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
Payment Policy S ubject: Psychiatric Day Programs P rograms Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Policy CareSource will reimburse participating providers for psychiatric day programs at negotiated per diem rate for the mental health and wellness services provided as part of the day program , as described herein . Definitions None required Provider Reimbursement Guidelines The purpose of this policy is to explain the r eimbursement for providers of psychiatric day facility programs and their component treatments and services as offered to CareSource members . CareSource typically enters into specific negotiated contract s with its providers which establish a defined per diem rate for psychiatric day services. Prior Authorization Prior authorization is required for reimbursement of psychiatric day facility programs. To request prior authorization for these services, please call 1-800-488-0134. During regular business hours, the call will be answered by the CareSource Medical Management Department. If calling after regular business hours, the call will be answered by the CareSource Nurse Triage Line. C overage Psychiatric facility services offered as day (outpatient) programs vary from facility to facility in the scope and content of their services. CareSource considers that all such services a re included in the established per diem rate negotiated with each participating fa cility. However, CareSource will separately reimburse a f acility for the following outpatient hospital and professional services : Speech therapy;Physical therapy;Laboratory ;Radiology ; and,Psychiatrist services.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 Archived These services are not considered to be included in the per diem rate and instead will be reimbursed to the facility in accordance with the fee schedule established at the time of the agreement negotiated and entered into by CareSource and that facility. Related Policies & References OAC Chapter 5160-8- 05, Psychology services provided by licensed psychologists . OAC Chapter 5160-29, Outpatient health facility services. 907 KAR 1:044, Coverage provisions and requirements regarding community mental health center services. 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
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: Dry Eye Syndrome Testing Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and OH Just4Me TM Po l i c y Effective February 1, 2014, CareSource will reimburse participating providers for dry eye syndrome testing 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) Dry Eye Syndrome , also known as keratoconjunctivitis sicca, (KCS), keratitis sicca, sicca syndrome, xerophthalmia, or simply, dry eyes, is an eye disease in which tear film evaporation is high or tear production is low, or there is an imbalance in the composition of the patients tears, or eyelid problems, medications, or environmental factors cause a lack of adequate tears, leading the patients eyes to dry out and become inflamed. (from www.mayoclinic.com)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 v i d e r Re i m b u r s e m e n t Gu i d e l i n e s Coverage Microfluidic analysis utilizing an integrated collection and analysis device to measure tear osmolarity (one eye) is a test covered by CareSource, and using the CPT code 83861. The American Academy of Ophthalmology Preferred Practice Pattern guideline for Dry Eye Syndrome specifically recommends tear osmolarity testing for the diagnosis and management of dry eye syndrome. The tear osmolarity test is considered to be a more sensitive method of diagnosing and grading the severity of dry eye compared to corneal and conjunctival staining, tear break-up time, Schirmer test and meibomian gland grading. CareSource acknowledges that this test can only be performed at the point-of-care, as tear fluid is a fragile sample with insufficient volume to allow for collection and transfer to a reference laboratory for analysis, as stated in AMAs CPT Assistant article on the associated CPT code (83861). 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 CareSource will reimburse all participating doctors offices, including optometrists offices,performing a medically necessary tear osmolarity test , provided that the doctors office has been certified as a laboratory under the Clinical Laboratory Improvement Act (CLIA) regulations, and has a CLIA license. Re l a t e d Po l i c ies & Re f e r e n c e s St a t e Ex c e p t i o n s NONE Do c u m e n t Re v i s i o n Hi s t o r y Archived
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