IN MP Reimbursement Policy Archived | Page 14

Mammography Services

Sterilization

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 2Payment Policy Subject: Just4Me-Sterilization Po l i c y CareSource provides coverage for sterilization when it meets the criteria for those services as outlined in this policy. The physician is responsible for obtaining the state-appropriate signed informed consent form from the member. De f i n i t i o n s Sterilization , means any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing. (From 42 CFR 441.251) 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 Prior Authorization CareSource requires prior authorization for inpatient voluntary sterilization of eligible members . Covered sterilization services include: Management and evaluation (office) visits and consultations for the purpose of providing sterilization services;Health education and counseling visits for the purpose of providing sterilization services;Medical/surgical services/procedures provided in association with the provision of sterilization services;Laboratory tests and procedures provided in association with the provision of sterilization services;Drugs administered in accordance with sterilization services; andSupplies provided in accordance with the provision of sterilization services.Billing Providers are responsible for using the appropriate CPT codes on their invoices . Rei mbursement CareSource will reimburse providers for sterilization services only if all the following requirements are met: The Member is at least 21 years of age at the time of the informed consent.The Member is mentally competent and not institutionalized. 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 Sterilization is the result of a voluntary request for services by a Member legally capable of consenting to such a procedure. The Member is given a thorough explanation of the procedure. In instances where the individual is blind, deaf or otherwise handicapped or unable to understand the language of the consent, an interpreter must be provided for interpretation. Informed consent is obtained on the state-appropriate forms, which are located on the CareSource website under the Provider section and in the Supplements/ Forms section of the CareSource manual, with appropriate, legible signature(s) and submitted to our health plan with the claim. Informed consent is not obtained while the individual to be sterilized is in labor or childbirth seeking to obtain or obtaining an abortion, or under the influence of alcohol or other substances that affect the individuals state of awareness. The procedure is scheduled at least 30 days, but not more than 180 days, after the consent is signed. These requirements are applicable to all sterilizations when the primary intent of the sterilizing procedure is fertility control. Re l a t e d Po l i c i es & Re f e r e n c e s OAC 5160-21, Medicaid covered reproductive health services, preconception care services . 907 KAR 1:054. Primary care center and federally-qualified health center services KAR 3:005 Section 4-10 Physician Services Do c u m e n t Re v i s i o n Hi s t o r y Archived

Chiropractic Care

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 4 Payment Policy Subject: Just4Me-Chiropractic Care Po l i c yCareSource will reimburse for covered services provided by a licensed chiropractor subject to the restrictions and limitations set out in this policy. De f i n i t i o n sChiropractic services are defined as the diagnosis and analysis of any interference with normal nerve transmission and expression, the procedure preparatory to and complementary to the correction thereof by an adjustment of the articulations of the vertebral column, its immediate articulation, and includes other incidental means of adjustments of the spinal column and the practice of drugless therapeutics. (from Indiana Code Title 25, Article 10 Chiropractors, Chapter 1 ) 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) Maintenance therapy means therapy that is performed to treat a chronic, stable condition or to prevent deterioration. (from OAC 5160:8-11) 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) Subluxation means an incomplete dislocation, off centering, misalignment, fixation, or abnormal spacing of the vertebrae anatomically, as demonstrated by x-ray film or other diagnostic test. (from OAC 5160:8-11)P r 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 sPrior Authorization Prior authorization for chiropractic procedures performed within the limits of this policy is not required. However, if medically necessary chiropractic treatments are required that exceed the limits of this payment policy, then the provider should obtain prior authorization from CareSource. Determination of medical necessity and appropriateness of service is the responsibility of chiropractors within the scope of accepted medical practice and Medicaid limitations, where appropriate. Chiropractors are held responsible if excessive or unnecessary services are ordered, regardless of who actually renders these services (e.g., x-rays), or if reimbursement is received for the service. 