Modifier QX is used to report when the anesthesia services are performed by a CRNA with medical direction by an anesthesiologist. B. Procedure code with mo difier QX appended will be reimbursed at 50% of the fee schedule amount. XX I . Modifie r QY-Anesthesia services when an Anesthesiologist medically directs one CRNA. A . Modifier QY is used to report when an Anesthesiologist medically directs one CRNA. B. Procedure code with modifier QY appended will be reimbursed at 50% of the fee schedule amount. XX I I. Modifie r QZ-Anesthesia services performed personally by a CRNA without m edical direction by a physician. A . Modifier QZ is used to report when the anesthesia services are personally performed by a CRNA . B. Procedure code with modifier QZ appended will be reimbursed at 100% of the fee schedule amount. XXI I I. Modifie r AE-Registered dietician A . Modifier AE is reported to indicate when a registered dietician provides the service. Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 9 B. Procedure code with modifier AE appended will be reimbursed at 85% of the fee schedule amount. XXIV . Modifie r AS-Physician Assistant (PA) , Nurse Practitioner (NP) or Certified Nurse Specialist (CNS) served as the assistant at surgery. A . Modifier AS must only be used if the PA, NP or CNS was acting as a surgical assistant in place of another surgeon. B . Procedure code with modifier AS appended will be reimbursed at 16 % of the base code allowable schedule before multiple surgery reductions are taken. No multiple surgery reductions will be taken on codes with the AS modifier. Note : Medical records a re not required with the claim, but must be available upon CareSources request. Clinical information documented in the patient's records must support the use of this modifier and operative notes must contain sufficient information to support the medical necessity of an assistant at surgery. I f there is no accounting by the surgeon for what was performed by the assistant the claim would be denied. XXV. Modifie r JG-Drug or biological acquired with 3 40B drug pricing program discount A. Providers are required to report modifier JG on the same claim line as the drug or biological HCPCS code to identify if a drug or biological was acquired under the 340B Program. B . HCPCS code with modifier JG append ed will reimburse at the average sales price (ASP) minus 2 2.5 % for certain separately payable drugs or biologicals that are acquired through the 340B Program . XXV I . Modifie r JW-Drug amount discarded (wasted)/not administered to any patient A. CareSource will consider reimbursement for: 1. A sing le-dose or single-use vial drug that is waste d, when Modifier JW is appended. 2. The wasted amount when billed with the amount of the drug that was administered to the member. 3. The wasted amount billed that is not administered to another patient. B. CareSource will NOT consider reimburse ment for: 1. The w asted amount of a m ulti-dose vial drug . 2. Any d rug wast ed that is billed when none of the drug was administered to the patient . 3. Any d rug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose . XXV I I. Modifie r SA-Nurse practitioner (NP) rendering service in collaboration with a physician A. Modifier SA is reported to indicate when a supervising physician is billing on behalf of a n ANP, o r CRNFA for non-surgical services. B. Modifier SA is used when the ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery. C. Procedure code with modifier SA appended will be reimbursed at 85% of the fee schedule amount. XXV I II. Modifie r TB-Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes. A. Modifier TB must be re ported to identify if a drug or biological was acquired under the 340B Program. B. The use of modifier TB will not trigger a payment adjustment . Providers will receive the average sales price (ASP), plus 6% for separately payable drugs furnished. XX I X . Modifie r TC-Technical Component Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 10 A. Technical component charges are institutional charges and not billed separately by physicians. B. A charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding Modifier TC to the usual procedure code. XXX. Modifie r 26-Professional Component A. Certain procedures are a combination of a physician component and a technical component. B. When the physician component is re ported separately, the service may be identified by adding the modifier 26 to the usual procedure number. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual CMS 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, our policies apply to both participating and nonparticipating providers and facilities . Note : 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 N/A G. Review/Revision History DAT EACT ION Da te Issue d 0 8 /01/2019 New policy Da te Re vise d Da te Effe ctive 0 8 /01/2019 H. References 1. Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS). (2018, April 2). Retrieved 3/22/2019 from https://www.cms.gov/Medicare/Medicar e-Fee-for-Service-Payment/HospitalOutp atientPPS/Do wnloa ds/Billing-340B-Mo difi ers-un der-Hos pital-OPPS.pdf 2. CPT overvie w and code approval. (2019, March 22). Retrieved from https://www.ama-assn.org/practice-management/cpt/cpt-o ver vie w-an d-co de-ap pr o val . 