REIMBURSEMENT POLICY STATEMENT GEORGIA MEDICAID Original Issue Dat e Next Annual Review Effective Da te 06/07/2017 06/07/2018 02/01/2018-10/31/2022 Policy Name Policy Number Nursing Facility Services PY-0321 Policy Type Medical Administrative Ph ar mac y REIMBURSEMENT Contents of PolicyREIMBURSEMENT PO LI CY STATEMENT ……………………………………………………………… 1 TABLE OF CONTENTS ………………………………………………………………………………………….. 1 A. SUBJECT …………………………………………………………………………………………………….. 2 B. BACKGROUND ……………………………………………………………………………………………. 2 C. DEFINITIONS ………………………………………………………………………………………………. 2 D. POLICY ……………………………………………………………………………………………………….. 2 E. CONDITIONS OF COVERAGE ……………………………………………………………………… 4 F. RELATED POLICIES/RULES ………………………………………………………………………… 4 G. REVIEW/REVISION HISTORY………………………………………………………………………. 4 H. REFERENCES ……………………………………………………………………………………………… 4 Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billin g , coding a nd documentation guidelines. Co din g methodology, regulatory requirements, industry-s t a ndard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edica l necessity, adherence to plan p o licie s and procedures, cla ims editing lo g ic, provider contractual agreement, and applicable re f erral, authorization, n otifica tion a nd u tiliza tion management guidelines. Me dica lly necessary services include, b ut a re n ot limit e d to, t hose health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the lo cal area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Me d ica lly necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage document s, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. Th is Po licy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often re f e rre d to as the Evidence of Co ve rage) for the service(s) referenced herein. If there is a co n flict between th is Po licy and the plan contract ( i. e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to make the determination. CS MG Co . and its a ffilia te s ma y use reasonable discretion in interpreting and applying th is Po licy to services provided in a particular case and may modify this Policy at any time. 2 A. SUBJECTNursing Facility Services B. BACKGROUND Skilled Nurs i n g Facility Serv ic es Georgia Med i c ai d PY-0321 Las t Rev i s ed 02/01/2018Nurs ing Facilities are ins titutions that prov ide nurs ing and medical care to p atients who no longer req uire ac ute c are s ettings, but do req uire lic ensed nurs ing s ervices , rehabilitation s ervices , o r o ther health-related s ervic es on a reg ular bas is , that c annot b e prov ided in the ho me. C. DEFINITIONS RUG (Res o urc e Utilization Group) is the sy stem of c lassif ying nursing facility res idents i nto c as e mix g roups. D. POLICY I. Prio r Autho rization is req uired f or all admissions to a Nurs ing Facility. II. Ad mission Criteria A. Prio r to nurs ing facility admis sion, all patients mus t have a Pre-Admiss ion Screening and Res id ent Rev iew (PASRR) c ompleted. B. In c as es where the p atients primary diagnosis is psy chiatric o r there is p syc hiatric c are inv o lv ed, the p atient is not considered a c andidate for intermediate care s ervices . The ind iv idual m ust als o have medic al c are needs that meet the crit eria for intermediate c are f ac ility placement. C. Intermed iate c are services may be p rovided to a p atient with a s table medical condition req uiring intermittent skilled nurs ing serv ic es under the d irec tion of a lic ensed physician when the f o llowing c riteria is met. 1. Med ic al Status a. Req uires mo nitoring and overall management of a medical condition(s) und er the d irec tion of a lic ensed phy sician . In addition to this criteria, the patients specific m edical condition m ust requi re any of the following (b-h) plus one item from 2 or 3. b. Nutritio nal management; which may inc lude therapeutic diets or maintenance of hy d ration s tatus. c. Maintenanc e and preventiv e skin care and treatment of s kin conditions such as c uts , ab rasions or healing d ecubiti. d. Catheter c are such as catheter c hange and irrigation. e. Therap y services such as o xygen therapy, phy sical therapy, speech therapy, o c c upational therapy (les s than five (5) times week ly ). f. Res to rative nurs ing s ervices s uch as rang e of motion exerc is es and bowel and b lad d er training. g. Mo nito ring of vi tal s igns and laboratory s tudies or weights. h. Manag ement and administration of med ic ations inc luding injections. 2. Mental Status ( m us t be such tha t the cognitive lo ss is m or e than occasional forgetfulness ). a. Do c umented short or long-t er m memory d e f ic it s wit h etiologic diagnosis Co g nitive los s addres sed on MDS/ care p lan for continued p lacement. b. Do c umented moderately o r sev erely impaired c ognitive s kills wi th etiologic diagnosis f or d a il y d ecision making. Co gnitive loss addres sed on MDS/ c are plan f o r c ontinued p lac ement. c. Problem behavior, i . e., wandering, v erbal abus e, phys ic ally and /or soc ially d is rup tiv e o r inappropriate behavior requiring appropriate superv ision o r interv ention. 