REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 03/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessar y 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for t he convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreti ng and applying this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health dis order will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………. 2 B. Background ………………………………………………………………………………………………………… 2 C. Definitions …………………………………………………………………………………………………………… 2 D. Policy …………………………………………………………………………………………………………………. 2 E. Conditions of Coverage ………………………………………………………………………………………… 4 F. Related Policies/R ules ………………………………………………………………………………………….. 4 G. Review/Revision History ……………………………………………………………………………………….. 4 H. References …………………………………………………………………………………………………………. 4Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 03/01/2024 The REIMBURSEMENTPolic y St ate m ent d e tail ed a bo ve h a s recei ve d due c onsi dera tio n a s d efin ed in the REIMBURSEMENT Polic y St ate m ent Po lic y a nd is a pp rove d. 2A. Subject Left Ventricular Assist Device (LVAD) SuppliesB. 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 wi ll 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 acc urate 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. A left ventricular assist device ( LVAD) is a surgically implanted battery-operated, mechanical pump, which helps the left ventricle (main pumping chamber of the heart) pump blood to the rest of the body. It is a treatment for a weakened heart or end stage heart failure. LVADs can be used as: Bridge-to-transpl ant therapy: A life-saving therapy for patients awaiting a heart transplant. Patients use the LVAD until a heart becomes available. In some cases, the LVAD is able to restore the failing heart, eliminating the need for a transplant. Destination therapy: Some patients are not candidates for heart transplants. In this case, patients can receive long-term treatment using an LVAD, which can prolong and improve patients' lives. C. Definitions Heart failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently causing symptoms to occur throughout the body. Left-sided heart failure occurs when the heart loses its ability to pump blood preventing organs from receiving enough oxygen. The condition can lead to complications that include right-sided heart failure and organ damage. Ventricular assist device (VAD) A surgically attached device to one or both intact ventricles used to assist or augment the ability of a damaged or weakened native heart to pump bl ood. Improvement in the performance of the native heart may allow the device to be removed. D. Policy I. Dressings and supplies A. CareSource considers reimbursement for LVAD dressings a covered service when all the following criteria are met: Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 03/01/2024 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 31. The initial dressings supplied under the bundled in-patient benefit at the facility where the LVAD was implanted are expended. 2. Dressings necessary for the effective use of a LVAD must be billed using the appropriate supply code . B. LVAD dressings are a disposable supply and , therefore , a purchase-only item . C. Supplies billed with miscellaneous code E1399 will be denied if a more appropriate code is available. II. The following codes are not all inclusive but provide a general reference of unlisted/miscellaneous codes that are generally used incorrectly.Code Description E1399 Durable medical equipment, miscellaneous Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device III. Batteries A. Batteries for LVADs should be billed using the following codes: 1. Q0503: Battery for pneumatic ventricular assist device, replacement only, each. 2. Q0506: Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only B. Batteries billed with miscellaneous code E1399 will be denied. C. A rechargeable battery may be approved with a spare for uninterrupted use. IV. Warranty CareSource may request warranty information regarding the DME item or supply. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization. V. Prior authorization submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review: A. a complete description of the item (including, as applicable, the manufacturer, model or style, and size), a list of all bundled components, and an itemization of all charges B. any other information requested by CareSource VI. Non-covered services A. monitoring of LVADs B. multiple battery packs beyond the pair required for continuous use Left Ventricular Assist Device (LVAD) Supplies-MP-PY-1465 Effective Date: 03/01/2024 The REIMBURSEMENTPolicy Stateme nt det ailed a bove has recei ved due consi deration as defined in the REIMBURSEMENTPolicy Stateme nt Po licy a nd is a pprove d. 4E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Codes in this policy reflect those found in CMS Transmittal 10837 for National Coverage Determination (NCD) 20.9.1 Ventricular Assist Devices (VADs). A. All unlisted or miscellaneous codes defined within this policy are subject to medical necessity review and prior authorization. B. Prior authorization is not a guarantee of payment. C. Claims must include an invoice. D . CareSource may verify the use of any code through post-payment audit. E. If a more appropriate code is discovered, CareSource may request recoupment. F. Related Policies/Rules NA G. Review/Revision History DATE ACTIONDate Issued 12/13/2023 New Policy, approved at Committee.Date Revised Date Effective 03/01/2024 Date Archived H. References1. Artificial Hearts and Related Devices, Including Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Medicare Coverage Database; 2020. Decision Memo CAG-00453N . Centers for Medicare & Medicaid Services. Accessed September 25, 2023. www.cms.gov 2. Heart failure. National Heart, Blood and Lung Institute. Accessed September 25, 2023. www.nhlbi.nih.gov 3. Left ventricular assist devices (LVADs) . Cleveland Clinic. Accessed September 25, 2023. www.my.clevelandclinic.org 4. NCD-Ventricular Assist Devices (VADs) (20.9.1). Centers for Medicare & Medicaid Services. Accessed Sep tember 25, 2023. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-1387 03/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference re garding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as t he 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 ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addi ction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. ………………………….. 2 B. Background ………………………….. ………………………….. ………………………….. ……………………. 2 C. Definitions ………………………….. ………………………….. ………………………….. ………………………. 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. … 2 E. State-Specific Information ………………………….. ………………………….. ………………………….. …. 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. ……. 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. ……… 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. …… 4 I. References ………………………….. ………………………….. ………………………….. …………………….. 4 Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-138 7Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTranscutaneous Electrical Nerve Stimulation (TENS) B. BackgroundReimbursement policies are designed to assist providers 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 claim s 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 office staf f are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusio n of a code in this policy does not imply any right to reimbursement or guaranteeclaims payment.Transcutaneous electrical nerve stimulat ors (TENS) are device s that produce mildelectrical stimulation that causes interference with transmission of painfu l stimuli. The stimulation is applied to the members painful area via electrodes applied to the skin. C. Definitions Accessories Reusable items used with a TENS machine, which includes, but is not necessarily limited to, adapters, clips, additional connecting cable for lead wires, carrying pouches, and covers. Supplies Typically disposable items used with a TENS machine, which includes, but is not necessarily limited to , electrodes of any type, lead wires, conductive p aste or gel, adhesive, adhesive remover, skin preparation materials, batteries, and battery charger for rechargeable batteries. Transcutaneous Electrical Nerve Stimulation (TENS) The application of mild electrical stimulation to skin electrodes placed ov er an area of the body experiencing pain, which causes interference with the transmission of pain. TENS requires a stimulator, a type of durable medical equipment (DME). D. PolicyI. TENS units may require medical necessity review. II. CareSource reimburses for TENS units and supplies based on the Centers forMedicare & Medicaid Services (CMS) guidelines. III. TENS units are reimbursed on a 13-month rent to purchase basis, after a successful1-month, non-reimbursable trial period. Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-138 7Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. DocumentationA. The pr ovider of the TENS unit must complete the Certificate of Medical Necessity-Transcutaneous Electrical Nerve Stimulator (TENS) Form , CMS-848. B. For post-operative pain, an attestation must be available for review upon CareSources request, confirming that tr eatment lasting no longer than 30 days is needed for acute pain following surgery and includes the date of surgery. C. An attestation that the use of a comparable TENS unit for a trial period of at least 30 days produced substantial relief from pain must be c ompleted and available for review upon CareSources request. D. Regarding a TENS unit that was not originally reimbursed by CareSource, documentation to confirm medical necessity must be available for review upon CareSources request before reimbursement is m ade for supplies or repair. E. The provider must also provide the member with verbal instruction on the use of the