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 4 Coverage Treatment by means of manual manipulation of the spine to correct a subluxation is a covered service when determined to be medically necessary. The existence of the subluxation must be demonstrated either by a diagnostic x-ray or by physical examination. Evidence must be retained as a part of the members medical record that a subluxation exists. The manual manipulation must have a direct therapeutic relationship to the members condition as documented in the medical record. The lack of documentation specifying the relationship between the members condition and treatment shall result in the service being ineligible for reimbursement. Only one of the spinal manipulation procedure codes is billable per day, per member. Clinical signs and symptoms must be consistent with the level of subluxation. If documentation other than x-rays supports the medical necessity of spinal manipulation for children, the x-ray requirement may be waived. CareSource reserves the right to request x-ray documentation if deemed necessary. X-Ray Services Diagnostic x-rays to determine the existence of a subluxation are covered with certain limitations. The covered units of service are as follows: Code Description 72010 Radiological exam, spine, entire, A&P 72020 Radiologic exam, spine, single view, specify level 72040 Radiologic exam, spine, cervical; 2 or 3 views 72050 Radiologic exam, spine, cervical; minimum of 4 views 72052 Radiologic exam, spine, cervical; complete, including oblique & flexion &/or extension studies 72069 Radiologic exam, spine, thoracolumbar, standing (scoliosis) 72 070 Radiologic exam, spine; thoracic, 2 views 72074 Radiologic exam, spine; thoracic, minimum of 4 views 72080 Radiologic exam, spine; thoracolumbar, 2 views 72100 Radiologic exam, spine, lumbosacral; 2 or 3 views 72110 Radiologic exam, spine, lumbosacral; minimum of 4 views 72114 Radiologic exam, spine, lumbosacral; complete including bending views Limitations of Coverage Just4Me members are covered for up to 12 visits per year for spinal manipulation. Prior authorization should be obtained from CareSource if additional spinal manipulations are medically indicated during any 12 month period. 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 3 of 4 Other limitations includ e: 1) Services which are not personally performed by the chiropractic physician with whom CareSource has a provider agreement: a) Services provided by licensed individuals with whom CareSource does not have an individual provider agreement are not reimbursable even though the covered services are provided under the personal supervision of a licensed chiropractic physician with whom CareSource does have a provider agreement. b) Services provided by unlicensed individuals under the personal supervision of a licensed chiropractic physician are not reimbursable. c) Services provided by students during an internship are not covered services. 2) Sp inal axis aches, strains, sprains, nerve pains, and functional mechanical disabilities of the spine are considered to provide therapeutic grounds for chiropractic manipulative treatment. Most other diseases and disorders do not provide therapeutic grounds for chiropractic manipulative treatment. Examples of non-covered diagnoses are multiple sclerosis, rheumatoid arthritis, muscular dystrophy, sinus problems and pneumonia. 3) Repeat x-rays or other diagnostic tests in members with chronic, permanent conditions will not be considered medically necessary and are not a covered service. 4) If there is no reasonable expectation that the continuation of treatment would improve or arrest deterioration of the condition within a reasonable and generally predictable period of time, coverage will be denied. 5) Continued repetitive treatments without an achievable and clearly defined goal will be considered maintenance therapy and will not be considered covered services. 6) Once the maximum therapeutic benefit has been achieved for any given condition, ongoing therapy is considered maintenance therapy which is not considered medically necessary. 7) When services are performed more frequently than generally accepted by peers, chiropractic manipulation will be considered excessive and will be denied as not medically necessary. Procedure Codes For chiropractic ser vic es, CS covers the following CPT codes . Code Description 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions 98942 Chiropractic 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 4 of 4 Noncovered Services Chiropractic services excluded from Medicaid coverage are all services other than manual manipulation of the spine and spinal x-rays. CareSource does not cover the following services when rendered by a chiropractor: Maintenance therapy; Laboratory test; Evaluation and management services; Physical therapy; Traction; Supplies where not included in the primary CPT code; Injections; Drugs; Diagnostic studies other than diagnostic xrays; Orthopedic devices; Equipment used for manipulation; and Any manipulation which the x-ray or other tests does not support the primary diagnosis. Consultations Fracture care Home visits Plaster casts Inpatient hospital visits Re l a t e d Po l i c i es & Re f e r e n c e s OAC Chapter 5160-8- 11 Physician Services / Covered chiropractic physician services and limitations KAR 3:125 Chiropractic Services and reimbursement Do c u m e n t Hi s t o r y Archived

Low Vision