3 Skilled Nurs i n g Facility Serv ic es Georgia Med i c ai d PY-0321 Las t Rev i s ed 02/01/2018d. Und etermined cognitive patterns whic h cannot be asses sed by a mental s tatus ex am, f or ex ample, d ue to aphasia. Func tio nal Status a. Trans f er and loc omotion performance of res ident requires limited ex tensive as s is tance by staff through help or o ne-person p hy sical ass is t. b. Assistance wit h feeding. Continuous stand-by s upervision, encouragement or c ueing req uired and s et-up help of meals . c. Req uires d irec t as sistanc e of another person to maintain c ontinence. d. Do c umented c ommunication d eficits in making s elf-understood or unders tanding o thers . Deficits m ust be addres sed in the medical rec ord with etiologic d i ag no s is ad d res s o n MDS/ care p lan for c ontinued p lac ement. e. Direc t s tand-by s upervision o r c ueing with one-pers on p hy sical as sistance f ro m s taf f to complete dres sing and personal hy giene. (If thi s is the only evaluation of care identified, another deficit in functional status is required ). III. Reimb ursement A. Reimb urs ement rates are neg otiated at the t i me of authorization request, upon approv al o f s erv ic es and bas ed on an ag reed perc entage of the RUG sc ore. B. Fo r memb ers admitted to a Nurs ing Facility prior to b ecoming effective wi th CareSource the f o llowing will ap ply : 1. If the memb er is already admitted to o ngoing no n acute treatment that has b een p rev io usly c ov ered prior to the patients effective date wi th CareSource, serv ic es will b e c o v ered for at least 30 c alendar d ays to allow time for a c linical rev iew and , if nec es s ary , Trans ition of Care. 2. CareSo urc e will no t be obligated to cov er serv ic es beyond 30 c alendar days, ev en if ano ther c arriers authorization was for a p eriod greater than 30 c alendar days, if the c linic al rev iew d etermines c ontinued authorization is not medically nec essary . C. The numb er o f d ays of c are c harg ed for nurs ing facility s ervices is always in units of full days, beginning at midnight and ends twenty-four hours later. Any p ar t of a day, including the d ay o f admis sion counts as a full day. However, the day of d is charge or d eath is not c o unted as a b illable day . If ad miss ion and discharge o r death occ ur o n the s ame day , the d ay is c onsidered a d ay of admission and c ounts as o ne b illable day . D. Mec hanic al Ventilation is reimbursed at a p er diem rate and is all inc lus iv e for the p atients c are; no o ther medical billing is allowed for nurs ing s ervices . E. Nurs ing Fac ilities that find, after as sessment, that a p atient req uires a s pecialized or custom wheelc hair in o rder to maxi mi ze independence, are responsible for the expens e of that specialized or c ustom wheelchair and my not b i ll s eparately or ins truc t a Durable Med ic al Provider to bill CareSource for pay ment. F. Th e reimb urs ement rat e established is an inclusive payment that cov ers the cost of the f o llowing: 1. Patients ro om and board 2. Sp ec ial d ietary needs 3. Dietary s up plements us ed for tube or oral feedings, when p res cribed by a p hysician. 4. Laund ry 5. Nurs ing and ro utine serv ic es, including the following (t his is not an exhaustiv e l is t ): nurs ing c are (ex c luding p rivate d uty nurs e), medic al s ocial serv ices, ac tiv ities p ro g ram, Physical therapy, Speec h therapy , Oc cupational therap y, s pecialized rehab ilitation s ervices, res torativ e nurs ing c are, hand feedings, ass is tance in p ers o nal c are and gro oming, nurs ing supplies, inc ontinence c are items, routine p ers o nal c are items and Ov er the Counter medic ations. G. If the p atient is b e i ng d is charged fro m the fac il i ty wi th no ex pec tation of return, a d is c harge s tatus c ode should be us ed on the c lai m f orm. 3. 4 Skilled Nurs i n g Facility Serv ic es Georgia Med i c ai d PY-0321 Las t Rev i s ed 02/01/2018H. Ap p ropriate revenue c odes must be us ed when billing p atient leav e days , whether p lanned or due to hospitalizations. Providers m ust o nl y b il l the d ays the patient is in the f acility. IV. In the case that a member will be s taying in a Nurs ing Facility for l o ng t erm c are and does no t p lan o n returning to the community, CareSource will initiate disenrollment b ack to Medicaid Fee f o r Serv ice, after 3 months . E. CONDITIONS OF COVERAGE HCP CS CP TAUTHORI ZATION PER I OD F. RELATED POLICIES/RULES G. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 06/07/2017 New policy.Date Revised Date Effective 02/01/2018 Date Archived 10/31/2022 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to f ollow CMS/State/NCCI guidelines without a f ormal documented Policy. H. REFERENCES1. Pro v ider Manuals, Nurs ing Facility Services . (n.d.). Retrieved May 30, 2017, from http s://www.mmis.georgia.gov/portal/PubAccess.Provider%20Information/Provider%20Manu als /tabId/54/Default.aspxThe Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved.
