REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANSOriginal Issue Date Next Annual Review Effective Date 11/29/2018 03/01/2020 03/01/2019 Policy Name Policy Number Applied Behavioral Analysis (ABA) Therapy PY-0 710 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 3 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 5 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Applied Behavioral Analysis (ABA) Therapy INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 03/01/2019 2 A.SUBJECT Applied Behavioral Analysis (ABA) Therapy 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. Autism Spectrum Disorder (ASD) can vary widely in severity and symptoms, depending on the developmental level and chronological age of the patient. Autism is often defined by specific impairments that affect socialization, communication, and stereotyped (repetitive) behavior, which collectively are called the Core symptoms of autism. Children with autism spectrum disorders have pervasive clinically significant deficits which are present in early childhood in areas such as intellectual functioning, language, social communication and interactions, as well as restricted, repetitive patterns of behavior, interests and activities. Individuals with a well-established diagnosis of autistic disorder, Aspergers disorder, or Pervasive Developmental Disorder NOS under previous diagnostic criteria should be given the diagnosis of ASD. There is currently no cure for ASDs, nor is there any one single treatment for the disorder. Individuals with ASDs may be managed through a combination of therapies, including behavioral, cognitive, pharmacological, and educational interventions. The goal of treatment for autistic patients is to minimize the severity of autism symptoms, maximize learning, facilitate social integration, and improve quality of life for both autistic individuals and their families or caregivers. Behavioral therapy programs studied to treat ASD include Intensive Behavioral Intervention (IBI), including Lovaas therapy, Early Intensive Behavioral Intervention (EIBI), or Applied Behavior Analysis (ABA). IBI therapy involves use of operant conditioning, a behavioral modification technique using positive reinforcement to increase desired behaviors, or a neutral response to not reinforce undesired behaviors. The operant conditioning is delivered in a highly-structured and intensive program, with one-to-one instruction by a trained therapist. Parents are active participants in the treatment process and are taught to continue the training at home. IBI is initiated when a child is young, usually by 2 years of age. Medical research has shown improved outcomes in children that receive early behavioral and developmental/relationship-based interventions. These intensive behavioral intervention programs involve time-intensive, highly-structured positive reinforcement techniques by a trained behavior analyst or therapist. There is a wide variation in ABA practices from philosophy, approach, interventions and methodology, and outcome reporting. Clinical evidence from small studies and meta-analyses suggests that intensive behavioral therapy may have effects on intellectual functioning, language-related outcomes, acquisition of daily living skills and social functioning for some individuals. Methodological problems including small sample sizes (limiting statistical analysis), lack of randomization, blind assessments, and use of prospective design limit the generalizability of the results. There is lack of definition and guidelines around characteristics of children who would benefit from treatment, lack of evidence-based guidelines for training and credentialing, program content, measurement of success, intensity, duration and clinical criteria. CareSource fully ArchivedApplied Behavioral Analysis (ABA) Therapy INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 03/01/2019 3 supports the recommendation for ongoing research, randomized control studies, standardized protocols, and longitudinal research to determine long term outcomes. The following professional societys recommendations are derived from the latest guidelines and scientific based literature available. American Academy of Pediatrics (AAP ) The AAP recommends universal screening in children aged 18 to 24 months to assist in early detection of ASD. Children that receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, adaptive behavior and social behavior. American Academy of Child and Adolescent Psychiatry (AACAP) The AACAP recommends children should routinely be tested for ASD during developmental assessments. When screening is indicative of significant ASD symptoms, a thorough diagnostic evaluation should be performed. Clinicians should coordinate an appropriated multidisciplinary assessment of children with ASD and the clinician should help the family obtain appropriate, evidence-based and structured educational and behavioral interventions for treatment. The AACAP has practice parameters for treatment of children and adolescents with ASD. The quality of the literature is variable. None of the treatment models have emerged as superior. C. DEFINITIONS Autism Spectrum Disorder: A neurological condition, including Asperger’s syndrome and autism, as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association Autism Diagnostic Interview-Revised (ADI-R): A clinical interview lasting two three hours in order to evaluate and probe for autistic symptoms or behaviors Autism Diagnostic Observation Schedule (ADOS): A standard diagnosis tool used as one facet of autism diagnostic evaluation in conjunction with other clinical information and the health care providers clinical expertise BCaBA: Board certified assistant behavior analyst undergraduate level (Bachelors degree) BCBA: Board certified behavior analyst graduate le vel (Masters degree) BCBA-D: Board certified behavior analyst doctoral level (Doctoral degree) QHP: Qualified healthcare professional (BCBA, BCBA-D) RBT: Registered Behavioral Technician is a paraprofessional who practices under the close, ongoing supervision of a BCBA, BCaBA, or BCBA-D D. POLICY I. Applied Behavioral Analysis (ABA) Therapy requires a prior authorization (PA). A. Prior Authorization (PA) is required for ABA Diagnosis and Evaluation, Initial Course of ABA Therapy and Continuation of ABA Therapy. II. CareSource reimburses for state and federal required covered services as part of a comprehensive plan of treatment for autism spectrum disorders when ordered by a licensed physician i.e. pediatrician or psychiatrist and provided by a certified, credentialed and/or licensed CareSource participating therapist as outlined in the Applied Behavioral Analysis (ABA) Therapy Medical policy, MM-02 59. III. ABA Therapy services may be approved for up to a six month period with subsequent interim assessment over the course of treatment. IV. CareSource will not reimburse for any exclusions listed in the Medical policy, MM-0259. V. Duplicate services or double billing are not reimbursable. Archived Applied Behavioral Analysis (ABA) Therapy INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 03/01/2019 4 VI. Codes listed below that state face-to-face with member means that QHP or technician must be physically present with member. A. Code 97151, Behavior identification assessment, can be billed a maximum of 24 units for a total of 6 hours. B. Code 97151 and 97152 can be billed for a combined total of 6 hours every 6 months after the initial assessment. VII. Codes listed in this policy below cannot be billed together for the same amount of time for the same date of service. A. BCBA or BCBA-D cannot bill the same amount of time, for the same date of service as the BCaBA or RBT (technician). B. All services administered by a technician must be directed and supervised by the BCaBA , BCBA or BCBA-D. C. A maximum of 1 hour of QHP supervision can be billed for every 10 hours of RBT time. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting Medicare approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Medicare 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 update s. CPT Code Description 97151 Behavior identification assessment , administered by a physician or other qualified healthcare professional , each 15 minutes of the physicians or other qualified healthcare professionals time face-to-face with member and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past dataI scoring/interpreting the assessment, and preparing the report/treatment plan. (Attended by member and QHP) 97152 Behavior identification supporting assessment , administered by one technician under the direction of a physician or other qualified healthc are professional, face-to-face with member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 9715P Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one member, each 15 minutes. (Attended by member and technician (QHP may substitute for the technician)) 9715Q Group adaptive behavior treatment by protocol, administered by technician under the directi on of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. (Attended by 2 or more members and technician (QHP may substitute for technician)) 97155 Adaptive behavior treatment by protocol modific ation, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. (Attended by member and QHP; may include technician and/or caregiver) 97156 Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the member present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. (Attended caregiver and QHP) Archived Applied Behavioral Analysis (ABA) Therapy INDIANA MARKETPLACE PLANS PY-0710 Effective Date: 03/01/2019 5 97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the member present), face-to-face with multiple sets guardians/caregivers, each 15 minutes. (Attended caregivers of 2 o r more members and QHP) 97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple members, each 15 minutes. (Attended by 2 or more members and QHP) 0362T Behavior identification supporting assessment , each 15 minutes of technicians time face-to-face with a member, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patients behavior. (Attended by member and 2 or more technicians;QHP on site) 0373T Adaptive behavior treatment with protocol modification each 15 minutes of technicians time face-to-face with patient, requiring the following components: administered by the physician or other qualified healthcare professional who is on site; with the assistance of two or more tech nicians; for a patient who exhibits destructive behavior; completed in an environment that is customized, to the patients behavior. (Attended by member and 2 or more technicians;QHP on site) F. RELATED POLICIES/RUL ES Applied Behavioral Analysis (ABA) Therapy MM-0259 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/29/2018 New Policy Date Revised Date Effective 0 3/ 0 1/2019 H. REFERENCES 1. Behavior Analyst Certification Board. (2018, November 12). Retrieved November 12, 2018 from https://www.bacb.com/. 2. Adaptive Behavior Assessment and Treatment Code Conversion Table. (2018, November 12). Retrieved from https://www.bacb.com/wp-content/uploads/CPT_Codes_Crosswalk_.pdf. The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. I nd e pe nde nt medi cal rev iew 2/2015 Archived
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 edi cal 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, dysfun ction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the l ocal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Med ically 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 n ot 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., Evidenc e of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time.REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Original Issue Date Next Annual Review Effective Date 01/01/2019 01/01/2020 01/01/2019 Policy Name Policy Number Provider Home Visits PY-0440 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2 D. POLICY ………………………….. ………………………….. ………………………….. …………….. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………. 14 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. ……….. 14 H. REFERENCES ………………………….. ………………………….. ………………………….. …. 14 2 Provider Home VisitsINDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 A. SUBJECTProvider Home Visits B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or se rvice that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Provider home visits are medical care visits rendered in the home setting to an individual for the examination, diagnosis, and/or treatment of an injury or illness. For the purposes of this policy, home is defined as the individual’s place of residence, in cluding, private residence/domicile,assisted living facility, long-term care facility, or skilled nursing facility. C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illne ss, or injury and meet accepted guidelines of medical practice. Place of Service (POS) – A two-digit code that indicates the setting in which a service was provided. Provider A physician with an MD or DO, a podiatrist, a nurse practitioner or a physician assistant. Home An individual’s place of residence, including, private residence/domicile, assisted living facility, long-term care facility, or skilled nursing facility. D. POLICY I. CareSource does not require a prior authorization for provider hom e/domicile visits. A. CareSource reimburses for home visit services per the Medicare fee schedule. B. Claim submission must include the appropriate CPT codes along with any applicable modifier with the appropriate place of service (POS) code. II. Place of service (POS) for provider services in the home or domicile include the following:A. POS 12 Home B. POS 13 Assisted Living C. POS 14 Group Home D. POS 31 Skilled Nursing Facility (SNF) E. POS 32 Nursing Facility F. POS 33 Long-term Facility III. Home services for CareSource members:A. CareSource members do not need to be confined to their home to receive home services, provided by a physician. B. The CareSource members medical record must document the medical necessity of the home visit made in lieu o f an office or outpatient visit. 