Payment PolicySubject: Just4Me – Low Vision Po l i c y CareSource will reimburse Just4Me (Ohio Marketplace) providers specializing in low vision care for covered low vision services, including eval uations, low vision aids, and training and instruction, as described in this policy. De f i n i t i o n sLow vision . A person with low vision is one who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception, or a visua l field less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of a task for which vision is essential. (From www.wh o.int/blindness/causes.com) 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 sPrior Authorization CareSource requires that a provider receive pre-authorization before providing a member with services under this low vision policy. ReimbursementCareSource will reimburse providers specializing in low vision care for the evaluation, prescription of optical devices, and for providing training and instruction to maximize the remaining usable vision for our Just4Me (Ohio Marketplace) members with low vision. After pre-authorization by CareSource,covered low vision services (both in-and out-of-network) will include one comprehensive low vision evaluation every 5 years, with a maximum allowed charge of $300; maximum low vision aid allowance of $600 wit h a lifetime maximum of $1,200 for items such as high-power spectacles, magnifiers and telescopes; and follow-up care of up to four visits in any five-year period, with a maximum reimbursement of $100 for each follow-up visit. CareSource will not reimbu rse for visual therapy, or for service and materials notmeeting accepted standards of optometric practice.BillingThe appropriate documentation must be attached to the claim form, or sent separately to CareSource for claims submitted electronically. Re l a t e d Po l i c i es & Re f e r e n c e sD o c u m e n t Re v i s i o n Hi s t o r y 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 1

Transcutaneous Electrical Nerve Stimulators (“TENS”)

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 5 Payment Policy Subject: Transcutaneous Electrical Nerve Stimulators ( TENS) 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 licensed suppliers for the rental or purchase of TENS units and supplies when medically necessary and only after a successful and non-reimbursable 30-day trial period as set forth in this policy. To be eligible for coverage, TENS units must be issued and used within the limits of this policy. De f i n i t i o n s Transcutaneous electrical nerve stimulation (TENS ) is the application of mild electrical stimulation to skin electrodes placed over a painful area. It causes interference with transmission of painful stimuli. (from Tabers Cyclopedic Medical Dictionary, 18thEdition) 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 Prior Authorization Prior authorization is not required when TENS units are prescribed within the limits of this policy. The pain must have been present for at least 6 months and other appropriate treatment modalities must have been tried and failed. Coverage CareSource considers only the following conditions as being eligible for the use of a TENS unit after other appropriate treatment modalities have been tried and have failed: Herpes zoster with other nervous system complications;Reflex sympathetic dystrophy;Other nerve root and plexus disorders;Mononeuritis of upper limb and mononeuritis multiplex;Mononeuritis of lower limb and unspecified site;Osteoarthrosis and allied disorders, if arthroplasty is not indicated, the patient has disabling knee pain or stiffness or the patient has inadequate response to 6 or more weeks of treatment with medication;Spondylosis of unspecified site;Intervertebral disc disorders;Brachial neuritis or radiculitis, not otherwise specified; 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 5 Spinal stenosis, other than cervical; Lumbago; Sciatica; Dysmenorrhea, if secondary causes have been ruled-out Myalgia and myositis, unspecifi ed; Neuralgia, neuritis, and radiculitis, unspecified; or Other postsurgical status when used for acute post-operative pain for 30 days from the day of surgery where conventional pain control techniques fail to adequately reduce pain and/or medication-related adverse events are unacceptable and/or Opioid dosage reduction is needed. Use of a TENS unit and related services for conditions not listed above are not eligible for reimbursement because the medical effectiveness of such therapy has not been established. Examples of conditions for which TENS therapy is not considered to be reasonable and necessary are (not all-inclusive): Headache Visceral abdominal pain Pelvic pain Temporomandibular joint (TMJ) pain Acute pain (e.g.; angina, back pain, fractures, musculoskeletal) Cancer or cancer treatment-related pain Chronic low back pain Fibromyalgia Multiple Sclerosis Neuropathy The conditions listed in this policy may not be associated with members treated with acupuncture, nor may they be associated with any variation of acupuncture techniques, as acupuncture is not a covered service . Documentation The provider of the TENS unit must complete a Certificate of Medical necessity attesting to the medical necessity of the services, which may be reviewed by CareSource. The provider must also assure that the member using the device is properly instructed in how to use the device in support of his or her ordered treatment plan and is aware of and understands any emergency procedures regarding the use of the TENS unit. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical re cord. The following documentation to be kept in the providers records: The Certificate of Medical Necessity. A face-to-face examination of the patient should be documented in the medical records. This record should clearly support and document the medical necessity of the TENS Unit as part of an overall treatment plan. ArchivedThis 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 3 of 5 Specific documentation as to what medical diagnosis the TENS unit is prescribed. The diagnosis must be complete. Chronic intractable pain in itself is not a sufficient diagnosis to warrant coverage. Attestation by the prescriber that a non-reimbursable trial period of at least 30 days resulted in substantial relief from pain (except for postoperative members). An estimated length of use for the unit must be in the medical records When a TENS unit is used specifically for acute post-operative pain, the medical necessity of the TENS unit is limited and will be reimbursed by CareSource only for 30 days from the day of surgery. No further reimbursement for this reason will be authoriz ed. Rental When used for the treatment of chronic, intractable pain, the TENS unit must be used by the member on a trial basis for a minimum of one month (30 days). This period is not reimbursable by CareSource to the provider. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain. CareSource will reimburse the provider for an additional, trial period of 1 month (30 days). A rental period of 90 days may be submitted to CareSource if the documentation in the providers records indicates pain control benefits such as a specific reduction in medications, e.g., muscle relaxants, narcotics, analgesics directly resulting from the use of the TENS unit. Payment for rental units includes all necessary accessories and supplies, and includes fitting and instructions/education in the proper use of the TENS unit. The provider must have a physical location available to the member for the initial face-to-face fitting and instruction/education efforts.CareSource will not consider reimbursement for any other HCPCS codes for supplies and accessories during the rental period. Supplies are included in the rental amount. Purchase TENS units are covered as rental only for a maximum of 4 months. For usage beyond 4 months, a ll prior rental payments made by CareSource for the use of a TENS unit by a member are applied to the subsequent purchase of the TENS unit. For coverage of a purchase, the physician must determine that the member is likely to derive significant therapeutic benefit from continuous use of the unit over a long er period of time. Upon receiving a claim for the purchase of a TENS unit, CareSource will reimburse the provider for the purchase price of the TENS unit, less any monthly rental payments already made for that unit. Purchase will only be considered after 3 months rental and when there is clear documentation in the medical record demonstrating that: 1. The use of the TENS Unit was successful in reducing pain; 2. You have assessed the patients condition and have determined that ongoing treatment with the TENS unit is medically necessary. 3. You submit a statement with the claim submission that attests to the requirements in 1. and 2. above. 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 4 of 5 TENS units provided to members must have two or four leads with more than one modality and must be covered by a warranty of 2 years or more when purchased on behalf of the CareSource member. CareSource will not authorize the purchase or rental of a used TENS unit unless the specific unit was used previously by the member . CareSource does not allow for the sharing of TENS units. If a TENS unit is ordered for use with four leads, the medical record must document why two leads are insufficient to meet the members needs. In the event that a member has already been renting a TENS unit before enrolling in CareSource and is eligible to purchase that unit, then the claim for the purchase must include appropriate documentation showing the full period of the rental. Supplies CareSource covers 1 unit of supplies for a two-lead TENS unit and 2 units of supplies for a four-lead TENS unit. For supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For products that are supplied as refills to the original order, suppliers must contact the member prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the member . This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Contact with the patient regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. For delivery of refills, th e supplier must deliver the product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. Industry standards state the TENS supply code A4595 includes the following: Electrodes (any type) Conductive paste or gel (if needed, depending on the type of electrode) Tape or other adhesive (if needed, depending on the type of electrode) Adhesive remover Skin preparation materials. Batteries (9 volt or AA, single use or rechargeable) Battery charger (if rechargeable batteries are used) Replacement lead wires (if more often than every 12 months per medical necessity)Supplies for a TENS unit owned by a patient must be dispensed and billed on a monthly basis in quantities no greater than actually needed by the patient as no automatic shipments or stockpiling of these supplies are permitted. No supplies may be billed before they have been provided to the patient. Reimbursement for supplies must be made under a single all-inclusive code [A4595]. CareSource will reimburse one (1) unit for a two-lead TENS Unit supplies and two (2) units for four-lead TENS unit. 