REIMBURSEMENT POLICY STATEMENT MARKETPLACE PLANS Original Issue Date Next Annual Review Effective Date 10/31/2013 05/01/2018 06/01/2017 Policy Name Policy Number Telemedicine Services PY-0109 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 ………………………….. ………………………….. ………………………….. …… 5 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 func tion, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or p rovider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contr act (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 Telemedicine ServicesMarketplace Plans PY-0109 Effective date: 06/01/2017 A. SUBJECTTelemedicine Services B. BACKGROUNDReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and 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. CareSource will reimburse participating providers, for telemedicine services, who are credentialed to deliver telemedicine services rendered to CareSource membe rs, as set forth in this policy. 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. C. DEFINITIONS Asynchronous store and forward technologies – means 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 – means 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 defin ition of an interactive telecommunications system. Originating Site – is the location of a CareSource member at the time the service, via a telecommunications system, occurs. Note: Independent Renal Dialysis Facilities are not considered originating sites Place of Service Codes (POS) – These codes specifically indicate where a service or procedure was performed. Telemedicine – is the direct delivery of services to a patient via synchronous, interactive, real-time electronic communication that comprises both audio and video elements. Telemedicine vendor – is the participating provider with CareSource that renders the telemedicine services. Note: Telehealth is sometimes used interchangeably with telemedicine in Current Procedural Terminology (CPT)/and Healthcare Common Procedure Coding System (HCPCS) code descriptions of services. D. POLICYI. CareSource does not require prior authorization for Telemedicine services. II. Telemedicine services may be reimbursed according to Medicare guidelines using appropriate CPT and/or HCPCS and modifier codes. 3 Telemedicine ServicesMarketplace Plans PY-0109 Effective date: 06/01/2017 III. As a condition of payment, providers must use an interactiveaudio 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 v ia 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). 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 https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx Th e 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. CareSource will reimburse participating providers for the following CPT/HCPCS codes when providing services to CareSource members via Telemedicine: 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 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 4 Telemedicine ServicesMarketplace Plans PY-0109 Effective date: 06/01/2017 G0459 Telehealth Pharmacologic Management 90791 and 90792 Psychiatric diagnostic interview examination 90832 90834 Individual psychotherapy 90836 90838 Individual psychotherapy 90845 Psychoanalysis 90846 Family psychotherapy (without the patient present) 90847 Family psychotherapy (conjoint psychotherapy) (with patient present) 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 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) Q3014 Telehealth originating site facility fee Modifier Description 5 Telemedicine ServicesMarketplace Plans PY-0109 Effective date: 06/01/2017 GT Via interactive audio and video telecommunication systems For further information please reference:1. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network – MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf 2. https://www.medicare.gov/coverage/telehealth.html#1368 AUTHORIZATION PERIOD F. RELATED POLICIES/RULESG. REVIEW/REVISION HISTORY DATE ACTIONDate Issued 10/31/2013Date Reviewed 11/29/2016 Date Effective 06/01/2017 Archive Date 03 /05 /2021 H. REFERENCES1. Telehealth – Centers for Medicare & Medicaid Services. (2016, August 1). Retrieved August 1, 2016 from https://www.cms.gov/Medicare/Medicare-General – Information/Telehealth/index.html 2. Telehealth Services. (2016, June 30). Retrieved June 24, 2016 from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network – MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf 3. Telehealth Services (2016, August 1). Retrieved August 1, 2016 from https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec410 – 78.pdf 4. Telehealth | Medicare.gov . (2016, August 1). Retrieved August 1, 2016 from https://www.medicare.gov/coverage/telehealth.html The Reimbursement Policy Statement detailed above has received due consideration as defined in the Reimbursement Policy Statement Policy and is approved. Independent medical review 2/2015