3 Provider Home VisitsINDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 C. A home visit cannot be billed by a physician unless the physician was actually present in the beneficiarys home. Note: Although CareSource does not require a prior authorization for provider home visits, CareSource may request documentation to support me dical necessity.Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes and the appropriate modifiers, if applicable. Please refer to the CMS fee schedule for appropriate codes. The following PDF list(s) of codes is provided as a reference. This list may not be all inclusive and is subject t o updates. Place of ServiceDescription 12 Location, other than a hospital or other facility, where the patient receives care in a private residence. Code Description 99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other p hysicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent fac e-to-face with the patient and/or family. 99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the present ing problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. 99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicia ns, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spe nt face-to-face with the patient and/or family. 99344 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with othe r physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family. Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 4 99345 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of hi gh complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is u nstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent face-to-face with the patient and/or family. 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coord ination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. T ypically, 15 minutes are spent face-to-face with the patient and/or family. 99348 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified h ealth care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face with t he patient and/or family. 99349 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are moderate to high severity. Typi cally, 40 minutes are spent face-to- face with the patient and/or family. 99350 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling a nd/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate t o high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. Place of ServiceDescription 13 Congregate residential facility with self-contained living units providing assessment of each residents needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 5 professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded proble m focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically , 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordinati on of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Med ical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Cou nseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenti ng problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 6 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at l east 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high comp lexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem( s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Place of ServiceDescription 14 A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration). Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 m inutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and /or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically , 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordinati on of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 7 nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver.99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination o f care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new prob lem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Cou nseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenti ng problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of thes e 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consi stent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high comp lexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem( s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Place of ServiceDescription 31 A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. Code Description Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 8 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity.Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the prob lem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided co nsistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordinat ion of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Coun seling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are prov ided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant co mplication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 9 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Couns eling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have devel oped a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Coun seling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physici ans, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of car e with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with t he nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified hea lth care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 10 and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit. Place of ServiceDescription 32 A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to individuals other than those with intellectual disabilities. Code Description 99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the prob lem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coord ination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate sev erity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordinat ion of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. T ypically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit. 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focu sed interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of th e problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making o f low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 11 family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other phys icians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Ty pically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Couns eling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have devel oped a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit. 99315 Nursing facility discharge day management; 30 minutes or less 99316 Nursing facility discharge day management; more than 30 minutes 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Coun seling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit. 99251 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused ex amination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 20 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99252 Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of car e with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 40 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99253 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other q ualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside a nd on the patient’s hospital floor or unit. 99254 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 12 Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity.Typically, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit. 99255 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicia ns, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 110 minutes are sp ent at the bedside and on the patient’s hospital floor or unit. Place of ServiceDescription 33 A facility which provides room, board, and other personal assistance services, generally on a long-term basis, and which does not include a medical component. Code Description 99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 m inutes are spent with the patient and/or family or caregiver. 99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and /or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver. 99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically , 45 minutes are spent with the patient and/or family or caregiver. 99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordinati on of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver. 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 13 comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and th e patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver. 99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Cou nseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. 99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expan ded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided cons istent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver. 99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver. 99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, o ther qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver. Modifiers Description24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service 33 Preventive Services 57 Decision for Surgery 59 Distinct Procedural Service A1 Dressing for one wound AI Principal physician of record AM Physician, team member service Provider Home Visits INDIANA MARKETPLACE PLANS PY-0440 Effective Date: 01/01/2019 14 AQ Physician providing a service in an unlisted health professional shortage area(HPSA) CC Procedure code change (use CC when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) GC This service has been performed in part by a resident under the direction of a teaching physician GV Attending physician not employed or paid under arrangement by the patient’s hospice provider GW Service not related to the hospice patient’s terminal condition HE Mental health program HO Masters degree level Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a ru ral area Q8 Two Class Bfindings RT Right side (used to identify procedures performed on the right side of the body) SA Nurse practitioner rendering service in collaboration with a physician F. RELATED POLICIES/RULESN/A G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 01/01/2019 New policyDate Revised Date Effective 01/01/2019 H. REFERENCES1. Medically Necessary – HealthCare.gov Glossary. (2018, July 1). Retrieved 7/1/2018 from https:// www.healthcare.gov/glossary/medically-necessary. 2. Medicare Claims Processing Manual. (2018, June 13). Retrieved 7/1/2018 from https:// www.cms.gov/Regulations-and – Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. 3. Place of Service Codes – Centers for Medicare & Medicaid Services. (2012, March 5). Retrieved 7/1/2018 from https:// www.cms.gov/Medicare/Coding/place-of-service – codes/index.html. 4. Place of Service Code Set – Centers for Medicare & Medicaid Services. (2016, November 17). Retrieved 7/1/2018 from https ://www .cm s.gov/Medicare/Coding/place-of-service – codes/Place_of_Service_Code_Set.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 I NDIANA MARKETPLACE PLAN SOriginal Issue Date Next Annual Review Effective Date 01/25/2018 0 7/15/2019 0 7/15/2018 Policy Name Policy Number Positive Airway Pressure Devices for Pulmonary Disorders PY-0 42 7 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. 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 patien t 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 lowes t 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 Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Positive Airway Pressure Devices for Pulmonary Disorders INDIANA MARKETPLACE PLANS PY-0427 Effective Date: 07/15/2018 2 A. SUBJECT Positive Airway Pressure Devices for Pulmonary Disorders 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. Positive airway pressure (PAP) devices, involve using a machine that includes a mask or other device that fits over the nose and/or mouth to provide positive pressure to keep breathing airways open. Continuous positive airway pressure or CPAP is used to treat sleep-related breathing disorders including sleep apnea. It also may be used to treat preterm infants who have underdeveloped lungs. Bilevel or two level positive airway pressure or BiPAP is used to treat lung disorders such as chronic obstructive pulmonary disease (COPD). While CPAP delivers a single pressure, BiPAP delivers positive pressure both on inhalation and exhalation. PAP can provide better sleep quality, reduction or elimination of snoring, and less daytime sleepiness. The PAP machines should always be used according to the physicians order as well as every time during sleep at home, while traveling, and during naps in order to produce the most effective outcome C. DEFINITIONS Medically necessary health products, supplies or services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted guidelines of medical practice. Compliance is the use of the device regularly as prescribed by the ordering physician and for 4 or more hours per night on 70% of nights. Deviation is the altered or lack of use of the device as prescribed by the orderin g physician. D. POLICY I.CareSource does not require a prior authorization for the first 3 month rental on a PAP machines (CPAP/BiPAP) for participating providers. A. CPAP (E0601) machines and BiPAP (E0470) are a 13 month rent to purchase. B. Prior authorization must be obtain through CareSource starting after the 3 rd month rental (months 4-13). C. CareSource follows the Local Coverage Determination (LCD) L33718 for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea for medical necessity determination. II.Providers that dispense the PAP machine must ensure and document the members compliance with its use. A. CareSource considers compliance with the use of PAP as the following: 1. The member uses the device regularly as prescribed by the ordering physician. ArchivedPositive Airway Pressure Devices for Pulmonary Disorders INDIANA MARKETPLACE PLANS PY-0427 Effective Date: 07/15/2018 3 2. If there is a discontinuation of use at any time, the PAP supplier is expected to ascertain adherence and stop billing for the equipment, related accessories and supplies. 