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 5 of 5 Billing Modifiers Rental Modifiers accepted by CareSource are as follows: RR Rental LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price) Purchase Modifiers accepted by CareSource are as follows: NU New equipment CPT codes E0720 or E0730 must be submitted with the modifier NU to indicate the purchase of the TENS unit. If a submitted claim does not include a modifier, or includes an incorrect or inappropriate modifier, the claim will be denied. Any such denials may be appealed by the provider via the CareSource Medical Management department. Re l a t e d Po l i c i es & Re f e r e n c e s CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-8, Chapter 5, Section 5.2.6: Medical Supplies (DME) / Transcutaneous electrical nerve stimulators (TENS) CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Sections 10.2, 160.7.1, 160.13, 160.27, 280.13. Ohio Administrative Code 4761:1-3- 02 Ohio Administrative Code 5160-10-15, Transcutaneous electrical nerve stimulators (TENS). Ohio Administrative Code 4752:02(B)(1) 201 Kentucky Administrative Regulations 2:350 , Home medical equipment service providers. Milliman Care Guidelines 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 04/30/2014Certificate of Medical Necessity required; Reimbursable rental period clarified; Reimbursement for purchase will subtract any rental payments; Documentation of rental required for new members; Appeals addressed; correct modifiers required. 10/31/2013 OAC Rule renumbered from 5101:3-10-15, per Legislative Service Commission Guidelines. Archived

Anesthesia

Payment Policy Subject: Anesthesia Programs Covered: OH Medicaid, KY Medicaid, OH MyCare, and Just4Me TM (all states)Effective Date: 6/1/2013 Policy CareSource will reimburse for medically necessary anesthesia procedures rendered within scope of practice in a physicians office, inpatient or outpatient facility . Definitions Anesthesia time is the actual number of anesthesia minutes as reported on the claim. Anesthesia time begins when the anesthetist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthetic supervision. (from OAC 51 60–4-21 (B)(4)) Base unit means the value for each anesthesia code that reflects all activities other than anesthesia time. Anesthesia activities include usual pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia care, and monitoring services.(from OAC 51 60-4-21 (B)(1) ) Base unit value. Each anesthesia code (procedure codes 00100-01999) is assigned a base unit value by the American Society of Anesthesiologists (ASA) and used for the purpose of establishing fee schedule allowances. Anesthesia services are paid on the basis of a relative value system, which include both base and actual time units. Base units take into account the complexity, risk, and skill required to perform the service. (from http://www.cms.hhs.gov) Medical direction is when a physician utilizes the assistance of a CRNA/AA, resident, intern, or fellow in the performance of the aesthesis services and is involved in no more than four concurrent anesthesia cases.(from OAC 5160-4-21 (C)(3)(a)) Me dical supervision is when the physician anesthesiologist is involved in furnishing services for more than four concurrent procedures or is performing other services while directing the concurrent procedures. In situations where the physician is involved in medically supervising more than four procedures concurrently, or is performing other services while directing the concurrent procedures, the physician must be involved in the pre-surgical anesthesia services. (from OAC 51 60-4- 21 (C)(3)(b) and (4)) Monitored Anesthesia Care (MAC) is a combination of local anesthesia and certain anxiolytic and analgesic medications. When this type of anesthesia is used, the patient maintains protective reflexes and consciousness except for a brief period of time.(f rom OAC 5160-4-21 ( I))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 5 Archived Time unit means the continuous actual presence of the physician (or of the medically-directed resident or medically-directed CRNA/AA) and starts when he/she begins to prepare the patient for anesthesia and ends when the anesthesiol ogist (or medically-directed CRNA/AA) is no longer in personal attendance with the exception of anesthesia for neuraxial analgesia for obstetrical services. (from OAC 5160-4-21 (B)(3)) Time unit value means one unit for each fifteen minutes of reported anesthesia time. Since only the actual time of a fractional time unit is recognized, the resulting time unit value will be rounded to one decimal place. (from OAC 5160-4-21 (B )(5 )) Provider Reimbursement Guidelines Prior Authorization Prior authorization for anesthesia services may be required depending on place of service . CareSource will reimburse a qualified provider for general, regional, or supplementation of local anesthesia services (or monitored anesthesia care services as described below) provided during a surgical or diagnostic procedure. Anesthesia services include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the basic monitoring procedures. ECG, temperature, blood pressure, oximetry, capnography and mass spectometry are considered usual monitoring procedures. Unusual monitoring procedures such as intra-arterial, central venous and Swan Ganz are not included in the payment for anesthesia services and may be separately billed and reimbursed. Provider Care Source will reimburse a qualified provider for anesthesia services only if that provider is acting exclusively as an anesthetist and is not also acting as the surgeon or assistant surgeon. An exception would be if a provider employs a Certified Registered Nurse Anesthetist (CRNA) to provide anesthesia services. In that case, the provider may bill and receive reimbursement for the services of the CRNA in addition to the reimbursement for the surgical procedures performed by the attending physician. For each patient, the provider must: a) Perform a pre-anesthetic examination and evaluation; b) Pre scribe the anesthesia plan; c) Personally participate in the most demanding procedures in the anesthesia plan, including induction and emergence; d) Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual; e) Monitor the course of anesthesia administration at frequent intervals; f) Remain physically present and available for immediate diagnosis and treatment of emergencies; and g) Provide indicated post-anesthetic care. 