3. Medicare Claims Processing Manual Chapter 12-Physicians/Nonphysician Practitioners. (2018 , November 30). Retrieved February 18, 2019 from https://www.cms.gov/Regulations-and-Guidance/Guida nce/Man uals/Downloa ds/clm104c1 2.pd f . 4. Medicare Claims Processing Manual Chapter 14-Ambulatory Surgical Centers. (2017, December 22). Retrieved February 18, 2019 from https://www.cms.gov/Regulations-a nd-Guidance/Guidance/Manuals/Downlo ads/clm104c 14.p df. 5. Optum360 EncoderProForPayers.com-Login. (2019, February 18). Retrieved February 18, 2019 from Archived Reim bursement Modifiers INDIANA MARKETPLACEPLANS PY-0 71 3 Effective Date: 0 8 /01/2019 11 h ttps://www.encoderprofp.com/e pr o4p ayers/allM odi fie rsHa ndle r.do ?_k=1 01* 0&_a=listRelated&menu=4 . 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. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Transcutaneous Electrical Nerve Stimulation (TENS) PY-0753 07/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 3 F. Related Policies/Rules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4 Transcutaneous Electrical Nerve Stimulation (TENS) INDIANA MARKETPLACE PLANS PY-0753 Effective Date: 07/01/2019 2 A. Subject Transcutaneous Electrical Nerve Stimulation (TENS) B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Transcutaneous electrical nerve stimulation (TENS) is a device that produces a mild electrical stimulation that causes interference with transmission of painful stimuli. The stimulation is applied to the members painful area via electrodes applied to the members skin. CareSource will reimburse licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day (1 month) trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. C. Definitions Transcutaneous electrical nerve stimulation (TENS) – is the application of mild electrical stimulation, to skin electrodes placed over a painful area that causes interference with transmission of painful stimuli. Supplies-includes but is not necessarily limited to electrodes of any type, lead wires, and adhesive tape. D. Policy I. CareSource does not require a prior authorization (PA) for a TENS unit or supplies for participating providers. A. Non-participating providers DO require a prior authorization for a TENS unit (E0720 or E0730) and for supplies (A4595). II. CareSource reimburses for TENS units and supplies based on the Centers for Medicare and Medicaid Services (CMS) guidelines. III. TENS units are reimbursed on a 13 month rent to purchase basis, after a successful 1 month non-reimbursable trial period. IV. Documentation A. The provider of the TENS unit must complete the Certificate of Medical Necessity-Transcutaneous Electrical Nerve Stimulator (TENS), Form CMS-848. B. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that treatment lasting no longer than 30 days is needed for acute pain following surgery and includes the date of surgery.Transcutaneous Electrical Nerve Stimulation (TENS) INDIANA MARKETPLACE PLANS PY-0753 Effective Date: 07/01/2019 3 C. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain must be completed and available for review upon CareSources request. D. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request, before reimbursement is made for supplies or repair. E. The provider must also provide the member with verbal instruction on the use of the TENS unit. F. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record. V. Rental of a TENS unit to treat post-operative pain is limited to a single 30 day period and may not be extended. Modifier RR should be used in this case. VI. Reimbursement for the purchase of a TENS unit may be made if the prescribing provider attests to the medical necessity of continued use of the TENS units (after the successful 1 month non-reimbursable trial period). VII. Supplies A. Supplies are not reimbursable during the trial period. B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-Lead TENS unit (E0720) or 2 units per month for a 4-Lead TENS unit (E0730). D. After a TENS unit has been purchased for an individual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed, at a frequency not to exceed once per month. E. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim will be denied. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual CMS fee schedule for appropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. HCPCS Code Description E0720 TENS unit, 2-lead, localized stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation (INCLUDES SUPPLIES DURING RENTAL) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead (FOR A RECIPIENT-OWNED UNIT) Modifiers Description RR Rental (use the ‘RR’ modifier when DME is to be rented) NU Purchase of new equipment Transcutaneous Electrical Nerve Stimulation (TENS) INDIANA MARKETPLACE PLANS PY-0753 Effective Date: 07/01/2019 4 F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 07/01/2019 New Policy Date Revised Date Effective 07/01/2019 H. References 1. Medicare National Coverage Determinations Manual. (2018, November 21). Retrieved from 3/11/2019 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf 2. Medicare National Coverage Determinations Manual. (2018, November 21). Retrieved 3/11/2019 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part2.pdf 3. Physician Fee Schedule Search. (2019, January 11). Retrieved from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx 4. Using TENS for pain control: the state of the evidence. (2015, March 1). Retrieved 3/11/2019 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186747/ The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Independent medical review 2/2015