3. In accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines, compliance is defined as use of PAP for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use of the PAP device and throughout the entire 13 month rental period. I II. Members that are not c ompliant with the use of their PAP machines will not be authorized further rental . A. Any reimbursement, for the PAP machine, that was dispensed during the time o f deviation will be recouped by CareSource. B. Any supplies that were dispensed during the time of deviation will be recouped by CareSource. Note:Although CareSource does not require a prior authorization during the first 3 months of use, CareSource may request documentation to support medical necessity that shows the members compliance with the use of the PAP machine. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. 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. The following list of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. Code Description A4604 Tubing with integrated heating element for use with positive airway pressure device A7030 Full face mask used with positive airway pressure device A7031 Face mask interface, replacement for full face mask A7032 Cushion for use on nasal mask interface, replacement only A7033 Pillow for use on nasal cannula type interface, replacement only, pair A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap A7035 Headgear used with positive airway pressure device A7037 Tubing used with positive airway pressure device A7038 Filter, disposable, used with positive airway pressure device A7039 Filter, non-disposable, used with positive airway pressure device E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface E0601 Continuous positive airway pressure (CPAP) device Archived Positive Airway Pressure Devices for Pulmonary Disorders INDIANA MARKETPLACE PLANS PY-0427 Effective Date: 07/15/2018 4 F.RELATED POLICIES/RUL ES N/A G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 01/25/2018 New Policy. Date Revised Date Effective 0 7/15/2018 H. REFERENCES 1. CPAP-NHLBI, NIH. (2018 , January 5). 2. Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) (2017, January 1). 3. Positive Airway Pressure (PAP) Devices: Complying with Documentation & Coverage Requirements. (2016, October). The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the ReimbursementPo licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENTINDIANA MARKETPLACE PLANS Original Issue Date Next Annual Review Effective Date 02/22/2018 07/15/2019 07/15/2018 Policy Name Policy Number Telemedicine Services PY-0425 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Contents of PolicyREIMBURSEMENT POLICY STATEMENT ………………………….. ………………………….. …. 1 TABLE OF CONTENTS ………………………….. ………………………….. ………………………….. .. 1 A. SUBJECT ………………………….. ………………………….. ………………………….. ………….. 2 B. BACKGROUND ………………………….. ………………………….. ………………………….. ….. 2 C. DEFINITIONS ………………………….. ………………………….. ………………………….. …….. 2 D. POLICY ………………………….. ………………………….. ………………………….. ……………. 2 E. CONDITIONS OF COVERAGE ………………………….. ………………………….. …………. 3 F. RELATED POLICIES/RULES ………………………….. ………………………….. …………… 5 G. REVIEW/REVISION HISTORY ………………………….. ………………………….. …………. 5 H. REFERENCES ………………………….. ………………………….. ………………………….. …… 6 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 care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical p ractice 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 ensu re an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e. , Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. 2 A. SUBJECTTelemedicine Services B. BACKGROUNDTelemedicine ServicesINDIANA MARKETPLACE PLANS PY-0425 Effective Date: 07/15/2018 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 se lf-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriateCPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Telemedicine is used to support health care when the provider and patient are physically separated. Typically, the patient communicates with the provider via interactive means that is sufficient to establish the necessary link to the provider who is working at a different location from the patient. CareSource will reimburse participating providers, for telemedicine services, who are credentialed to deliver telemedicine services rendered to CareSource members, as set forth in this policy. C. DEFINITIONS Asynchronous store and forward technologies – is the transmission of a patients medical information from an originating site to the physician or practitioner at the distant site. Distant Site – is the location of the physician or provider rendering health care services, via a telecommunications system. Interactive telecommunications system – is multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system. Originating Site – is the location of a CareSource member at the time the service, via a telecommunications system, occurs. Place of Service Codes (POS) – are codes that specifically indicate where a service or procedure was performed. Telemedicine Services – means Health Care Services delivered by the use of interactive audio, video or other electronic media, including medical examinations and consultations and evaluations related to Behavioral Health Care Serv ices. The term Telemedicine Services does not include the delivery of Health Care Services by use of a telephone transmitter for transtelephonic monitoring or a telephone or other communication for the consultation from one (1) Provider to another Provider . Telemedicine vendor – is the participating provider with CareSource that renders the telemedicine services. Note: Telehealth is sometimes used interchangeably with telemedicine in CurrentProcedural Terminology (CPT)/and Healthcare Common Procedure Coding System (HCPCS) code descriptions of services. D. POLICYI. CareSource does not require prior authorization for Telemedicine services. 3 Telemedicine ServicesINDIANA MARKETPLACE PLANS PY-0425 Effective Date: 07/15/2018 II. Telemedicine services may be reimbursed according to Medicare guidelines set forth by Centers for Medicare & Medicaid Services (CMS) and using appropriate CPT and/or HCPCS and modifier codes. III. As a condition of payment, providers must use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the CareSource member, at the originating site. A. The service must be furnished via an interactive telecommunications system. B. The service must be furnished by a physician or authorized practitioner. C. The service must be furnished to an eligible telehealth individual. D. The individual receiving the service must be located in a telehealth originating site. Note: Asynchronous store and forward technology is permitted only in Federal telemedicine demonstration programs in Alaska or Hawaii. IV. For ESRD-related services, a physician, NP, PA, or CNS must furnish at least one hands on visit (not telehealth) each month to examine the vascular access site, for End-Stage Renal Disease (ESRD). V. Originating sites are paid an originating site facility fee for telehealth services as described byHCPCS code Q3014. A. Independent Renal Dialysis Facilities are not considered originating sites. B. When a Community Mental Health Center (CMHC) serves as an originating site, the originating site facility fee does not count toward the number of services used to determine payment for partial hospitalizatio n services. Note: Although telemedicine/telehealth services do not require a prior authorizationCareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. E. CONDITIONS OF COVERAGEReimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the Medicare fee schedule. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Codes DescriptionG0108 and G0109Individual and group diabetes self-management training services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training G0270 Individual and group medical nutrition therapy G0396 and G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services G0425 G0427 Telehealth consultations, emergency department or initial inpatient G0406 G0408 Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs G0420 and G0421 Individual and group kidney disease education services G0436 and G0437 Smoking cessation services G0436 and G0437 Smoking cessation services 4 Telemedicine ServicesINDIANA MARKETPLACE PLANS PY-0425 Effective Date: 07/15/2018 G0438 Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) first visit G0439 Annual Wellness Visit, includes a personalized prevention plan of service (PPPS) subsequent visit G0442 Annual alcohol misuse screening, 15 minutes G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes G0444 Annual depression screening, 15 minutes G0445High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi – annually, 30 minutes G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes G0447 Face-to-face behavioral counseling for obesity, 15 minutes G0459 Telehealth Pharmacologic Management 90791 Psychiatric Diagnostic Evaluation w/o Medical 90792 Psychiatric Diagnostic Evaluation w/ Medical 90832 Individual Psychotherapy – 30 minutes 90833 Individual Psychotherapy w/ E/M Service 90834 Individual Psychotherapy 45 minutes 90836 Individual Psychotherapy w/ E/M Service 90837 Individual Psychotherapy 60+ minutes 90838 Individual Psychotherapy w/ E/M Service 90846 Family Psychotherapy w/o patient 50 minutes 90847 Family psychotherapy (conjoint, w/ patient present) 50 minutes 90849 Multiple-family group psychotherapy 90853 Group Psychotherapy (not multi-family group) 96101 Psychological Testing 96111 Developmental Testing 96116 Neurobehavioral Status Exam 96118 Neuropsychological Testing 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961 End-Stage Renal Disease (ESRD) -related services included in the monthly capitation payment 90963End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) 90964End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents (effective for services furnished on and after January 1, 2016) 90965End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents. 90966 End-Stage Renal Disease (ESRD) -related services for home dialysis per full month, for patients 20 years of age and older. 96116 Neurobehavioral status examination 96150 96154 Individual and group health and behavior assessment and intervention 5 Telemedicine ServicesINDIANA MARKETPLACE PLANS PY-0425 Effective Date: 07/15/2018 97802-97804 Individual and group medical nutrition therapy 99201 99215 Office or other outpatient visits 99231 99233 Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days 99307 99310 Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days 99354 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour 99355Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes 99356Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service). 99357Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service). 99406 and 99407 Smoking cessation services 99495 Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge) 99496 Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge) H0036 Community Psychiatric Supportive Treatment Individual or Group H0001 SUD Assessment H0004 SUD Individual Counseling H0005 SUD Group Counseling H0006 SUD Case Management Q3014 Telehealth originating site facility fee Modifier Description GT Via interactive audio and video telecommunication systems 95 Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System For further information please reference: 1. https:// www.cms.gov/Outreach-and-Education/Medicare-Learning-Network – MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf 2. Medicare.gov: Coverage for Telehealth. F. RELATED POLICIES/RULESN/A G. REVIEW/REVISION HISTORYDATE ACTIONDate Issued 02/22/2018 New Policy.Date Reviewed Date Effective 07/15/2018 Archive Date 03 /05/2021 6 H. REFERENCESTelemedicine ServicesINDIANA MARKETPLACE PLANS PY-0425 Effective Date: 07/15/2018 1. Telehealth – Centers for Medicare & Medicaid Services. (2017, December 1). 2. Telehealth Services. (2016, November). 3. Telehealth Services (2017, December 1). 4. Telehealth | Medicare.gov . (2017, December 1). 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 PLANOriginal Issue Date Next Annual Review Effective Date 09/06/2017 06/ 15 /2019 06/ 15 /2018 Policy Name Policy Number Genetic Testing-Polymerase Chain Reaction PY-030 9 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY ………………………………………………………………………………………………….. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 4 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Genetic Testing-Polymerase Chain Reaction INDIANA Marketplace Plan PY-0309 Effective Date: 06/15/2018 2 A.SUBJECT Genetic Testing-Polymerase Chain Reaction B. BACKGROUND Polymerase Chain Reaction (PCR) is a genetic amplification technique that only requires small quantities of DNA, for example, 0.1 mg of DNA from a single cell, to achieve DNA analysis in a shorter laboratory processing time period. Knowing the gene sequence, or at minimum the borders of the target segment of DNA to be amplified, is a prerequisite to a successful PCR amplification of DNA. PCR plays a diagnostic role when selected pathogens pose difficulties for specimen collection or culture characteristics (time, environment, or substrate constraints). For example, evaluating viral load by PCR technique for HIV helps gauge response to therapies. However, the technique is also so sensitive that amplified contaminant DNA is problematic to achieving valid test results. False positive results may also occur if DNA from one specimen contaminates another. The technique cannot distinguish DNA from colonizing organisms, or even DNA from dead microbes in a specimen, from those causing clinically significant infections. In fact, for many types of microbes the test sensitivities, specificities, and predictive values of PCR gene testing are not reported for large patient groups. Repeated cycles of synthesizing complementary strands of DNA are performed in a stepwise manner up to 30 times to achieve adequate gene amplification for diagnosis. Cycles involve 1) denaturing DNA with heat to create single strands, 2) annealing PCR primers of oligonucleotides (short pieces of DNA of 20-30 base pairs each) to the DNA to be amplified, and 3) enzymatic synthesis of complementary DNA with Taq polymerase or Pfu polymerase. All facilities in the United States that perform laboratory testing on human specimens for health assessment or the diagnosis, prevention, or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Waived tests include test systems cleared by the FDA for home use and those tests approved for waiver under the CLIA criteria. Although CLIA requires that waived tests must be simple and have a low risk for erroneous results, this does not mean that waived tests are completely error-proof. Errors can occur anywhere in the testing process, particularly when the manufacturer’s instructions are not followed and when testing personnel are not familiar with all aspects of the test system. Some waived tests have potential for serious health impacts and unintended consequences if performed incorrectly. To decrease the risk of erroneous results, the test needs to be performed correctly, by trained personnel and in an environment where good laboratory practices are followed. CareSource may periodically require rev iew of a providers office testing policies and procedures when performing CLIA-waived tests. CareSource will cover influenza testing with the CPT 87502 only when a CLIA-waived manufacturer testing system performs gene amplification by polymerase chain reaction (PCR) or nucleic acid amplification technology (NAT) testing. Appropriate indications must be documented in the members medical record and available for review by CareSource upon request. C. DEFINITIONS Polymerase Chain Reaction (PCR) – a genetic amplification technique also known as a Nucleic Acid Amplification Test (NAAT) D. POLICY I. A Prior Authorization is not required for selected PCR testing. II. CareSource considers nucleic acid amplification testing (NAAT) by polymerase chain reaction (PCR) to be medically necessary for the following indications in oncology and heritable conditions: ArchivedGenetic Testing-Polymerase Chain Reaction INDIANA Marketplace Plan PY-0309 Effective Date: 06/15/2018 3 A.Chronic Lymphocytic Leukemia (CLL) [1] B. BCR-ABL testing for Chronic Myelogenous Leukemia (CML) [2] [3] [4] C. Mucosa-Associated Lymphoid Tissue (MALT) [5] D. Ly nch syndrome [6] [7] E. BRAF mutation which is seen in colorectal carcinoma, gliomas, hepatobiliary carcinomas, melanoma, papillary thyroid carcinoma, ovarian teratomas and serous tumors, and hairy-cell leukemia (HCL). [8,9] F. The use of PCR gene testing for persons who meet criteria has been demonstrated in a variety of heritable conditions and is supported by published literature or endorsed by consensus professional societies. These conditions include certain primary thrombophilias[10], Tay-Sachs and Canavan diseases[11], Fabry disease[12], Gaucher disease[13], Niemann-pick disease[14], Hemochromatosis[15], Rett syndrome[16], Huntington’s disease[17], Celiac disease[18], Ankylosing spondylitis[19], Prader-Willi or Angelman syndrome, and other short-stature syndromes[20], Fragile Xsyndrome[21], and sickle-cell disease[22]. Applications of selected PCR techniques are also part of the workup and management for candidates donating organs and tissues. [23, 24] The first-line screening test for Tay-Sachs remains an enzyme activity test rather than genotyping. Genotyping is used for preimplantation diagnosis and confirmatory testing. In contrast, DNA-based testing is used for Canavan screening and diagnosis. G. Methylenetetrahydrofolate reductase (MTHFR) polymorphism testing has little clinical utility and does not meet medical necessity criteria as meta-analyses have disproven an association between elevated homocysteine and risk for coronary artery disease and between MTHFR polymorphisms and risk for venous thromboem bolism.[25] III. CareSource considers NAAT by PCR to be medically necessary for the following indications in infectious disease management: A. Shiga toxin –producing Escherichia coli (STEC) [26] B. C. difficile enterocolitis [27-29] C. Entamoeba species [30,31] D. Tuberculosis[32] E. Staphylococcus aureus[33] F. Actinomyces species may be identified in tissue specimens with a 16s rRNA sequencing and PCR assay.[34, 35] G. Dengue is a mosquito-borne febrile illness and diagnosis requires laboratory confirmation by culture, NAAT or testing for dengue specific antibodies.[37] For other mosquito-borne illnesses such as West Nile virus and Zika, PCR also has diagnostic utility, including in saliva tests.[38] Ebola may be diagnosed by PCR techniques on plasma.[39] IV. CareSource considers viral PCR testing in conjunction with a Clinical Laboratory Improvement Amendments (CLIA)-approved reference lab as medically necessary for indications endorsed in a primary or supplemental diagnostic approach as described by the Infectious Diseases Society of America (IDSA) . [40] Many molecular diagnostic tests for viral pathogens include PCR techniques, offered by CLIA-certified reference laboratories. Viral syndrome testing is considered based on the patient’s age, history, immune status, and other variables. According to the IDSA, diagnostic samples are obtained and tested for the most likely agents.[40] Samples are commonly held frozen in the microbiology laboratory for additional testing if necessary, given that it is not cost-effective to test initial samples broadly for multiple viruses.[40] These viral pathogens include: A. Herpes virus infections [41, 42], Varicella and Zoster[43], Measles[44], Mumps[45], Cytomegalovirus [40], Adenovirus [40], Enterovirus [42], and Parvovirus [40]. B. For persons with positive HIV, antigen/antibody combination immunoassays and either HIV-1 negative or indeterminate HIV-2 differentiation immunoassay, PCR testing is indicated.[40, 46, 47] Archived Genetic Testing-Polymerase Chain Reaction INDIANA Marketplace Plan PY-0309 Effective Date: 06/15/2018 4 C.The diagnosis of hepatitis B (HBV) or C (HCV) typically begins with an antibody test for screening or in the presence of acute hepatitis. For hepatitis B, PCR viral genetic assays may be applied to determine viral genotype, detecting genotypic drug resistance mutations, and identifying core promoter/precore mutations.[48] For hepatitis C, persons with positive screening test results should undergo confirmatory or supplemental testing for HCV RNA by molecular test methods. V. PCR techniques have been developed for a variety of respiratory pathogens and may be included in diagnostic algorithms for affected persons in the pediatric and adult populations. The Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) consensus guidelines on the management of community-acquired pneumonia in adults report that testing is optional for persons who are not hospitalized [49]. However, patients who require hospitalization should have pretreatment blood cultures, culture and Gram stain of good-quality samples of expectorated sputum and, if disease is severe, urinary antigen tests for S. pneumoniae and Legionella pneumophila, when available . [49] Evaluation of bronchoscopically obtained samples and/or thoracentesis-obtained samples of pleural fluid may be necessary for diagnosis in hospitalized persons unable to produce a sputum sample. PCR testing may be applied in selected cases where microorganisms are suspected based upon age, history, immune status, and other variables. PCR testing is available for Mycoplasma. [ 49] VI. CareSource considers PCR testing for pathogens of other types or in other anatomic sites medically necessary as described by the IDSA and the American Society for Microbiology (ASM) in A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). [40] Guidelines were developed by both laboratory and clinical experts and provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions.[40] VII. For many pathogens, while a PCR test is available, the clinical utility is not clearly defined by available evidence, evidence is insufficient or inconclusive, or there is no support for quantification PCR testing. For Bartonella henselae and quintona species, immunofluorescent antibody assay serology is sensitive and specific, and there is no inconclusive evidence of an indication for quantification . [50, 51]. For many pathogens, such as Chlamydia pneumoniae, Hepatitis G, herpes simplex virus (HSV), Herpes virus-6, Legionella pneumophilia, Mycobacteria avium-intracellulare, Mycoplasma pneumoniae, Neisseria gonorrhoeae, and Streptococcus, group A guidelines from the IDSA do not have a recommendation for quantification.[40] VIII. For sexually transmitted infections including Chlamydia, Gonorrhea, Syphilis, and other pathogens, refer to the CareSource Sexually Transmitted Infection (STI) policy. E. CONDITIONS OF COVERAGE HCPCS CPT AUTHORIZATION PERIOD F. RELATED POLICIES/RUL ES 1. Genetic Testing, Genetic Screening and Genetic Counseling (MM-0003) 2. Sexually Transmitted Infections (PY-0037) ArchivedGenetic Testing-Polymerase Chain Reaction INDIANA Marketplace Plan PY-0309 Effective Date: 06/15/2018 5 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 09/06/2017 New Policy. Date Revised Date Effective 06/ 15 /2018 H. REFERENCES [1] D. Kienle, A. Benner, C. Laufle, D. Winkler, C. Schneider, A. Buhler , et al., “Gene expression factors as predictors of genetic risk and survival in chronic lymphocytic leukemia,” Haematologica, vol. 95, pp. 102-9, Jan 2010. [2] F. Notta, C. G. Mullighan, J. C. Wang, A. Poeppl, S. Doulatov, L. A. Phillips , et al., “Evolution of human BCR-ABL1 lymphoblastic leukaemia-initiating cells,” Nature, vol. 469, pp. 362-367, 2011. [3] A. A. Darji and P. D. Bharadia, “CHRONIC MYELOGENOUS LEUKEMIA: A REVIEW AND UPDATE OF CURRENT AND FUTURE THERAPY,” International Journal of Pharmacy and Pharmaceutical Sciences, vol. 8, 2016. [4] M. W. Deininger, “Molecular monitoring in CML and the prospects for treatment-free remissions,” Hematology Am Soc Hematol Educ Program, vol. 2015, pp. 257-63, 2015. [5] A. D. Zelenetz, J. S. Abramson, R. H. Advani, C. B. Andreadis, J. C. Byrd, M. S. Czuczman , et al. , “NCCN Clinical Practice Guidelines in Oncology: non-Hodgkin’s lymphomas,” JNatl Compr Canc Netw, vol. 8, pp. 288-334, Mar 2010. [6] H. Hampel, “NCCN increases the emphasis on genetic/familial high-risk assessment in [7] K. M. Chin, B. Wessler, P. Chew, and J. Lau, “Genetic Tests for Cancer,” in Genetic Tests for Cancer , ed Rockville (MD), 2006. [8] P. G. Febbo, M. Ladanyi, K. D. Aldape, A. M. De Marzo, M. E. Hammond, D. F. Hayes , et al., “NCCN Task Force report: Evaluating the clinical utility of tumor markers in oncology,” Journal of the National Comprehensive Cancer Network, vol. 9, pp. S-1-S-32, 2011. [9] S. Pakneshan, A. Salajegheh, R. A. Smith, and A. K. Lam, “Clinicopathological relevance of BRAF mutations in human cancer,” Pathology, vol. 45, pp. 346-56, Jun 2013. [10] S. Moll, “W ho should be tested for thrombophilia?,” Genet Med, vol. 13, pp. 19-20, 01//print 2011. [11] A. Colaianni, S. Chandrasekharan, and R. Cook-Deegan, “Impact of gene patents and licensing practices on access to genetic testing and carrier screening for Tay-Sachs and Canavan disease,” Genet Med, vol. 12, pp. S5-S14, 04//print 2010. [12] R. Schiffmann, M. Fuller, L. A. Clarke, and J. M. F. G. Aerts, “Is it Fabry disease?,” Genet Med, 05/19/online 2016. [13] C. R. Scott, G. Pastores, H. Andersson, J. Charrow, P. Kaplan, E. Kolodny , et al., “The clinical expression of Gaucher disease correlates with genotype: Data from 570 patients,” Genet Med, vol. 2, pp. 65-65, 01//print 2000. [14] R. Y. Wang, O. A. Bodamer, M. S. Watson, and W. R. Wilcox, “Lysosomal storage diseases: Diagnostic confirmation and management of presymptomatic individuals, ” Genet Med, vol. 13, pp. 457-484, 05//print 2011. [15] C. Mura, O. Raguenes, V. Scotet, S. Jacolot, A.