REIMBURSEMENT POLICY STATEMENT MARKETPLACE PLANSOriginal Issue Date Next Annual Review Effective Date 06/01 /2017 05 /15 /2018 06 /01 /2017 Policy Name Policy Number Screening and Surveillance for Colorectal Cancer PY-0073 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 ………………………….. ……………………………………… 4 H.REFERENCES ………………………………………………………………………………………… 4Archived Screening and Surveillance for Colorectal Cancer MARKETPLACE PLANS PY-0073 Effective Date: 06/01/17 2 A.SUBJECTScreening and Surveillance for Colorectal Cancer B.BACKGROUNDReimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing.Health care providers and their office 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 Co llege of Gastroenterology (ACG). Applicable clinical criteria for the following colorectal cancer screening health services are described in the corresponding medical policy entitled Screening and Surveillance for Colorectal Cancer Air Contrast Barium Enema (ACBE) every 5 years;Flexible sigmoidoscopy every 5 years in combination with fecal occult blood testing(FOBT) or fecal immunochemical testing (FIT) every 3 years.Multi-targeted stool DNA test (Cologuard) every 3 years when clinical criteria are met;(see the Screening and Surveillance for Colorectal Cancer policy )Screening Colonoscopy every 10 years in average risk patients.Screening Colonoscopy every 24 months in high risk patientsFOBT or FIT annually C.DEFINITIONSN/A D.POLICYCareSource will reimburse providers for Screening and Surveillance for Colorectal Cancer utilized through the Health Insurance Exchange when approved by CareSource according to the following tier hierarchy reimbursement format.I. First, Health Insurance Exchange Screening and Surveillance for Colorectal Cancer are r eimbursed based on the Medicare fee schedule. Please refer to:https://www.cms.gov/Medicare/Medicare.html II.If the screening and surveillance for colorectal cancer does not fall under the Medicare fee schedule, then CareSource will reimburse a higher percentage based on the Medicaid feeschedule. Please refer to: https://www.medicaid.gov/III.If screening and surveillance for colorectal Cancer does not fall under the Medicare orMedicaid fee schedule, then CareSource will reimburse at a percent of billed charges outlined by each market. Archived Screening and Surveillance for Colorectal Cancer MARKETPLACE PLANS PY-0073 Effective Date: 06/01/17 3 IV. If required, providers must submit their prior authorization number, their claim form, as well asappropriate HCPCS and/or CPT codes along with appropriate modifiers in accordance withCMS. E.CONDITIONS OF COVERA GEReimbursement is dependent on, but not limited to, submitting CMS approved HCPCS and CPTcodes along with appropriate modifiers. Please refer to :https://www.cms.gov/Medicare/Medicare.html The following list(s) of codes is provided as a reference . This list may not be all inclusive an d is subject to updates. Please refer to the above referenced sources for the most current coding information. CPT/HCPCS Codes 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 G0121 Colorectal cancer screening; colonoscopy on individual not mee ting 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 postprocessing (Not covered by Medicare) 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 (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal ne oplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection) Modifiers Code Description 33 Preventive Services (For CPT Code 82270: may be appended when this service is performed as a preventive service as identified by the US Preventive Services Task Force.) PT Colorectal cancer screening test; converted to diagnostic test or other procedure QW CLIA waived AUTHORIZATION PERIOD If applicable, reimbursement is dependent upon products and services frequency, duration and timeframe set forth by CareSource Screening and Surveillance for Colorectal Cancer medical policy. F.RELATED POLICIES/RUL ESScreening and Surveillance for Colorectal Cancer, MM-0092 (MPP) Archived Screening and Surveillance for Colorectal Cancer MARKETPLACE PLANS PY-0073 Effective Date: 06/01/17 4 G.REVIEW/REVISION HISTORY DATE ACTION Date Issued 06/01/2017 Date Revised Date Effective 06/01/2017 H.REFERENCES1. Medicare. (2016, May 17). Retrieved May 17, 2016, from https://www.cms.gov/Medicare/Medicare.html 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 MARKETPLACE PLANS Original Issue Date Next Annual Review Effective Date 5/15/2017 05/01/2018 05/15 /2017 Policy Name Policy Number Hepatitis Panel PY-0 2 11 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policies prepared by CSMG Co. and its affiliates (including CareSource) are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medical ly necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, inc reased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided m ainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conf lict 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 ……………………………………………………………………. 6 G.REVIEW/REVISION HISTORY ………………………….. ……………………………………… 6 H.REFERENCES ………………………………………………………………………………………… 6Archived Hepatitis Panel Marketplace Plans PY-0211 Effective Date: 05-15-2017 2 A.SUBJECT Hepatitis Panel 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. Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other causes. Viral hepatitis can be due to one of at least five viruses, discussed here. Most cases of viral hepatitis are caused by Hepatitis A virus (HAV), Hepatitis Bvirus (HBV), or Hepatitis Cvirus (HCV), although viral hepatitis can also be caused by the less-prevalent viruses Hepatitis Dand E. The diagnosis of acute HBV infection is best established by documentation of a positive result for the IgM antibody against the core antigen (HBcAb-IgM), and by identifying a positive result for the hepatitis Bsurface antigen (HBsAg). The diagn osis of chronic HBV infection is established primarily by identifying a positive hepatitis Bsurface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core antigen (HBcAb-IgG). Additional tests such as Hepatitis Be-antigen (HBeA g) and Hepatitis Be-antibody (HBeAb), which are the envelope antigen and antibody for Hepatitis B, are not included in the standard Hepatitis Panel. However, they can be a marker of replication and infectivity associated with an increased risk of transmi ssion. This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury.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. D. POLICY I. Prior authorization is not required for hepatitis panel tests that are medical necessary. II. Hepatitis panel test referred to in this policy are selected laboratory tests. Material related to diagnostic testing in this policy is included to clarify coverage for diagnostic versus screening indications. Hepatitis panel test consists of the following: A. Hepatitis A antibody (HAAb), IgM Antibody B. Hepatitis Bcore antibody (HBcAb), IgM Antibody C. Hepatitis Bsurface antigen (HBsAg) D. Hepatitis Cantibody III. CareSource will reimburse providers for the medically necessary screening, d iagnoses, and subsequent treatments for, and management of hepatitis as documented in the medical record in the following circumstances: A. To detect viral hepatitis infection when there are abnormal liver function test results, Archived Hepatitis Panel Marketplace Plans PY-0211 Effective Date: 05-15-2017 3 with or without signs or symptoms of hepatitis; and B. Prior to and subsequent to liver transplantation. IV. Coverage A. CareSource will reimburse for hepatitis screening with the appropriate laboratory tests when ordered and performed by a provider for these services, and when used in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations. B. CareSource will reimburse for an acute hepatitis panel once per calendar year for screening when medically necessary to test for hepatitis in asymptomatic men and women if accompanied by one or more of the appropriate ICD-10 codes. CareSource will reimburse for a repeat panel approximately two weeks to two months after the initial one to exclude the possibility of hepatitis in a patient with continued symptoms of liver disease despite a completely negative first Hepatitis Panel. Note: Although a Hepatitis Panel does 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. V. Non-Covered Services A. Once a diagnosis of hepatitis has been made, CareSource will not cover ongoing hepatitis panel testing. CareSource will cover, appropriate and medically necessary, individual hepatitis testing for its members. E. CONDITIONS OF COVERA GE 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 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 source for the most current coding information. Codes Description 80074 Acute Hepatitis Panel Codes Description B15.0 Hepatitis A with hepatic coma B15.9 Hepatitis A without hepatic coma B16.0 Acute hepatitis Bwith delta-agent with hepatic coma B16.1 Acute hepatitis Bwith delta-agent without hepatic coma B16.2 Acute hepatitis Bwithout delta-agent with hepatic coma B16.9 Acute hepatitis Bwithout delta-agent and without hepatic coma B17.0 Acute delta – (super) infection of hepatitis Bcarrier B17.10 Acute hepatitis Cwithout hepatic coma B17.11 Acute hepatitis Cwith hepatic coma B17.2 Acute hepatitis EB17.8 Other specified acute viral hepatitis B17.9 Acute viral hepatitis, unspecified B18.0 Chronic viral hepatitis Bwith delta-agent B18.1 Chronic viral hepatitis Bwithout delta-agent B18.2 Chronic viral hepatitis CB18.8 Other chronic viral hepatitis ArchivedHepatitis Panel Marketplace Plans PY-0211 Effective Date: 05-15-2017 4 B18.9 Chronic viral hepatitis, unspecified B19.0 Unspecified viral hepatitis with hepatic coma B19.10 Unspecified viral hepatitis Bwithout hepatic coma B19.11 Unspecified viral hepatitis Bwith hepatic coma B19.20 Unspecified viral hepatitis Cwithout hepatic coma B19.21 Unspecified viral hepatitis Cwith hepatic coma B19.9 Unspecified viral hepatitis without hepatic coma G93.3 Post-viral fatigue syndrome I85.00 Esophageal varices without bleeding I85.01 Esophageal varices with bleeding I85.10 Secondary esophageal varices without bleeding I85.11 Secondary esophageal varices with bleeding K70.41 Alcoholic hepatic failure with coma K71.0 Toxic liver disease with cholestasis K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.2 Toxic liver disease with acute hepatitis K71.3 Toxic liver disease with chronic persistent hepatitis K71.4 Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 Toxic liver disease with hepatitis, not elsewhere classified K71.7 Toxic liver disease with fibrosis and cirrhosis of liver K71.8 Toxic liver disease with other disorders of liver K71.9 Toxic liver disease, unspecified K72.00 Acute and subacute hepatic failure without coma K72.01 Acute and subacute hepatic failure with coma K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K74.0 Hepatic fibrosis K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.0 Abscess of liver K75.1 Phlebitis of portal vein K75.2 Nonspecific reactive hepatitis K75.3 Granulomatous hepatitis, not elsewhere classified K75.81 Nonalcoholic steatohepatitis (NASH) K75.89 Other specified inflammatory liver diseases K75.9 Inflammatory liver disease, unspecified K76.2 Central hemorrhagic necrosis of liver K76.4 Peliosis hepatis K76.6 Portal hypertension K76.7 Hepatorenal syndrome K76.81 Hepatopulmonary syndrome R10.0 Acute abdomen R10.10 Upper abdominal pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain Archived Hepatitis Panel Marketplace Plans PY-0211 Effective Date: 05-15-2017 5 R10.2 Pelvic and perineal pain R10.30 Lower abdominal pain, unspecified R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain R10.811 Right upper quadrant abdominal tenderness R10.821 Right upper quadrant rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight Code Description R10.83 Colic R10.84 Generalized abdominal pain R10.9 Unspecified abdominal pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.14 Bilious vomiting Archived Hepatitis Panel Marketplace Plans PY-0211 Effective Date: 05-15-2017 6 R11.2 Nausea with vomiting, unspecified R16.0 Hepatomegaly, not elsewhere classified R16.2 Hepatomegaly with splenomegaly, not elsewhere classified R17 Unspecified jaundice R53.0 Neoplastic (malignant) related fatigue R53.1 Weakness R53.2 Functional quadriplegia R53.81 Other malaise R53.82 Chronic fatigue, unspecified R53.83 Other fatigue R56.00 Simple febrile convulsions R56.01 Complex febrile convulsions R56.1 Post traumatic seizures R62.0 Delayed milestone in childhood R62.50 Unspecified lack of expected normal physiological development in childhood R62.51 Failure to thrive (child) R62.52 Short stature (child) R62.59 Other lack of expected normal physiological development in childhood R63.0 Anorexia R63.1 Polydipsia R63.2 Polyphagia R63.3 Feeding difficulties R63.4 Abnormal weight loss R63.5 Abnormal weight gain R63.6 Underweight AUTHORIZATION PERIOD F. RELATED POLICIES/RUL ES G. REVIEW/REVISION HISTORY DATE ACTION Date Issued 05/15/2017 Date Revised Date Effective 05/15/2017 H. REFERENCES 1. Medically Necessary-HealthCare.gov Glossary | HealthCare.gov. (2017, March 16). Retrieved 3/14/17 from https://www.healthcare.gov/glossary/medically-necessary/ 2. National Coverage Determination (NCD) for Hepatitis Panel/Acute Hepatitis Panel (190.33). (2003, January 1). Retrieved 3/14/17 from https://www.cms.gov/medicare-coverage-database/(S(3tjsiy55tghspmei3ysxvqir))/details/ncd-det ails.aspx?NCDId=166&ncdver=1&CALId=147&ver=9&CalName=Hepatitis+Panel+(R emoval+of+ICD-9-CM+Code+784.69%2C+Other+symbolic+dysfunction%2C+from+the+list+of+Codes+Cov ered+by+Medicare)&bc=BAgAAAAAgBAA& 3. Physician Fee Schedule Search. (2017, January 19). Retr ieved 3/14/17 from https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx Archived Hepatitis Panel Marketplace Plans PY-0211 Effective Date: 05-15-2017 7 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
PAYMENT POLICY STATEMENT Original Effective Date Next Annual Review Date Last Review / Revision Date 11/17/2014 11/17/2016 11/17/2015 Policy Name Policy Number Preventive Services and Sick Visit on Same Date of Service PY-0007 Payment 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 Payment Policies. I n addition to this Policy, payment of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practi ce in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or payment 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. A.SUBJECTPreventive Services and Sick Visit on Same Date of ServiceB. BACKGROUND CareSource will reimburse participating providers as outlined in this policy when a preventiv e s ervices visit or exam and a sick visit are performed on the same date of service for aCareSource member.C.D EFINITIONSCurrent Procedural Terminology (CPT) codes are numbers assigned to every task,medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American MedicalA ssociationPrev entive Services are exams and screenings to check for health problems, with the intention to prevent any problem discovered from becoming worse. Preventive services may include, but are not limited to, physical checkups, hearing, vision, and dental checks,nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age, but are especially important for childre n under the age of 21ArchivedD. POLICY Preventive medicine exam codes 99381-99387 and 99391-99397 should be billed with the appropriate ICD-9 diagnosis codes (if before 10/1/2015) or ICD-10 diagnosis codes (after 10/1/2015). When a provider conducts a preventive medicine service or exam at the time of an acute care visit, Evaluation & Management CPT codes 99201-99205 or 99212-99215 may be submitted along with the appropriate ICD-9 or ICD-10 code, indicating the reason for t he acute care visit, as a secondary diagnosis. CareSource will reimburse the provider for the preventive medicine CPT code at 100% of the allowed amount, and will reimburse the provider for the acute care CPT code at 50% of the allowed amount. Please see the examples provided below. Correct Billing Example (this examp le is pre-10/1/2015, using ICD-9) Date of Service Procedure Diagnosis Code Billed Amount Allowed Amount01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 462 $100.00 $20.19 (50%) Incorrect Billing Example (this example is pre-10/1/2015, using ICD-9) Date of Service ProcedureDiagnosis Code Billed Amount Allowed Amount 01/15/2014 99392 V20.0 $150.00 $52.97 (100%) 01/15/2014 99213 V20.0 $100.00 $0.00 For Medicare Plan members, reference the Applicable National Coverage Descriptions (NCD) and Local Coverage Descriptions (LCD).CONDITIONS OF COVERAGE HCPCS CPT A UTHORIZATION PERIOD E. RELATED POLICIES/RULES F. REVIEW/REVISION HISTORY Date Issued: 11/17/2014 Date Reviewed: 11/17/2014, 11/17/2015 Date Revised: 11/17/2015 Revision includes payment policy legal language. G. REFERENCES The Payment Policy Stateme nt detailed a bove has r eceived due con side ration as defined in the PaymentPo licy Stateme nt Policy and is a pprove d. Archived