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Emergency Department Electrocardiogram (EKG/ECG) Interpretation PY-07 88 0 7 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulator y requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………… 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Archived Emergency Department Electrocardiogram (EKG/ECG) Interpretation INDIANA MARKETPLACE PLANS PY-07 88 Effective Date: 0 7 /01/2019 2 A. Subject Emergency Department Electrocardiogram (EKG/ECG) Interpretation B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a membe r and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. An electrocardiogram (EKG/ECG) is a non-inv asive test that records the electrical activity of the heart. It is used when a possible cardiac issue occurs and the patient is seen in the Emergency Department due to an emergency medical condition. An electrocardiogram (EKG/ECG) may need to be perform ed to address the situation quickly. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service. C. Definitions Emergency medical condition-is a medical condition with sudden severity and onset that in the absence of immediate medical attention could placing the patient’s health in serious jeopardy. This includes labor and delivery, but not routine prenatal or postpartum care, or services related to an organ transplant procedure. Electrocardiogram (EKG/ECG) is a test that records the electrical activity of the heart. For the purpose of this policy EKG will be used to represent both EKG and ECG. D. Policy I. CareSource does not require a prior authorization (PA) for EKGs completed in the Emergency Department (Place of service (POS) 23). A. Regardless of POS, the modifier appended to the CPT code determines a duplicate service. II. CareSource will reimburse the first EKG claim that is received for the member of the date of service. A. If another claim for the same service EKG is received for reimbursement, CareSource will only reimburse the first claim received for the same member on the same da te of service. B. Care Source will not reimburse for duplicate claims, for the same service on the same date of service for the same member. 1. Example: 93010 is received and is reimbursed. Another 93010 claim is received for the same date of service and is denied as duplicate service. C. If a second EKG is medically necessary, on the same date of service, to determine a cardiac change before the member is discharged, modifier 76 or modifier 77 must be appended to the second EKG for reimbursement. Archived Emergency Department Electrocardiogram (EKG/ECG) Interpretation INDIANA MARKETPLACE PLANS PY-07 88 Effective Date: 0 7 /01/2019 3 1. Example: 93010 is received and reimbursed. Another 93010 is completed and submitted for reimbursement. The second 93010 has modifier 76 or 77 (whichever is applicable) appended (93010-76 or 93010-77) to distinguish between the first and second EKG p erformed on the same member on the same date of service. III. CareSource expects providers to work with other departmen ts, within their organization, to determine which department will submit the claim to prevent duplicate claim submissions. E. Conditions o f Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual CMS fee schedule for app ropriate codes. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. CPT Code Description 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only 93225 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93227 External electrocardiographic recording up to 48 hours by continuous rhythm record ing and storage; review and interpretation by a physician or other qualified health care professional Modifier Description 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional F. Related Policies/Rules N/A G. Review/Revision History DATE ACTION Date Issued 0 7 /01/2019 New policy Date Revised Date Effective 0 7 /01/2019 Archived Emergency Department Electrocardiogram (EKG/ECG) Interpretation INDIANA MARKETPLACE PLANS PY-07 88 Effective Date: 0 7 /01/2019 4 H. References 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (2018, October 1). Retrieved 3/12/2019 from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37283&ver=9&DocType=2&Cntrctr=238&Cntrctr Selected=238*2&s=42&bc=AAIAAAAAAAAA& . 2. Electrocardiogram. (2019, March 12). Retrieved 3/12/2019 from https://www.nhlbi.nih.gov/health-topics/electrocardiogram 3. Physician Fee Schedule Search. (2019). Retrieved 3/12/2019 from https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=3&H1=93010&M=5 . 