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 5Archived The provider may either personally perform the services itemized above, without the assistance of a CRNA/AA, resident, intern, fellow, or other qualified anesthetist , or the provider may use the assistance of a CRNA/AA, resident, intern, fellow or other qualified anesthetist in the performa nce of these services, and not perform any other services while providing medical direction. For physician-directed/supervised CRNA/AA services, providers should submit the appropriate procedure code, modifier and applicable time units for both the physici an and CRNA/AA on separate claim lines. Submit the primary anesthesia service as the first claim line. Care Source will not compensate E&M services when invoiced with anesthesia services, as the E&M service is included in the anesthesia service. Submitting a separate E&M service in place of a physician is appropriate if the only service provided was a pre-operative evaluation and no anesthesia was administered. Submitting an E&M procedure code for a pre-operative consultation is not appropriate unless the surgery is cancelled subsequent to the pre-operative visit. Care Source will reimburse for anesthesia services for a teaching anesthesiologist involved in an anesthesia procedure with a resident. The teaching physician must document in the medical records that he/she was present during all critical or key portions of the procedure. The teaching physicians physical presence during only the preoperative or post-operative visits with the patient is not sufficient to receive reimbursement. Time & the Reimbursement Formula Providers must report the start and end time for the administration of anesthesia, as well as the total number of minutes that anesthesia services were rendered. For example, if the total time of anesthesia was two (2) hours and ten (10) minutes, services should be submitted at 130 minutes. Every 15-minute interval will be converted by CareSource into 1 unit, rounding up to the next unit for 8 to 14 minutes, rounding down for 1 to 7 minutes. Claims submitted in units will be rejected. During claims processing, submitted minutes will be converted to time units. The formula for calculating the reimbursement of anesthesia services will be the base unit value and the time unit value multiplied by the appropriate conversion factor , if an y, or percentage of a conversion factor, as applicable. The following formula exceptions apply: Pain-management physicians are sometimes called in to manage postoperative patients who received an epidural catheter during surgery, which is indicated with CPT code 01996 ( daily management of epidural or subarachnoid drug administration). Anesthesia code 01996 will be paid based on the base units specified in the relative value guide. No calculation for time is allowable for this anesthesia code; Services invoiced with the AD modifier will be paid at three times the appropriate conversion factor, if any . 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 3 of 5 Archived No additional reimbursement will be paid for the physical status of the patient, the age of the patient, body hypothermia, body hyperthermia, emergency conditions, or time of day. Reimbursement for monitored anesthesia care is the same as for general anesthesia when all of the conditions for reimbursement are met. There is no additional reimbursement for monitored anesthesia. CPT Codes and Modifiers The following anesthesia modifiers must be used for anesthesia services: AA Anesthesia services personally performed by the anesthesiologist. The modifier AA may be used if a teaching anesthesiologist is continuously involved in one procedure with one resident or with one student certified registered nurse anesthetist. The teaching anesthesiologist must document in the medical records that he or she was present during all critical portions of the procedure including induction and emergence. AD Medical supervision by a physician: more than four concurrent anesthesia procedures; QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals; QX CRNA with medical direction by a physician or anesthesia assistant with m edical direction by an anesthesiologist; QY Medical direction of one CRNA by an anesthesiologist; and QZ CRNA without medical direction by physician. Note: Anesthesiologist assistants may use the modifier QX for services provided under the medical direction of an anesthesiologist if they are employed by a physician or in an independent practice. An anesthesiologist may use the QY modifier if he/she provides medical direction to an anesthesiologist assistant. When it is medically necessary to provide general anesthesia services for extensive restorative dental procedures or for a covered oral surgery procedure for which there is not a surgical code, the anesthesia services must use code 00170 modified by the appropriate anesthesia modifier. For the reimbursement of anesthesia services the provider must use the anesthesia code that best describes the anesthesia procedure performed modified by the appropriate anesthesia modifier, and report the total anesthesia ti me in minutes. Surgical CPT codes that include the administration of anesthesia in the description of that CPT code will only be reimbursed when an anesthesia CPT code in the range 00100-01999 is also coded on the claim. Certain CPT codes will not be reimbursed by CareSource because it is not considered to be a surgery or incident to another surgery. For this policy, CareSource follows the guidelines provided by OAC Rule 5160-2- 21, Policies for Outpatient Hospital Services, and applies the same exceptions identified in Appendix Cof that Rule. 