This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 Payment Policy Subject: Colonoscopies Programs Covered: OH Medicaid, KY Medicaid, OH MyCare, and Just4Me TM (all states) Po lic y Effective February 1, 2014, CareSource will reimburse participating providers for medically necessary and preventive screening colonoscopies as set forth in this policy. De f i n i t i o n s Current Procedural Terminology (CPT ) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. (from OAC 5160-10-02) Pr o vi d er Rei m b u r se m e n t Gu i d e lin e s CareSource Just4Me & Medicaid CareSource will reimburse participating providers for the cost of medically necessary and preventive screening colonoscopies for any member aged 50 or older, and for high-risk members, with no limit on frequency. For high risk patients under the age of 50, CareSource requires the provider submit documentation of family history. No prior authorization is required for participating providers. See the qualifying high-risk factors in the section below. CareSource MyCare-For its MyCare members, CareSource will reimburse participating providers for the cost of screening colonoscopies once every 10 years, when no risk factors are present. ( G0121 with dx V76.51 Special screening for malignant neoplasm of the colon ). For high-risk MyCare members, CareSource will reimburse participating providers for the cost of a screening colonoscopy every 2 years ( G0105 plus appropriate diagnosis code ). High risk factors include: oA close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.o A family history of familial adenomatous polyposis. Archived This CareSource Management Group Proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 o A family history of hereditary nonpolyposis colorectal cancer. o A personal history of adenomatous polyps. o A personal history of colorectal cancer. o Inflammatory bowel disease, including Crohns disease and ulcerative colitis. Re l a t e d Po l i c i es & Re f e r e n c e sOAC 5160-4-34, Preventive medicine services. St a t e Exc ep t i o n s NONE Do c u m e n t Rev i si o n Hi s t or y Archived
Payment Policy S ubject: CPT Codes Not Covered in an Emergency Room Setting P rograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and Just4Me (all states) TM Policy CareSource will not reimburse claims for CPT Codes 93308, 93971, or 95992 when submitted with a Place of Service code 23 (Emergency Room-Hospital) , as set forth in this policy . This policy is not new and therefore has no specific effective date; rather, its purpose is to clarify any misunderstandings among our providers around these procedure codes. Definitions Current Procedural Terminology (CPT) codes are numbers assigned to every task, medical procedure, and service a medical practitioner may provide to a patient. CPT codes are developed, maintained and updated annually, and copyrighted by the American Medical Association. (From ama-assn.org) Healthcare Common Procedure Coding System (HCPCS ) is a set of health care procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT) . HCPCS currently includes two levels of codes: Level I consists of the American Medical Association’s Current Procedural Terminology (CPT) and is numeric. Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I) . (from www.wikipedia.org) Medically necessary services are those health services that are necessary for the diagnosis or treatment of disease, illness, or injury and meet accepted standards of medical practice. ( from OAC 5160-10-02) Place of Service Codes, (POS) means codes which are regularly published by the Centers for Medicare & Medicaid Services, and which are used on reimbursement claims submitted for professional services rendered by healthcare providers. These codes specifically indicate where a service or procedure was performed. (from www.cms.gov )This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2Archived Provider Reimbursement Guidelines CPT Codes Addressed 93308: Follow-up or limited transthoracic echo (no Doppler or colorflow). 93971: Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study. 95992 : Standard canalith repositioning procedures (e.g., Epley maneuver, Sermont maneuver), per day. ( Note: audiologists cannot bill Medicare for this procedure, as canalith repositioning procedures are not di agnostic tests) Prior Authorization No prior authorization from CareSource is required before providing these services to its members. Reimbursement It is CareSource policy to reimburse providers for the procedures defined by these CPT codes, unless these procedures are performed in the setting of an Emergency Room or freestanding emergency room (POS 23). When performed in an ER setting, the results of these procedures are generally referred to and read by the appropriate on-call specialist (a cardiologist, is one likely example) and the code is billed by that specialist. If the code is also billed by the emergency room unit, that means that CareSource is processing two separate claims for the same procedure, when only one procedure was rendered to the CareSource member. CareSource does not reimburse multiple providers for a single procedure, and on that basis, CareSource will deny claims for these procedures when performed in an ER setting . Related Policies & References State Exceptions NONE Document History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Archived