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. I nd e pe n de nt med i ca l r e v iew 2/2015 Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Readmission PY-0 725 06 /01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : Reimbursement Policies prepared by CSMG Co. and its af f iliates (including CareSource) are intended to provide a general ref erence regarding billing, coding and documentation guidelines. Coding methodology, re gulatory requirements, industry-standard claims editing logic, benef its design and other f actors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benef its and eligibility on th e date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re f erral, authorization, notif ication and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary f or the diagnosis or treatment of disease, illness, or injury and w ithout w hich the patient can be expected to suf f er prolonged, increased or new morbidit y, impairment of f unction, dysf unction of a body organ or part, or signif icant pain and discomf ort. These services meet the standards of good medical practice in the local area, are the low est cost alternative, and are not provided mainly f or the convenie nce of the member or provider. Medically necessary services also include those services def ined in any f ederal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please ref er to the plan contract (of ten referred to as the Evidence of Coverage) f or the service(s) ref erenced herein. If there is a conf lict betw een this Poli cy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) w ill be the controlling document used to make the determination. CSMG Co. and its af f iliates may use reasonable discretion in interpreting and app lying this Policy to services provided in a particular case and may modif y this Policy at any time. Table of Contents Reimbursement Policy Statement ………………………….. ………………………….. ………………………….. .. 1 A. Subject ………………………….. ………………………….. ………………………….. ………………………….. ….. 2 B. Background ………………………….. ………………………….. ………………………….. ………………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………….. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. …….. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……….. 5 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …………. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ………. 5 H. References ………………………….. ………………………….. ………………………….. …………………………. 5 Archived Readm ission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 0 6 /01/2019 2 A. Subject Re a dmission B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims of Readmissions for our Medicare Advantage members may be subject to limitations and/or qualifications. 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 pro cessing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the prod uct or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Following a hospitalization, readmission within 30 days is often a costly preventable event and is a qua lity of care issue . It has been estimated that readmissions within 30 days of discharge can cost health plans more than $1 billion dollars on an annual basis. Readmissions can result from many situations but most often are due to lack of transitional care or discharge planning. Readmissions can be a major source of stress to the patient, family and caregivers. However, there are some readmissions that are unavoidable due to the inevitable progression of the disease state or due to chronic conditions. The p urpose of this policy is to improve the quality of inpatient and transitional care that is being rendered to the members of CareSource. This includes but is not limited to the following: 1. improve communication between the patient, caregivers and clinicia ns, 2. provide the patient with the education needed to maintain their care at home to prevent a readmission, 3. perform pre discharge assessment to ensure patient is ready to be discharged, and 4. provide effective post discharge coordination of care. C. Definitions Readmission : a subsequent inpatient admission to any acute care facility which occurs within 30 days of the discharge date; excluding planned admissions. Planned Readmission : a non-acute admission for a scheduled procedure for limited types of care to include: obstetrical delivery, transplant surgery and maintenance chemotherapy/radiotherapy/immunotherapy. Same or Similar Condition : a condition or diagnosis that is the same or a similar condition as the diagnosis or condition that is documente d on the initial admission. Same Day : CareSource deli neat es same day as midnight to midnight of a single day . Archived Readm ission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 0 6 /01/2019 3 D. Policy I. This is a reimbursement policy that defines the payment rules for hospitals and acute care facilities that are reimbursed for inpatient or observational services for the following categories: A. Same day readmission or observational stay for a related condi tion B. Same day readmission or observational stay for an unrelated condition C. Planned Readmissions and/or leave of absence D. Unplanned admissions to an acute, general, short-term hospital occurring within 30 calendar days from the date of discharge from the same or another acute, general, short-term hospital II. Prior authorization of the initial or subsequent inpatient stay or admission to observation status is not a guarantee of payment and are subject to administrative review as well as review for medical nec essity at the discretion of CareSource. A. All inpatient prior authorization requests that are submitted without medical records will automatically deny which will result in a denial of the claim. III. An administrative review of all readmissions will take place based on the following Medicare readmission review criteria: A. Same day readmission or observational stay for a related condition criteria: 1. CareSource will conduct an administrative review to ens ure that billing guidelines were followed bas ed on Chapter 3, Sec tion 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital combine the two admissions on one claim. 