-Y. Mercier, and C. Ferec, “A 6-year survey of HFE gene test for hemochromatosis diagnosis,” Genet Med, vol. 7, pp. 68-73, 01//print 2005. [16] T. Bienvenu and J. Chelly, “Molecular genetics of Rett syndrome: when DNA methylation goes unrecognized,” Nat Rev Genet, vol. 7, pp. 415-426, 06//print 2006. [17] W. H. Rogowski, S. D. Grosse, and M. J. Khoury, “Challenges of translating genetic tests into clinical and public health practice,” Nat Rev Genet, vol. 10, pp. 489-495, 07//print 2009. [18] G. J. Tack, W. H. M. Verbeek, M. W. J. Schreurs, and C. J. J. Mulder, “The spectrum of celiac disease: epidemiology, clinical aspects and treatment,” Nat Rev Gastroenterol Hepatol, vol. 7, pp. 204-213, 04//print 2010. [19] L. -S. Tam, J. Gu, and D. Yu, “Pathogenesis of ankylosing spondylitis,” Nat Rev Rheumatol, vol. 6, pp. 399-405, 07//print 2010. Archived Genetic Testing-Polymerase Chain Reaction INDIANA Marketplace Plan PY-0309 Effective Date: 06/15/2018 6 [20] S. B. Cassidy, S. Schwartz, J. L. Miller, and D. J. Driscoll, “Prader-Willi syndrome,” Genet Med, vol. 14, pp. 10-26, 01//print 2012. [21] D. C. Crawford, J. M. Acuna, and S. L. Sherman, “FMR1 and the fragile Xsyndrome: Human genome epidemiology review,” Genet Med, vol. 3, pp. 359-371, 09//print 2001. [22] M. Bender and G. D. Seibel, “Sickle cell disease,” 2014. [23] N. Kamani, S. Spellman, C. K. Hurley, J. N. Barker, F. O. Smith, M. Oudshoorn , et al., “State of the art review: HLA matching and outcome of unrelated donor umbilical cord blood transplants,” Biol Blood Marrow Transplant, vol. 14, pp. 1-6, Jan 2008. [24] L. D’Orsogna, S. Fidler, A. Irish, B. Saker, H. Moody, and F. T. Christiansen, “HLA donor-specific antibody detected by solid phase assay identifies high-risk transplantation pairs irrespective of CDC crossmatch results: case reports and literature review,” Clin Transpl, pp. 497-501, 2006. [25] S. E. Hickey, C. J. Curry, and H. V. Toriello, “ACMG Practice Guideline: lack of evidence for MTHFR polymorphism testing,” Genet Med, vol. 15, pp. 153-6, Feb 2013. [26] L. H. Gould, C. Bopp, N. Strockbine, R. Atkinson, V. Baselski, B. Body , et al., “Recommendations for diagnosis of shiga toxin –producing Escherichia coli infections by clinical laboratories,” MMWR Recomm Rep, vol. 58, pp. 1-14, Oct 16 2009. [27] S. H. Cohen, D. N. Gerding, S. Johnson, C. P. Kelly, V. G. Loo, L. C. McDonald , et al., “Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA),” Infect Control Hosp Epidemiol, vol. 31, pp. 431-55, May 2010. [28] S. B. Selvaraju, M. Gripka, K. Estes, A. Nguyen, M. A. Jackson, and R. Selvarangan, “Detection of toxigenic Clostridium difficile in pediatric stool samples: an evaluation of Quik Check Complete Antigen assay, BD GeneOhm Cdiff PCR, and ProGastro Cd PCR assays,” Diagnostic Microbiology and Infectious Disease, vol. 71, pp. 224-229, 11// 2011. [29] M. H. Wilcox, T. Planche, F. C. Fang, and P. Gilligan, “What is the current role of algorithmic approaches for diagnosis of Clostridium difficile infection?,” JClin Microbiol, vol. 48, pp. 4347-53, Dec 2010. [30] S. Roy, M. Kabir, D. Mondal, I. K. M. Ali, W. A. Petri, and R. Haque, “Real-time-PCR assay for diagnosis of Entamoeba histolytica infection,” Journal of clinical microbiology, vol. 43, pp. 2168-2172, 2005. [31] S. Solaymani-Mohammadi, C. M. Coyle, S. M. Factor, and W. A. Petri Jr, “Amebic colitis in an antigenically and serologically negative patient: usefulness of a small-subunit ribosomal RNA gene-based polymerase chain reaction in diagnosis,” Diagnostic Microbiology and Infectious Disease, vol. 62, pp. 333-335, 11// 2008. [32] P. Nahid, S. E. Dorman, N. Alipanah, P. M. Barry, J. L. Brozek, A. Cattamanchi , et al., “Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis,” Clinical Infectious Diseases, p. ciw376, 2016. [33] D. L. Stevens, A. L. Bisno, H. F. Chambers, E. P. Dellinger, E. J. Goldstein, S. L. Gorbach , et al. , “Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America,” Clinical Infectious Diseases, vol. 59, pp. e10-e52, 2014. [34] M. J. Belmont, P. M. Behar, and M. K. Wax, “Atypical presentations of actinomycosis,” Head & neck, vol. 21, pp. 264-268, 1999. [35] T. Hansen, M. Kunkel, E. Springer, C. Walter, A. Weber, E. Siegel , et al., “Actinomycosis of the jaws –histopathological study of 45 patients shows significant involvement in bisphosphonate-associated osteonecrosis and infected osteoradionecrosis,” Virchows Arch, vol. 451, pp. 1009-17, Dec 2007. [36] C. L. Schroeder, H. P. Narra, M. Rojas, A. Sahni, J. Patel, K. Khanipov , et al., “Bacterial small RNAs in the Genus Rickettsia,” BMC Genomics, vol. 16, p. 1075, 2015. [37] M. G. Teixeira and M. L. Barreto, “Diagnosis and management of dengue,” BMJ, vol. 339, 2009. ArchivedGenetic Testing-Polymerase Chain Reaction INDIANA Marketplace Plan PY-0309 Effective Date: 06/15/2018 7 [38]D. Musso, C. Roche, T. X. Nhan, E. Robin, A. Teissier, and V. M. Cao-Lormeau, “Detection of Zika virus in saliva,” JClin Virol, vol. 68, pp. 53-5, Jul 2015. [39] J. R. Spengler, A. K. McElroy, J. R. Harmon, U. Stroher, S. T. Nichol, and C. F. Spiropoulou, “Relationship Between Ebola Virus Real-Time Quantitative Polymerase Chain Reaction-Based Threshold Cycle Value and Virus Isolation From Human Plasma,” JInfect Dis, vol. 212 Suppl 2, pp. S346-9, Oct 1 2015. [40] E. J. Baron, J. M. Miller, M. P. Weinstein, S. S. Richter, P. H. Gilligan, R. B. Thomson , et al., “A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2013 Recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM) a,” Clinical Infectious Diseases, vol. 57, pp. e22-e121, August 15, 2013 2013. [41] D. W . Kimberlin, “Diagnosis of herpes simplex virus in the era of polymerase chain reaction,” The Pediatric infectious disease journal, vol. 25, pp. 841-842, 2006. [42] R. L. DeBiasi and K. L. Tyler, “Molecular methods for diagnosis of viral encephalitis,” Clinical microbiology reviews, vol. 17, pp. 903-925, 2004. [43] P. A. Thomas and P. Geraldine, “Infectious keratitis,” Current opinion in infectious diseases, vol. 20, pp. 129-141, 2007. [44] R. S. van Binnendijk, S. van den Hof, H. van den Kerkhof, R. H. G. Kohl, F. Woonink, G. A. M. Berbers , et al., “Evaluation of Serological and Virological Tests in the Diagnosis of Clinical and Subclinical Measles Virus Infections during an Outbreak of Measles in The Netherlands,” Journal of Infectious Diseases, vol. 188, pp. 898-903, September 15, 2003 2003. [45] C. H. Krause, K. Eastick, and M. M. Ogilvie, “Real-time PCR for mumps diagnosis on clinical specimens comparison with results of conventional methods of virus detection and nested PCR,” Journal of clinical virology, vol. 37, pp. 184-189, 2006. [46] CDC. (2014, Quick reference guide-Laboratory testing for the diagnosis of HIV infection : updated recommendations. CDC Stacks. Available: https://stacks.cdc.gov/view/cdc/23446 [47] G. Murphy and C. Aitken, “HIV testing the perspective from across the pond,” Journal of Clinical Virology, vol. 52, pp. S71-S76, 2011. [48] A. Valsamakis, “Molecular testing in the diagnosis and management of chronic hepatitis B,” Clinical microbiology reviews, vol. 20, pp. 426-439, 2007. [49] L. A. Mandell, R. G. Wunderink, A. Anzueto, J. G. Bartlett, G. D. Campbell, N. C. Dean , et al. , “Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults,” Clinical Infectious Diseases, vol. 44, pp. S27-S72, March 1, 2007 2007. [50] P. E. Fournier, J. L. Mainardi, and D. Raoult, “Value of microimmunofluorescence for diagnosis and follow-up of Bartonella endocarditis,” Clin Diagn Lab Immunol, vol. 9, pp. 795-801, Jul 2002. [51] L. M. Mofenson, M. T. Brady, S. P. Danner, K. L. Dominguez, R. Hazra, E. Handelsman , et al., “Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics,” MMWR Recomm Rep, vol. 58, pp. 1-166, Sep 4 2009. [52] K. A. Workowski, S. Berman, C. Centers for Disease, and Prevention, “Sexually transmitted diseases treatment guidelines, 2010,” MMWR Recomm Rep, vol. 59, pp. 1-110, Dec 17 2010. [53] ACOG, “ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis,” Obstet Gynecol, vol. 107, pp. 1195-1206, May 2006. The Reimbursement Policy Statement detailed a bove has r eceived due consi deration as defined in the Reimbursement Po li cy Stateme nt Po li cy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANSOriginal Issue Date Next Annual Review Effective Date 09/06/2017 06/ 15 /2019 06/ 15 /2018 Policy Name Policy Number Smoking & Tobacco Cessation PY-0 3 79 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RULES ……………………………………………………………………. 3 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 3 H.REFERENCES ………………………………………………………………………………………… 4Archived Smoking & Tobacco Cessation INDIANA MARKETPLACE PLANS PY-0379 Effective Date: 06/15/2018 2 A. SUBJECT Smoking & Tobacco Cessation B. BACKGROUND The use of tobacco products generally leads to tobacco/nicotine dependence 6and often results in serious health problems. Quitting smoking greatly reduces the risk of developing smoking-related diseases . Tobacco/nicotine dependence is a condition that often requires repeated treatments, as nicotine is strongly addictive. Because of this, quitting smoking and ending the use of tobacco use may be a difficult process requiring several, staged attempts, and may involve stress, irritability, and other withdrawal symptoms for those addicted to nicotine 8,9, 10. However, continued tobacco use in any form is far more harmful. Tobacco smoke contains seriously harmful chemicals and carcinogens 5, 8, 11and leads to lung and other cancers, chronic lung disease, heart disease, strokes, vascular disease, and infertility. Additionally, smokeless tobacco is directly linked to cancers of the mouth, tongue, cheek, gum, esophagus, and pancreas. Counseling and medication are both effective means for ending dependency on tobacco products, and are even more effective together than either method alone 10. Counseling can be effective when delivered via individual, group, or telephone counseling, one-on-one brief help sessions with a provider, behavioral therapies, or even through mobile phone apps. Medications which have been found to be effective include prescription non-nicotine medications such as bupropion SR (Zyban ) and varenicline tartrate (Chantix ), and nicotine replacement products such as nicotine patches, inhalers or nasal sprays available by prescription, a nd over-the-counter nicotine patches, gums or lozenges 10, 17. The United States government recognizes the health dangers and risks associated with the use of tobacco in its citizens and has set up a free telephone support service to help people stop smoking and stop the use of tobacco, 1-800-QUIT-NOW. Callers are routed through this service to their states specific resource, and may be able to obtain free support, advice, and counseling from experienced quit-line coaches, a personalized plan to quit, practical information on how to quit, including ways to cope with nicotine withdrawal, the latest information about stop-smoking medications, free or discounted medications (available for at least some callers in most states), referrals to other resources, and/or mailed self-help materials. CareSource encourages all of its members to refrain from the use of tobacco, and if using it in any form , to make concerted and ongoing attempts to quit its use as soon as possible. C. DEFINITIONS Tobacco products means any product containing tobacco or nicotine, including (but not limited to) cigarettes, pipes, cigars, cigarillos, bidis, hookahs, kreteks, e-cigarettes, vaporized and other inhaled tobacco and nicotine products, smokeless tobacco (e.g., dip, chew, snuff, snus), dissolvable tobacco (e.g., strips, sticks, orbs, lozenges), or other ingestible tobacco products, and/or chewing tobacco. D. POLICY I. Prior authorizations are required for participating (contracted) providers only when the services they are providing for tobacco cessation exceed the limits of this policy. Archived Smoking & Tobacco Cessation INDIANA MARKETPLACE PLANS PY-0379 Effective Date: 06/15/2018 3 II. Non-participating providers (not contracted with CareSource) should contact CareSource for prior authorization for these services. III. CareSource will reimburse its participating providers for the following tobacco use intervention and cessation care methods: A. An encounter for evaluation and management of the member on the same day as counseling to prevent or cease tobacco use; and, B. One screening for tobacco use per member per calendar year, if necessary; and, C. Three individual tobacco cessation counseling attempts per calendar year. 1. Each attempt may include a maximum of 4 intermediate or intensive sessions, with a total benefit of up to 12 sessions per calendar year per member. D. Nicotine replacement or non-nicotine medications prescribed and approved for use for tobacco cessation. IV. CareSource will not reimburse claims for counseling to prevent or cease tobacco use in excess of 12 sessions within a calendar year, unless prior authorization has been obtained by the provider. V. The number of CPT, HCPCS, and diagnosis codes (ICD-10) potentially associated with the diagnosis and treatment of tobacco use and addiction is too great to list. As such the specific tobacco cessation codes provided below are eligible to be reimbursed with any appropriate, associated code. VI. Evaluation and management service for the member on the same day as counseling to prevent or cease tobacco use should be reported with modifier-25 to indicate that the service is separately identifiable from the counseling. 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 to the CMS fee schedules. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODES DESCRIPTION 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes S9453 Smoking cessation classes, non-physician provider, per session F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 09/06/2017 New Policy. Date Revised Date Effective 06/ 15 /2018 ArchivedSmoking & Tobacco Cessation INDIANA MARKETPLACE PLANS PY-0379 Effective Date: 06/15/2018 4 H.REFERENCES 1.42 U.S. Code 18021-Qualified health plan defined | US Law | LII / Legal Information Institute. (n.d.). Retrieved from https://www.law.cornell.edu/uscode/text/42/18021 2.CDC-Fact Sheet-Quitting Smoking-Smoking & Tobacco Use. (n.d.). Retrieved August 31, 2017, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm 3. Counseling to Prevent Tobacco Use. ( Transmittal 2058, 2010, September 30). Centers for Medicare & Medicaid Services, Department of Health & Human Services. Retrieved September 5, 2017 from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/ 4. Treating Tobacco Use and Dependence. Clinical Practice Guideline. (n.d.). Fiore, Michael C (panel chair), Guideline panel members. (University of Wisconsin Medical School, Center for Tobacco Research and Intervention (Madison, WI)) Retrieved August 25, 2017, from http://lib.adai.washington.edu/dbtw-wpd/exec/dbtwpub.dll?AC=GET_RECORD&XC=/dbtw-wpd/exec/dbtwpub.dll&BU=http%3A%2F%2Flib.adai.washington.edu%2Febpchecksearch.ht m&TN=EBP&SN=AUTO30019&SE=457&RN=4&MR=0&TR=0&TX=1000&ES=1&CS=0&XP=&RF=Brief+Display&EF=&DF=Full+Display&RL=1&EL=1&DL=0&NP=3&ID=&MF=searchb utton.ini&MQ=&TI=0&DT=&ST=0&IR=50&NR=0&NB=0&SV=0&SS=0&BG=&FG=000000&QS=&OEX=ISO-8859-1&OEH=ISO-8859-1 5. U.S. Department of Health and Human Services. The Health Consequences of Smoking50 Years of Progress: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. 6. National Institute on Drug Abuse. Research Report Series: Is Nicotine Addictive? . Bethesda (MD): National Institutes of Health, National Institute on Drug Abuse, 2012. 7.American Society of Addiction Medicine. Public Policy Statement on Nicotine Addiction and To bacco . Chevy Chase (MD): American Society of Addiction Medicine, 2008. 8. U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. 9.U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. 10. Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 UpdateClinical Practice Guidelines . Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality, 2008. 11. National Toxicology Program. Report on Carcinogens, Thirteenth Edition . Research Triangle Park (NC): U.S. Department of Health and Human Sciences, National Institute of Environmental Health Sciences, National Toxicology Program, 2014. 12.U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. 13. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon General . Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1990. 14.Centers for Disease Control and Prevention. Quitting Smoking Among AdultsUnited States, 20002015 . Morbidity and Mortality Weekly Report 2017;65(52):1457-64. 15. Centers for Disease Control and Prevention. Youth Risk Behavior SurveillanceUnited States, 2015 . Morbidity and Mortality Weekly Report [serial online] 2016;66 (SS6):1 174. Archived Smoking & Tobacco Cessation INDIANA MARKETPLACE PLANS PY-0379 Effective Date: 06/15/2018 5 16.Centers for Disease Control and Prevention. The Guide to Community Preventive Services: Reducing Tobacco Use and Secondhand Smoke Exposure . 17. U.S. Food and Drug Administration. The FDA Approves Novel Medication for Smoking Cessation . FDA Consumer, 2006. The Reimbursement Policy Statement detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Original Issue Date Next Annual Review Effective Date 10/01 /2017 06/03/2019 06/03/2018 Policy Name Policy Number Drug Testing PY-0329 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 mem ber benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guideli nes. 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 pr olonged, 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 no t 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 the re is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e., Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 3 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 6 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 7 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 7 H.REFERENCES ………………………………………………………………………………………… 7Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 2 A.SUBJECT Drug Testing B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. Claims submitted to CareSource must be complete in all respects; and all use of the Health Insurance Claim Form CMS-1500 must comply with the most recent version of the Medicare Claims Processing Manual. Monitoring for controlled substances is performed to detect the use of prescription medications and illegal substances of concern for the purpose of medical treatment. Monitoring for controlled substances plays a key role particularly in the care of persons undergoing medical treatment with chronic pain therapy and substance-related disorder . Drug testing that is medically necessary for the management of members being treated with drugs that are potentially abusive or addictive such as opioids and related medications, or for members suspected of using illicit drugs solely or in combination with prescribed controlled substances is billable to CareSource . Qualitative/presumptive drug testing performed as part of routine, prenatal care for pregnant members is also billable to CareSource. Providers should have a working knowledge of analytic detection including primary agents, metabolites, lab threshold concentrations, and time periods involved in detection. Th e combination of a patient’s self-report and drug testing results serve as important tools in controlled substance monitoring, as well as a point of patient engagement. Qualitative/presumptive testing is a routine part of care, used when immediate results are needed, knowing results may be less accurate than quantitative/confirmatory tests. Quantitative/confirmatory testing is used when results may affect changes in medication, when patients dispute qualitative/presumptive results, or in treatment transitions. Anecdotal evidence to support testing for individual patients should be balanced with the limited population evidence for added value of multiple tests for chronic pain patients or SUD patients. For example, in a 2015 evaluation of 2,551,611 de-identified patients urine drug test results over four years in the U.S., Quest Diagnostics identified that the best achieved yearly inconsistency rate (when the results of a drug screen are not consistent with the patients history and prescribed medicines) in all urine drug tests was 53% (in 2014 vs 63% in 2011). C. DEFINITIONS Qualitative analysis-The testing of a substance or mix ture to determine its chemical constituents, also known as presumptive testing. Quantitative test-A test that determines the amount of a substance per unit volume or unit weight, also known as confirmatory testing. Random alcohol and drug test a lab test administered at an irregular interval which is not announced in advance to the person being tested, and which detects the presence of alcohol, drugs or substances in the individual . Independent laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a provider s office. Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 3 Participating/Non-pa rticipating Participating means in-network and contracted with CareSource. Non-participating means out-of-network, not contracted by CareSource. For further definitions please refer to the CareSource Drug Testing Medical Policy (MM-0130) posted here: https://www.caresource.com/providers/medicare-medical-policies/ D.POLICY NOTE:CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. I. General Criteria for Coverage : Clinical guidelines, standards, and scenarios for drug te sting 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 for drug testing, documentation required for claims, and CareSource monitoring and review of drug testing claims. II.Individualized Testing : In all cases other than routine qualitative/presumptive drug testing as part of prenatal care, medical necessity for submitted charges must be individualized and documented in the members medical record and included in the treatment plan of care. CareSource does not provide coverage for drug testing for forensic, legal, employment, transportation, school purposes, or other third-party requirement. III. Non-Urine Testing:CareSource will reimburse blood testing without a prior authorization in emergency department settings only, to evaluate acute overdose. Drug testing with blood samples performed in any other setting outside of an ER requires the provider or lab to obtain prior authorization in order to be reimbursed. Hair, saliva, or other body fluid testing for controlled substance monitoring has limited support in medical evidence and is not covered without prior authorization. Additionally, when non-urine drug testing is prior authorized, that non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing. NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. IV. Urine Testing : Urine for clinical drug testing is the specimen of choice because of its high drug concentrations and well-established testing procedures. Nevertheless, urine is one of the easiest specimens to adulterate. A. If the provider suspects such an occurrence, the provider may choose to evaluate specimen validity using validity tests. Specimen validity testing is considered to be a quality control issue and is included in the CPT code payment. Additional codes for specimen validity testing should not be separately billed to CareSource . Tests for creatinine, specific gravity, temperature, or nitrates are not billable to and will not be reimbursed by CareSource when submitted simultaneously with a drug testing CPT code and ICD substance-related disorder code. Failure to document customized tests with medical necessity information for each individual member and for each of the drug tests ordered will result in the denial of the claim for reimbursement, audit, and/or overpayment requests, and any other program means for enforcing this policy. Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 4 B.Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse. C. Orders for custom profiles, standing orders, drug screen panel, custom panel, blanket orders, reflex testing or to conduct additional testing as needed, are not billable to and will not be reimbursed by CareSource. D. Testing on a routine basis is neither random nor individualized. Routine or reflex testing is not billable to and will not be reimbursed by CareSource. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random. E. CareSource does not provide coverage for drug testing as a requirement to stay in a facility, for example, in sober living or residential locations. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. F. . V. Provider Orders : CareSource requires that the ordering provider s name appear in the appropriate lines of the claims forms;. A signed and dated provider order for the drug testing is required. The provider s order must specifically match the number, level and complexity of the testing components performed. VI. Non-participating providers :Non-participating providers are not covered for drug testing laboratory services. Non-participating providers may use participating laboratories for drug testing services. VII. Documentation Requirements : All documentation must be accurate, complete, maintained in the members medical record and available to CareSource upon request. The following documentation requirements apply: A. Medical record documentation (e.g., history and physical, progress notes) maintained by the ordering provider/treating provider must indicate the medical necessity for performing a qualitative/presumptive drug test. B. Every page of the record must be legible and include appropriate member identification information (e.g., complete name, dates of service(s)). C. The record must include the identity of the physician or non-physician practitioner responsible for and providing the care of the member. D. The submitted medical record should support the use of the selected ICD-10-CM code(s) with appropriate indications for urine drug testing. E. The submitted CPT/HCPCS code should accurately describe the service performed. F. Copies of test results alone without the proper provider s order for the test are not sufficient documentation of medical necessity to support a claim. G. Drug testing records and related entries in a members medical record must be provided to CareSource upon request for auditing of medical necessity. Documentation must support medical necessity and specify why each test is ordered. Documentation must also support the number of analytes requested for testing, and what action the provider will take upon the findings. VIII. Confirmatory and Duplicative Testing A. Routine multi-drug confirmatory testing is not billable to and will not be reimbursed by CareSource .Quantitative/confirmatory testing must be individualized and medically necessary. Routine confirmations (quantitative) of drug tests with negative results are not deemed medically necessary and are not covered by CareSource without a review and prior authorization . Quantitative/confirmatory testing is covered for a negative drug/drug class test when the negative finding is inconsistent with the members documented medical history and/or current documented chronic pain medication list. B. Routine nonspecific or wholesale orders for drug testing (qualitative), confirmation, and Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 5 quantitative drugs of abuse testing are not billable. IX. Independent Laboratories A. Drug testing conducted for CareSource members by non-participating labs or facilities is not billable to and will not be reimbursed by CareSource, even if such tests were ordered by a participating provider. B. CareSource may require documentation of FDA-approved complexity level for instrumented equipment, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab. C. Both participating providers and non-participating providers may potentially order laboratory tests for CareSource members. D. Only participating independent laboratories can bill for quantitative/confirmatory drug tests. E. Laboratories must have the appropriate level of CLIA certification for the testing perform ed and be contracted (participating) with CareSource. F. Claims are not billable to CareSource if submitted by laboratories that are non-participating (not contracted) with CareSource. G. The ordering/referring provider must include the clinical indication/medical necessity in the order for the drug test as outlined above. H. The independent laboratory performing the drug testing must maintain hard copy documentation of the lab results, along with copies of the ordering/referring provider s order for the drug test. I. Participating laboratories performing drug testing services must bill CareSource directly. CareSource does not allow pass-through billing of services. Any claim submitted by a provider which includes services ordered by that provider but are performed by a person or entity other than that provider or a direct employee of that provider, is not billable to CareSource. X. Other Non-billable Drug Testing A. Standing orders set up between a provider and laboratory which are prewritten and/or result in the same drugs and drug classes to be tested on a routine, repeat basis, are not billable to and will not be reimbursed by CareSource. B. Drug testing is not billable to and will not be reimbursed by CareSource if required by a third party such as: 1. For medico-legal purposes (e.g., court-ordered drug testing); 2. For employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment); 3. As a condition of: 3.1 Participation in school or community athletic activities or programs 3.2 Participation in school or community extra circular activities or programs 4. As a component of a routine physical/medical examination; (e.g. enrollment in school, enrollment in the military, etc.) 5. As a component of medical examination for any other administrative purposes not listed above (e.g., for purposes of marriage licensure, insurance eligibility, etc.). 