. Payment Policy Subject: Payments to Just4Me TM Out-of-Network Providers Policy C areSource will reimburse out-of-network providers for preauthorized, medically necessary services provided to CareSource Just4Me members in accordance with the guidelines in this policy. Provider Reimbursement Guidelines Just4Me Providers INDIANA Preauthorized, medically necessary services rendered to CareSource Just4Me members by out-of-network providers in the state of Indiana will be reimbursed at 100% of the then-current Medicare fee schedule. If a service or procedure is not priced by Medicare, then it will be reimbursed to the provider at 150% of the then-current Indiana Medicaid fee schedule. If a service or procedure is not priced on the Indiana Medicaid fee schedule, then it will be reimbursed to the provider at 35% of billed charges. Just4Me Providers KENTUCKY Preauthorized, medically necessary services rendered to CareSource Just4Me members by out-of-network providers in the Commonwealth of Kentucky will be reimbursed at 100 % of the then-current Medicare fee schedule. If a service or procedure is not priced by Medicare, then it will be reimbursed to the provider at 87.75% of the then-current Kentucky Medicaid fee schedule. If a service or procedure is not priced on the Kentucky Medicaid fee schedule, then it will be reimbursed to the provider at 35% of billed charges. Just4Me Providers OHIO Preauthorized, medically necessary services rendered to CareSource Just4Me members by out-of-network providers in the state of Ohio will be reimbursed at 100% of the then-current Medicare fee schedule. If a service or procedure is not priced by Medicare, then it will be reimbursed to the provider at 135 % of the then-current Ohio Medicaid fee schedule. If a service or procedure is not priced on the Ohio Medicaid fee schedule, then it will be reimbursed to the provider at 35% of billed charges. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the c laim is received for processing. Page 1 of 2 Archived Related Policies & References NONE Document Revision History This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the c laim is received for processing. Page 2 of 2Archived
This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 2 PaymentPolicySubject: Pass-Through Billing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4MeTM Po lic yEffective November 1, 2014, CareSource prohibits pass-through billing as set forth in this policy. Any claim submitted by a provider which includes services ordered by that provider, but which were performed by a person or entity other than that provider or a direct employee of that provider will not be reimbursed. De f i ni t i on sCLIA, means the Clinical Laboratory Improvement Amendments of 1988, which are federal regulatory standards that apply to all clinical laboratory testing performed on hum ans in the United States except clinical trials and basic research. (from http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA & Intern al CareSource definition) Direct Employee, means an employee of a provider who is under direct supervision of the ordering provider and the services is billed by the ordering provider. An employee is person that receives a W-2 (as opposed to a 1099) from the participating provider and does not have their own provider or NPI number. (CareSource internal definition) Pr o vi d er Rei m b u r se m e n t Gu i d el i n es CareSource prohibits pass-through billing. Pass-through billing occurs when an ordering provider requests and bills for services that are not performed by the ordering provider or by a direct employee of that provider. With respect to laboratory services, CareSource will reimburse for the services which the provider itself is certified through CLIA to perform. Claims may not be submitted to CareSource for any laboratory services for which a provider lacks the applicable CLIA certification. Additionally, CareSource members cannot be billed for any such services. CareSource considers any claim for services related to pass-through billing not eligible for reimbursement. Providers must bill CareSource only for those services which they or their direct employees perform. Providers will not bill, charge, seek payment for or submit any claims to CareSource, nor will they have any recourse against CareSource or any of its members for amounts related to the provision of pass-through billing. This CareSource Management Group proprietary policy is not a guarantee of payment. Payments may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 2 Rel at ed Po l i c i e s & Ref e r en ce s42 CFR 493, Standards and certification: Laboratory Requirements. St a t e Exc ep t i o n s NONE Doc u m e nt Hi s t o r y
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