2. If the member is readmitted during the same day as the initial admission for the same or a related condition and both the initial and the subsequent admission are billed separately, CareSource will deny the claim as separate DRGs. The facility must submit the initial admi ssion and the subsequent admission on one claim to receive reimbursement. B. Same day readmission or observational stay for an unrelated condition criteria: 1. CareSource will conduct an administrative review to ensure that billing guidelines were followed bas ed on Chapter 3, Section 40.2.5 (Repeat Admissions) in the Medicare Claims Processing Manual which requires that the acute, general, short-term hospital to bill the claims separately but the claim that contains an admission date that is the same as the dis charge date must include condition code B4 as indicated in the Medicare billing guidelines . C. Planned readmission and/or leave of absence criteria: 1. When a readmission to the same acute care facility or inpatient hospital is expected and the member does not require a hospital level of care during the timeframe between the two admissions, the member may be placed on leave of absence by the provider. a. CareSource follows the Medicare Inpatient Hospital Services billing guidelines found in the Medic are Claim s Processing Manual, Chapter 3 for leave of absence billing guidelines which requires that the facility Archived Readm ission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 0 6 /01/2019 4 submit one claim and receive one combined DRG payment for both admissions both are for the treatment of the same episode of illness. b. Examples of a planne d readmission include, but are not limited to, situations where surgery could not be scheduled immediately due to scheduling availability, a specific surgical team that is needed for the procedure is not available, bilateral staged surgery was planned, o r when further treatment is indicated following diagnostic tests but cannot begin at the time of initial admission. c. CareSource reserves the right to request medical records to determine if the claim was properly billed. d. Leave of absence does not apply to cancer chemotherapy or similar repetitive treatments. D. Determination of Unplanned Readmissions criteria: 1. CareSource will review the clinical documentation on all potential readmissions to determine if the admission was a potentially preventable readmissi on (PPR) based on the following Medicare guidelines: a. Premature discharge of patient that resulted in subsequent readmission of patient to same hospital. Premature discharge includes when a patient is discharged even though he/she should have remained in t he hospital for further testing or treatment or was not medically stable at the time of discharge. A patient is not medically stable when, in CareSource judgement, the patient’s condition is such that it is medically unsound to discharge or transfer the pa tient. Evidence such as elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a patient may have been prematurely discharged from the hospital; b. When a patient is readmitted to a hospital for care that, pursuant to professionally recognized standards of health care, could have been provided during the first admission. This action does not include circumstances in which it is not medically appropriate to provide the care during th e first admission. c. The readmission is the result of a lack of documentation and/or coordination of care between the inpatient and outpatient team in regards to post discharge care and coordination with a CareSource Care Manager for the member. E. The followin g readmission criteria listed below are excluded from this readmission policy and if billed appropriately, claims will be reviewed for payment: a. If the member is being transferred from an out-of-network to an in-network facility or if the member is being tr ansferred to a facility that provides care that was not available at the initial facility; b. Transfers to distinct psychiatric units within the same facility. When transferring within the same facility, documentation must show that the diagnosis necessitati ng the transfer was psychiatric in nature and that the patient received active psychiatric treatment. c. If the readmission is part of planned repetitive treatments or staged treatments, such as chemotherapy or staged surgical procedures; ArchivedReadm ission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 0 6 /01/2019 5 d. Readmissions where the discharge status of the first discharge was left against medical advice (AMA); e. Obstetrical readmissions. IV. Post Payment Review and Appeals Process: 1. CareSource reserves the right to monitor and review claim submissions to minimize the need for post-payment claim adjustments as well as review payments retrospectively. a. Medical reco rds for both admissions must be included with the claim submission to de termine if the admission (s) is appropriate or is considered a readmission. 