6. As a requirement to live in sober housing or residential services. Other than medically necessary indications for testing, drug testing required for a residential program is included in the cost of and payment for that program. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis, subsequent medical review audits, recovery of overpayments identified, and provider prepay review. Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 6 E.CONDITIONS OF COVERA GE Reimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPT codes along with appropriate modifiers and ICD-10 codes. Please refer to the CMS fee schedules . https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. NOTE: Drug testing codes listed in this policy which may include blood or other non-urine bodily fluids, or other physical samples in their coding definitions, are not billable to and will not be reimbursed by CareSource unless (1) the test is performed in the ER setting AND the sample used is blood, as stated above; or, (2) prior authorization has been obtained by the provider or lab. If covered, non-urine drug testing is reimbursed at the lesser of coverage amounts per CPT for urine testing and non-urine testing.Codes Description 80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service 80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service 80307 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) inc ludes sample validation when performed, per date of service G0480 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), includ ing, 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 re cognized 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 vari ations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed G0481 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and ( 3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class( es), including metabolite(s) if performed Archived Drug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 7 G0482 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/M S (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for mat rix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all so urces, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed G0483 Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 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 dehydrog enase)), (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 con trol material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed F. RELATED POLICIES/RULES See Drug Testing Medical Policy ( MM-0130) G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/01/2017 New Policy. Date Revised 11/29/2017 Updated limits, prior authorization requirements, and covered/defunct codes. 02/16/2018 Removed quantity limits and prior authorization. Date Effective 06/03/2018 H. REFERENCES 1. Current Procedural Terminology (CPT) and National Uniform Billing Committee (NUBC) Licenses. (n.d.). Retrieved from https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34645&ContrId=143&ver=26&ContrVer=1&CntrctrSelected=143*1&Cnt rctr=143&DocType=Active%7cFuture&s=All&bc=AgAAAAQAAAAAAA%3d%3d& 2. Barthwell, “Statement of Consensus on the Proper Utilization of Urin e Testing in Identifying and Treating Substance Use Disorders,” 2015. [Online]. Available: http://farronline.org/wp-content/uploads/2015/11/Final-Report-Statement-of-Consensus-on-the-Proper-Utilization-of-Urine-Testing-in-Identifying-and-Treating-Substance-Abuse-Disorders.pdf 3. A. Pesce, C. West, K. Egan City and J. Strickland, “Interpretation of uri ne drug testing in pain patients,” Pain Medicine, vo l. 13, no. 7, pp. 868-85, 2012. Mayo Clinic, “Approximate detection times of drugs of abuse,” Oct 2016. [Online]. Available: http://www.mayomedicallaboratories.com/test-info/drug-book/viewall.html4. K. E. Moeller, K. C. Lee and J. C. Kissack, “Urine drug screening: Practical guide fo r clinicians,” Mayo Clinic Proceedings, vol. 83, no. 1, pp. 66-76, Jan 2008. 5. S. Vakili, S. Currie and N. el-Guebaly, “Evaluating the utility of drug testing in an outpatient addiction program,” Addictive Disorders and their Treatment, vol. 8, no. 1, pp. 22-32, 2009. ArchivedDrug Testing INDIANA MARKETPLACE PLANS PY-0329 Effective Date: 06/03/2018 8 6. A. Jaffe, S. Molnar, N. Williams, E. Wong, T. Todd, C. Caputo, J. Tolentino and S. Ye, “Review and recommendations for drug testing in substance us e treatment contexts,” Journal of Reward Deficiency Syndrome and Addiction Science, vol. 2, no. 1, pp. 28-45, 2016.7. K. Dolan, D. Rouen and J. Kimber, “An overview of the use of urine, hair, sweat and saliva to detect drug use,” Drug and Alcohol Review, vol. 23, no. 2, pp. 213-217, 2004. 8. A. G. Verstraete, “Detection times of drugs of abuse in blood, ur ine, and oral fluid,” Therapeutic Drug Monitoring, vol. 26, no. 2, pp. 200-205, 2004. 9. ASAM, Principles of Addiction Medicine, 5th Edition ed., R. K. Ries, D. A. Fiellin , S. C. Miller and R. Saitz, Eds., Philadelphia, PA: Lippincott Williams & Wilkins, 2014. 10. A. Rzetelny, B. Zeller, N. Miller, K. E. City, K. L. Kirsh and S. D. Passik, "Counselors clinical useof definitive drug testing results in their work with substance-use pa tients: A qualitative study,”International Journal of Mental Health and Addictio n, vol. 14, no. 1, pp. 64-80, 2016. 11.J. Dupouy, V. Macmier, H. Catala, M. Lavit, S. Oustric and M. Lapeyre-Mestre, “Does u rine drug abuse screening help for managing patients? A systematic revi ew,” Drug and Alcohol Dependence,vol. 136, pp. 11-20, 2014. 12. E. Y. Hilario, M. L. Griffin, R. K. McHugh, K. A. McDermott, H. S. Connery, G. M. Fitzmaurice and R. D. Weiss, “Denial of urinalysis-confirmed opioid use in prescription opioid dependence,”Journal of Substance Abuse Treatment, vol. 48, no. 1, pp. 85-90, 2015. 13.ASAM, “Drug Testing: A White Paper of the American So ciety of Addiction Medicine,” AmericanSo ciety of Addicti on Medicine, Chevy Chase, MD, 2013. 14.Quest Diagnostics Health Trends Prescription Drug Monitori ng Report 2015, Prescription Drug Misuse in America, Diagnostic Insights in the Continuing Drug Epidemic Battle. Accessed on December 8, 2016. Located at https://www.questdiagnostics.com/dms/Documents/health-trends/Health_Trends_27281_MI4854_V5_LG_082715_Small.pdf The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACEOriginal Issue Date Next Annual Review Effective Date 10/04/2017 0 4 /15/2019 0 4 /15/2018 Policy Name Policy Number Breast Imaging PY-0 396 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Breast Imaging INDIANA MARKETPLACE PY-0396 Effective Date: 04/15/2018 2 A. SUBJECT Breast Imaging B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests for breast cancer as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and American College of Radiology (ACR). Mammography is the utilization of a low-dose x-ray imaging system for the examination of the breasts and is currently considered to be the best available method for early detection of breast cancer, particularly in the case of small or non-palpable lesions. This imaging is often employed for screening purposes in an effort to reduce morbidity and mortality of unsuspected breast cancer through earlier detection and treatment in asymptomatic patients. A Screening Mammogram typically includes two standard views of each breast (cranio-caudal and medial lateral oblique) and does not require the presence of, or m onitoring by the interpreting radiologist. When abnormalities are observed a diagnostic test is required to confirm the presence of malignancy. C. DEFINITIONS Technical Component (TC) services rendered outside the scope of the physicians interpretation of the results of an examination. Professional Component (PC) physicians interpretation of the results of an examination. Global Component encompasses both the technical and professional components. D. POLICY I. CareSource does not require prior authorization for screening and diagnostic mammograms for participating providers. II. All other breast imaging, other than x-ray mammograms, require a prior authorization. III. CareSource follows the Evidence of Coverage (EOC) document criteria for mammography. For further information please refer to: https://www.caresource.com/documents/mp2017-in-eoc/ IV. CareSource considers diagnostic mammography medically necessary for any person diagnosed with breast disease. Archived Breast Imaging INDIANA MARKETPLACE PY-0396 Effective Date: 04/15/2018 3 Note: Global billing is not permitted for services furnished in an outpatient facility. Critical Access Hospitals (CAHs) may not use global HCPCS codes as the TC and PC components are paid under different methodologies. E. CONDITIONS OF COVERA GE 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. The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. CPT Codes Mammography Code Description 77065 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 77066 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed G0202 Sc reening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (List separately in addition to G0204 or G0206) CPT Codes Requiring Prior Authorization Code Description 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 76498 Unlisted magnetic resonance procedure (e.g., diagnostic, interventional) 76499 Unlisted diagnostic radiographic pro cedure 76641 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 76642 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; limited 77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 77061 Digital breast tomosynthesis; unilateral 77062 Digital breast tomosynthesis; bilateral 77063 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) C8903 Magnetic resonance imaging with contrast, breast; unilateral C8904 Magnetic resonance imaging without contrast, breast; unilateral Archived Breast Imaging INDIANA MARKETPLACE PY-0396 Effective Date: 04/15/2018 4 C8905 Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral C8906 Magnetic resonance imaging with contrast, breast; bilateral C8907 Magnetic resonance imaging without contrast, breast; bilateral C8908 Magnetic resonance imaging without contra st followed by with contrast, breast; bilateral F. RELATED POLICIES/RUL ES Breast Imaging Medical Policy MM-0131 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 10/04/2017 New Policy. Date Revised Date Effective 0 4 /15/2018 H. REFERENCES 1. American Cancer Society. (2017, September). Retrieved September 18, 2017, from http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs 2. Mammograms. (2017, September 18). Retrieved September 18, 2017, from https://www.medicare.gov/coverage/mammograms.html 3. U.S. Preventive Services Task Force; Breast Cancer: Screening. (2016, January). Retrieved September 18, 2017, from http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=mammography The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE PLANS Original Issue Date Next Annual Review Effective Date 08/23/2017 0 3/17/2019 03/17/2018 Policy Name Policy Number Long Acting Reversible Contraceptives (LARCs) PY-03 4 5 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 3 F.RELATED POLICIES/RULES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Long Acting Reversible Contraceptives (LARCs) INDIANA MARKETPLACE PLANS PY-0345 Effective Date: 03/17/2018 2 A. SUBJECT Long Acting Reversible Contraceptives (LARCs) B. BACKGROUND CareSource recognizes Long Acting Reversible Contraceptive methods (LARCs) to be among the most effective contraception available to our members in assisting with their reproduction and family planning decisions . While LARCs do not prevent or reduce the likelihood or danger of sexually transmitted infections or their transmission, they do allow sexually active members a greater degree of certainty with a better percentage of success, and generally, less frequent medical maintenance and intervention, than other available contraceptive methods. C. DEFINITIONS Implantable Contraceptive , or Contraceptive Implant , means a single-rod contraceptive releasing device inserted under the skin of a womans upper arm . Intrauterine Device , or IUD, means a device inserted into a womans uterus by a healthcare professional in order to prevent pregnancy. IUDs may or may not be designed to also release hormones during the period of time they are implanted in the uterus. Once placed, they should be monitored, removed, and replaced periodically. D. POLICY I. Prior authorization is not required for the long acting reversible contraceptives (LARCs) covered by this policy. NOTE: Although the LARCs covered by this policy do not require a prior authorization, CareSource may request documentation to support medical necessity. Appropriate and complete documentation must be presented at the time of review to validate medical necessity. II.Services covered under this policy include: A. Management and evaluation (office) visits and consultations for the purpose of providing LARCs; B. Health educationand counseling visits for the purpose of providing LARCs; C. Medical/surgical services/procedures provided in association with the provision of LARCs; D. Laboratory tests and procedures provided in association with the provision of LARCs; E. Drugs administered as part of LARCs; and F. Supplies provided as part of LARCs. III. Covered Settings and Timing for the insertions or removals of LARCs A. Insertion or removal of a LARC may be performed and billed in conjunction with an initial or annual comprehensive visit, a follow up comprehensive medical visit, a brief medical visit, or a supply visit by a member to a qualifying provider participant, as detailed in the corresponding CareSource Family Planning reimbursement policy. B. CareSource will also reimburse providers for LARCs inserted immediately postpartum in a hospital setting, in addition to and separately from the Diagnostic Related Group reimbursement process for the hospital. 