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 4 of 5 Archived NOTE: Effective June, 1 2013 CareSource is no longer making exceptions to this policy for CPT codes 64479/64480 and 64483/64484. CareSource previously excluded these codes from the logic of this policy; however this was rescinded because Primary/Secondary logic does not apply to facility coding, making that exclusion incorrect . Related Polic ies & References OAC Rule 5160-2-21 Policies for Outpatient Services / Surgical Claim Edits OAC 5160-4- 05 (E) (1) (i) OAC Rule 5160-4-21 Physician Services / Anesthesia Services 201 KAR 8:550. Anesthesia and sedation. 907 KAR 3:010. Reimbursement for physicians’ services-Sections 3 & 4 Document Revision History 10/31/2013 OAC Rules renumbered from 5101:3-2- 21, 5101:3-4-5(E)(1)(i), and 5101:3-4- 21, per Legislative Service Commission Guidelines. 1/26/2015-Updated, effective 6/1/2013 exception is no longer being made for certain CPT codes (from Network Notification (June 2012) ); updated references to OAC rules . 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 5 of 5 Archived

Allergy Testing and Allergen Immunotherapy

Payment Policy Subject: Allergy Testing and Allergen I mmunotherapy Programs Covered: OH Medicaid, KY Medicaid, OH Special Needs Program, OH MyCare, and Just4Me TM (all states)Effective Date: 2/1/2015 Policy For its eligible members, CareSource will reimburse providers for allergy testing and allergen immunotherapy services as outlined in this policy . Definitions Allergen immunotherapy (desensitization, hyposensitization) is parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage maintained as maintenance therapy . (from OAC 5160-4-19) A llergy refers to an acquired potential for developing adverse reactions that are mediated by the immune system (via IgE antibodies). Allergic disease represents the clinical manifestations of these adverse immune responses. (from BlueCross BlueShield Online Medical Dictionary, www.bcbsms.com))A llergy testing is identifying the offending antigen(s) for a patient by in-vivo testing percutaneous, intradermal, and less commonly, patch and photo patch tests. (from www.tuftshealthplan.com ) Dose , means a 1cc aliquot of medicine or serum taken from a single, multi-dose vial. Ten doses are typically obtained from such a vial. In accordance with CMS guidelines, diluted doses will not be reimbursed; instead , if the medication or serum is diluted, only those doses designated from the maintenance vial (a maximum of ten) will be reimbursed. . Provider Reimbursement Guidelines CareSource will reimburse a participating provider of physician services for a llergy testing and injections administered by a properly instructed person in an office setting in accordance with the physicians prescribed plan of treatment. C areSource does not cover : Allergen immunotherapy that is considered experimental,investigational, or unproven;Allergen therapy administered by the member at home, from vials of serum prepared by the provider.P rior Authorization Authorization is not required for immunotherapy services administered by a participating provider within the limitations outlined below. This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 1 of 4 Archived Allergy testing CareSource will reimburse providers of physician services for the performance and evaluation of allergy sensitivity tests when the following conditions are met . A complete medical and allergic/immunologic history and physical examination must be done prior to performing diagnostic testing and be made available to CareSource upon request; and The testing must be performed based on the medical and allergic/ immunologic history and physical examination that documents that the antigen being used for the testing exists within a reasonable probability of exposure in the patients environment and be documented in the patients medical record; and Based on the information in the medical record, the testing must be limited to the minimal number of necessary tests to reach a diagnosis. Percutaneous tests, intracutaneous/intradermal tests, photo patch tests, and patch tests, photo tests, or application tests are reimbursed on a per test basis. When submitti ng claims, the provider must specify the number of tests performed. Quant itative or semi-quantitative in-vitro allergen specific IgE tests (formerly referred to a RAST tests) are covered if skin testing is not possible or not reliable and they are performed by providers certified under the Clinical Laboratory Improvement Amendment of 1988 (CLIA 88) to perform the tests . Ophthalmic mucous membrane tests and direct nasal mucous membrane tests are allowed only when skin testing cannot test allergens. If an ingestion challenge test is completed in less than 61 minutes, according to CPT/RUC rules, an E/M code should be used instead of 95076, if appropriate. Th e add-on code [95079] is intended to be used for challenges lasting beyond the two hour base code. CPT rules require that an add-on must last at least for 1 min. more than 50% of the total duration of the code, which means physicians should not use 95079 until the additional time equaled at