01. Failure from the acute care facility or inpatient hospital to provide complete medical records will result in an automatic denial of the claim. b. If the included documentation dete rmines the readmission to be an inappropriate or medically unnecessary , the hospital must be able to provide additional documentation to CareSource upon request or the claim will be denied. c. If the readmission is determined at the time of documentation re view to be a preventable readmission, the reimbursement for the readmission will be combined with the initial admission and paid as one claim to cover both, or all, admissions. 2. Appeals Process a. All acute care facilities and inpatient hospitals have the rig ht to appeal any readmission denial and request a peer-to-peer review or formal appeal. E. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer t o the CMS f ee schedule for appropriate codes. F. Related Policies/Rules G. Review/Revision History DAT EACT ION Da te Issue d 04/01/2019 Da te Re vise d Da te Effe ctive 06 /01/2019 H. References 1. McIlvennan, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction program. Circulation , 131 (20), 1796-803.McIlvenn an, C. K., Eapen, Z. J., & Allen, L. A. (2015). Hospital readmissions reduction progra m. Circulation , 131 (20), 1796-803. Archived Readm ission INDIANA MARKETPLACE PLANS PY-0725 Effective Date: 0 6 /01/2019 6 2. Hospital Readmission Reduction Program. (2018, December 04). Ret rieved from https://www.cms.gov 3. Medicare Claims Processing Manual. (2018, November 9). Retrieved January 23, 2019, from https://www.cms.gov The Reimbursement Po l i c y St a t e m e nt d e t ai l e d a bo v e h a s r ecei v e d due c on si d e ra t i o n a s d e f i n e d i n the Reimbursement Po li c y St a t e m e nt Po li c y a nd i s a pp r o v e d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Policy Name Policy Number Effective Date Avastin for use in Ophthalmology Billing Guideline PY-0737 05/01/2019 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement: Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Table of Contents Reimbursement Policy Statement …………………………………………………………………………………. 1 A. Subject ……………………………………………………………………………………………………………….. 2 B. Background …………………………………………………………………………………………………………. 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage …………………………………………………………………………………………. 2 F. Related Policies/Rules ………………………………………………………………………………………….. 2 G. Review/Revision History ……………………………………………………………………………………….. 3 H. References …………………………………………………………………………………………………………. 3 Avastin for use in Ophthalmology Billing Guideline INDIANA MARKETPLACE PLANS PY-0737 Effective Date: 05/01/2019 2 A. Subject Avastin for use in Ophthalmology Billing Guideline B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Avastin is a drug used in the treatment of wet age-related macular degeneration, diabetic eye disease and other problems of the retina. Avastin is injected into the eye and helps to slow down disease related vision loss. The use of Avastin to treat eye disease is considered off-label, which is allowed by the FDA when doctors are well informed regarding the drug and there are studies that prove its an effective treatment option. There is no cure for macular degeneration, treatment is aimed at slowing down the progression of the disease and preventing vision loss. C. Definitions Macular Degeneration a progressive vision impairment resulting from deterioration of the central part of the retina, known as macula. D. Policy I. CareSource does not require a Prior Authorization for the use of Avastin in Ophthalmology, when billed with the following codes: A. J3490 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. B. J3590 will be reimbursed as follows, when billed with NDC 50242-0061-01 or 50242-0060-01: 1. For units 1 to 1.25, reimbursement is up to $70.00 per eye, per calendar month. 2. For units 2 to 2.50, reimbursement is up to $140.00 for both eyes, per calendar month. E. Conditions of Coverage HCPCS J3490, J3590 NDC 50242-0061-01 or 50242-0060-01 F. Related Policies/Rules N/A Avastin for use in Ophthalmology Billing Guideline INDIANA MARKETPLACE PLANS PY-0737 Effective Date: 05/01/2019 3 G. Review/Revision History DATE ACTION Date Issued 05/01/2019 New policy Date Revised Date Effective 05/01/2019 H. References 1. Boyd, K. (2018, May 22). What Is Avastin? Retrieved October 29, 2018, from https://www.aao.org/eye-health/drugs/avastin 2. “Off-Label” and Investigational Use Of Marketed Drugs, Biologics, and Medical Devices-Information Sheet. (2018, July 12). Retrieved October 29, 2018, from https://www.fda.gov/regulatoryinformation/guidances/ucm126486.htm The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
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