1. In this circumstance, if the provider uses one of the following implantable devices, it must be inserted within ten minutes of birth to decrease the likelihood of expulsion of the device: 1.1 J7297-Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52m g; 1.2 J7298-Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52mg; ArchivedLong Acting Reversible Contraceptives (LARCs) INDIANA MARKETPLACE PLANS PY-0345 Effective Date: 03/17/2018 3 1.3J7300-Intrauterine copper contraceptive (ParaGard); or, 1.4 J7301-Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5mg; 1.5 J7307-Etonogestrel (contraceptive) implant system, including implant and supplies. IV. Implantable Contraceptive Capsules A. CareSource will reimburse the following providers for the insertion and removal of implantable contraceptive capsules, after each has been trained in accordance with the manufacturers guidelines: 1. Physicians; 2. Nurse practitioners; 3. Midwives; and, 4. Physicians assistants. B. Documentation of this training must be maintained in the providers personnel or training record. C. The insertion, management and monitoring, and removal of these capsules must be performed in compliance with all manufacturers recommendations. D. Insertions are limited to once per member within any three year period. V. Intrauterine Devices A. CareSource will reimburse the following providers for the insertion and removal of intrauterine devices, after each has been trained in accordance with the manufacturers guidelines: 1. Physicians; 2. Nurse practitioners; 3. Midwives; and, 4. Physicians assistants. B. Documentation of this training must be maintained in the providers personnel or training record. C. The insertion, management and monitoring, and removal of these capsules must be performed in compliance with all manufacturers recommendations. NOTE : Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. 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 to the CMS fee schedules . https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced source for the most current coding information. CODE DESCRIPTION J7297 Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg J7298 Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg J7300 Intrauterine copper contraceptive ( ParaGard ) J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7306 Levonorgestrel (contraceptive) (Jadelle) implant system, including implants and supplies J7307 Etonogestrel (contraceptive) implant system, including implant and supplies S4989 Contraceptive intrauterine device (e.g., Progestacert (Kyleena) IUD), including implants and supplies ArchivedLong Acting Reversible Contraceptives (LARCs) INDIANA MARKETPLACE PLANS PY-0345 Effective Date: 03/17/2018 4 11976 Removal, implantable contraceptive capsules 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, non-biodegradable drug delivery implant 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) Z30.014 Encounter for initial prescription of intrauterine contraceptive device Z30.017 Encounter for initial prescription of implantable subdermal contraceptive Z30.019 Encounter for initial prescription of contraceptives, unspecified Z30.43 Encounter for surveillance of intrauterine contraceptive device Z30.430 Encounter for insertion of intrauterine contraceptive device Z30.431 Encounter for routine checking of intrauterine contraceptive device Z30.432 Encounter for removal of intrauterine contraceptive device Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device Z30.46 Encounter for surveillance of implantable subdermal contraceptive Z30.8 Encounter for other contraceptive management (encounter for routine exam for contraceptive maintenance) Z45.89 Encounter for adjustment and management of other implanted devices Z45.9 Encounter for adjustment and management of unspecified implanted device Z47.5 Presence of (intrauterine) contraceptive device F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 08/23/2017 New Policy. Date Revised Date Effective 03/17/2 018 H. REFERENCES 1. Preventive Services | HHS.gov. (n.d.). Retrieved 5/10/17 from https://www.hhs.gov/opa/title-x-family-planning/preventive-services/index.html 2. Medical Policy Manual. (n.d.). Family Planning Services, pp. 114-115, r etrieved August 11, 2017, from http://provider.indianamedicaid.com/general-provider-services/provider-reference-materials.aspx 3. Long-Acting Rever sible Contraception Program-ACOG. (n.d.). Retrieved August 7, 2017, from https://www.acog.org/About-ACOG/ACOG-Departments/Long-Acting-Reversible-Contraception The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
REIMBURSEMENT POLICY STATEMENT INDIANA MARKETPLACE Original Issue Date Next Annual Review Effective Date 11/01/2017 0 3/17/2019 0 3/1 7/ 2018 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0 406 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic , benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan polic ies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services o r supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunctio n of a body organ or par t, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorizati on or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e. , Evidence of Coverage), then t he plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CSMG Co. and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this Policy at any time. Contents of Policy REIMBURSEMENT POLICY STATEMENT ………………………………………………………….. 1 TABLE OF CONTENTS …………………………………………………………………………………… .. 1 A.SUBJECT ……………………………………………………………………………………………….. 2 B.BACKGROUND ……………………………………………………………………………………….. 2 C.DEFINITIONS ………………………………………………………………………………………….. 2 D.POLICY …………………………………………………………………………………………………. 2 E.CONDITIONS OF COVERA GE ………………………………………………………………….. 2 F.RELATED POLICIES/RUL ES ……………………………………………………………………. 4 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 5 H.REFERENCES ………………………………………………………………………………………… 5Archived Screening and Surveillance for Colorectal Cancer INDIANA MARKETPLACE PLANS PY-0406 Effective Date: 03/17/2018 2 A. SUBJECT Screening and Surveillance for Colorectal Cancer B. BACKGROUND Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests for colorectal cancer as required by federal statute through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology (ACG). C. DEFINITIONS See Screening and Surveillance for Colorectal Cancer medical policy, MM-0195 D. POLICY I. CareSource does not require prior authorization for screening and diagnostic colonoscopies for participating providers. II.CareSource reimburses for screening and diagnostic colonoscopies according to CareSource Medical policy MM-0195. Members must meet the criteria found in medical policy MM-0195. III. When billing for screening and surveillance colorectal services, providers should use the appropriate CPT/HCPCS codes and modifiers, if applicable. E. CONDITIONS OF COVERAGE Reimbursement is dependent on, but not limited to, submitting The Centers for Medicare & Medicaid Services (CMS) approved HCPCS and CPT codes. Please refer to: CALONG https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx The following list(s) of codes is provided as a reference. This list may not be all inclusive and is subject to updates. Please refer to the above referenced sources for the most current coding information. Code Description G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema ArchivedScreening and Surveillance for Colorectal Cancer INDIANA MARKETPLACE PLANS PY-0406 Effective Date: 03/17/2018 3 G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122 Colorectal cancer screening; barium enema (Not covered by Medicare) G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations 74263 Computed tomographic (CT) colonography, screening, including image post processing (Not covered by Medicare) 44401 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 44402 Colonoscopy through stoma; with endoscopic stent placement (including pre-and post-dilation and guide wire passage, when performed) 44403 Colonoscopy through stoma; with endoscopic mucosal resection 44404 Colonoscopy through stoma; with directed submucosal injection(s), any substance 44405 Colonoscop y through stoma; with transendoscopic balloon dilation 44406 Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 44408 Colonoscopy through stoma; with decompression (for pathologic distention) ( e.g., volvulus, megacolon), including placement of decompression tube, when performed 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot bio psy forceps 45334 Sigmoidoscopy, flexible; with control of bleeding, any method 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, flexible; with decompression (for pathologic distention) ( e.g., volvulus, megacolon), including placement of decompression tube, when performed 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45346 Sigmoidoscopy, flexible; with ablation of tumor( s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre-and post-dilation and guide wire passage, when performed) 45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection 45350 Sigmoidoscopy, flexible; with band ligation(s) ( e.g., hemorrhoids) 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separ ate procedure) 45379 Colonoscopy, flexible; with removal of foreign body(s) 45380 Colonoscopy, flexible; with biopsy, single or multiple ArchivedScreening and Surveillance for Colorectal Cancer INDIANA MARKETPLACE PLANS PY-0406 Effective Date: 03/17/2018 4 45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 Colonoscopy, flexible; with control of bleeding, any method 45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 Colonoscopy, flexible; with transendoscopic balloon dilation 45388 Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) 45389 Colonoscopy, flexible; with e ndoscopic stent placement (includes pre-and post-dilation and guide wire passage, when performed) 45390 Colonoscopy, flexible; with endoscopic mucosal resection 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examinatio n limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 45393 Colonoscopy, flexible; with decompression (for pathologic distention) ( e.g., volvulus, megacolon), including placement of decompression t ube, when performed 45395 Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy 45397 Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure ( e.g., colo-anal anastomosis), with creation of c olonic reservoir ( e.g., J-pouch), with diverting enterostomy, when performed 45398 Colonoscopy, flexible; with band ligation(s) ( e.g., hemorrhoids) 74263 Computed tomographic (CT) colonography, screening, including image postprocessing (Not covered by Medicare) 74270 Radiologic examination, colon; contrast ( e.g., barium) enema, with or without KUB 74280 Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon 81528 Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result (Cologuard) 82270 Blood, occult, by peroxidase activity ( e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening ( i.e., pa tient was provided 3 cards or single triple card for consecutive collection) 82272 Blood, occult, by peroxidase activity ( e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 82274 Bl ood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations F. RELATED POLICIES/RUL ES Screening and Surveillance for Colorectal Cancer, MM-0195 Archived Screening and Surveillance for Colorectal Cancer INDIANA MARKETPLACE PLANS PY-0406 Effective Date: 03/17/2018 5 G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 11/01/2017 New Policy. Date Revised Date Effective 0 3/17/2018 H. REFERENCES 1. Physician Fee Schedule Search. (2017, October 5). Retrieved 10/9/2017 from https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=0&HT=0&CT=3&H1=81528&M=5 The Reimbursement Policy Stateme nt detai led above has received due con side ration as defined in the Reimbursement Po licy Stateme nt Po licy a nd is a pprove d. Archived
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