least 31 minutes beyond the first two hour oral food challenge. Allergen immunotherapy Providers may be reimbursed for the professional services necessary for allergen immunotherapy. An office visit may be reimbursed in addition to the allergen immunotherapy codes (95115, 95117, 95144-95180) only if other identifiable services are provided at that time. If an office visit code is submitted with an allergen immunotherapy service, the modifier 25 must be used. Allergen immunotherapy will not be covered for the following antigens: newsprint, tobacco smoke, dandelion, orris root, phenol, formalin, alcohol, sugar, yeast, grain mill dust, goldenrod, pyrethrum, marigold, soybean dust, honeysuckle, wool, fiberglass, green tea, or chalk since they are not considered medically necessary. This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 2 of 4 Archived CareSource recognizes two components of allergen immunotherapy, one being the administration (injection) of the antigen, which includes all professional services associated with the administration of the antigen, and the other being the antigen itself. These two components must be s eparate on the claim , regardless of whether or not the provider who prescribes and provides the antigen is the same as the provider who administers the antigen. Injections For reimbursement for the administration (injection) of allergenic extract or stinging insect venom, the provider must use CPT code 95115 or 95117. The allergenic extract may be administered by the physician or by a properly instructed employee under the general supervision of the physician in an office setting. These codes may not be used with CPT code 95144 [Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vials ]. Antigens (excluding stinging insect venoms) When the provider prescribes and provides single or multiple antigens for allergen immunotherapy in multiple-dose vials (i.e., vials containing two or more doses of antigens), the provider must use CPT code 95165 [Profession al services for the supervision or preparation and provision of antigens for allergen immunotherapy; single or multiple antigens ] in the procedure/service code block and the number of doses contained in the vial in the unit(s) block on the invoice. If the provider dispenses two or more multiple-dose vials of antigen, for each vial dispensed CPT code 95165 must be listed on a separate line along with the corresponding number of doses. F or example, if a patient cannot be treated with immunotherapy by placing all antigens in one vial and two multidose vials containing ten doses each must be dispensed, the CPT code 95165 must be listed on two separate lines and a 10 (for ten doses) must be entered for the corresponding units. C PT code 95144, the single dose vial antigen preparation code, must not be used as one of the components of a complete service performed by a provider. The code must be used only if the provider providing the antigen is providing it to be injected by some other entity. The number of vials prepared must be indicated. C areSource does not recognize CPT codes 95120 through 95134 because they represent complete services, i.e., services that include the injection service as well as the antigen and its preparation. Only component billing will be allowed. Providers providing both components of the service must do component billing. The provider must, as appropriate, use one of the injection CPT codes (95115 or 95117) and one of the antigen/antigen preparation CPT c odes (95145 through 95149, 95165, or 95170). The number of doses must be specified. This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 3 of 4 Archived Insect venoms in single dose vials or preparations If the provider administers the venom(s), CPT code 95115 or 95117 must be used for the injection(s) of the antigen(s). When a provider prescribes and/or provides stinging insect venom antigens in single dose vials or preparations, CPT codes 95145 to 95149 must be used . a) For each single dose vial or preparation provided, a unit of service of 1 must be reported. b) If the provider also administers the venom, CPT code 95115 or 95117 must be used for the injection(s). Insect venoms in mult iple dose vials or preparations When a provider prescribes and provides single or multiple stinging insect venom(s) in multiple dose vials, CPT codes 95145 to 95149 must be used . The number reported as the unit of service must represent the total number of doses contained in the vial. Regardless of the number of doses, the date of service reported should be: a. The date the vial is dispensed to the patient, if the patient takes the vial home to be administered at a different office ; or b. The date that the first dose is administered to the patient, if the vial is kept in the physicians office. If the provider also administers the venom, CPT code 95115 or 95117 must be used for the single or multiple injection(s). The correct quantity is one for either code. Related Polic ies & References OAC Chapter 51 60-4- 19 Physician Services / Allergy services . CareSource Policy-Antigen Leukocyte Cellular Antibody Testing (ALCAT) Federal Register 65 FR 65376 State Exceptions NONE Document Revision History 10/18/2013: Initial publication 2/1/2015: Definition of dose; non-covered services; updated OAC reference. This CareSource Management Group proprietary policy is not a guarantee of payment. Payment s may be subject to limitations and/or qualifications and will be determined when the claim is received for processing. Page 4 of 4 Archived

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