TENS unit. F. The provider must maintain written documentation regarding the members instruction on the use of the TENS unit in the members medical record. V. Rental of a TENS unit to treat post-operative pain is limited to a single 30-day period and may not be extended. Modifier RR should be used in this case. VI. Reimbursement for the purchase of a TENS unit may be made if the prescrib ing provider attests to the medical necessity of continued use of the TENS units (after the successful 1-month, non-reimbursable trial period). VII. SuppliesA. Supplies are not reimbursable during the trial period.B. Supplies are not reimbursable during the rental period. C. Once the members TENS unit has converted to a purchase, CareSource covers only 1 unit of supplies (A4595) per month for a 2-lead TENS unit (E0720) or 2 units per month for a 4-lead TENS unit (E0730). D. After a TENS unit has been purchased for an in dividual, regardless of payment source: 1. Separate payment may be made for necessary supplies, which must be dispensed only when they are needed at a frequency not to exceed once per month. 2. The payment made for supplies is an all-inclusive lump sum and does not depend on the number or nature of items in a particular shipment. 3. No separate payment is allowed for individual supply items. E. If a submitted claim does not include a modifier or includes an incorrect or inappropriate modifier, the claim may deny. E. Stat e-Specific InformationNA Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-138 7Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 F. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. Please refer to the individual fee schedule for appropriate codes. The following list(s) of codes are provided as a reference. This list may not be all inclusive and is subject to updates.HCPCS CodeDescription E0720 TENS unit, 2-lead, localized stimulation (includes supplies during rental ) – All TEN Sunits must include a battery charger and battery pack. E0730 TENS unit, 4 lead large area/multiple nerve stimulation ( includes supplies during rental ) – All TENS units must include a battery charger and battery pack. A4595 TENS supplies, for 2 or 4 lead ( for a recipient-owned unit ) Modifiers DescriptionRR Rental (use the ‘RR’ modifier when DME is to be rented) NU Purchase of new equipment G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 10/26/2022Date Revised 12/13 /2023 Annual review: updated code list and references. Approved at Committee. Date Effective 03/01/2024 Date Archived I. References1. Gibson W, Wand BM, Meads C, Catley MJ, OConnell NE. Transcutaneous electrical nerve stimulation (TENS) for chronic pain an overview of Cochrane reviews. Cochrane Database Syst Rev . 2019;4:CD011890. doi:10.1002/14651858.CD011890.pub3 2. Johnson MI, Paley CA, Wittkopf PG, Mulvey MR, Jones G. Characterising the features of 381 clinical studies evaluating transcutaneous electrical nerve stimulation (TENS) for pain relief: a secondary analysis of the meta-TENS study to improve future research. Medicina (Kaunas) . 2022;58(6 ):803. doi:10.3390/medicina58060803 3. Local Coverage Article: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database. A52520. Revised January 1, 2023. Accessed November 9, 2023. www.cms.gov 4. Local Coverage Determination: Transcutaneous Electrical Nerve Stimulators (TENS). Medicare Coverage Database. L33802. Revised November 20, 2021. Accessed November 9, 2023. www.cms.gov Transcutaneous Electrical Nerve Stimulators (TENS) -MP-PY-138 7Effective Dat e: 03/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 5. Vance CGT, Dailey DL, Chimenti RL, et al. Using TENS for pain control: update on the state of the evidence. Medicina . 2022;58(10):1332. doi:10.3390/medicina58101332
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name Policy Number Effective Date Single Dose Vial Claims Modif ier s PY-PHARM-0104 07-01-2023 Policy Type Medical Administrative Pharmacy REIMBURSEMENT Reimbursement Policy Statement : R eimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, indust ry-standard claims editing lo gic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable re ferral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patien t can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowes t cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statem ents, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service (s) referenced herein. If there is a conflict between this Policy and the plan contract ( i.e., Evidence of Coverage), then the plan contract ( i.e. , Evidence of Coverage) will be the controlling document used to make the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy to services provided in a particular case and may modify this P olicy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsReimbursement Policy Statement ………………………….. ………………………….. ………………………. 1 A. Subject ………………………….. ………………………….. ………………………….. ……………………….. 2 B. Background ………………………….. ………………………….. ………………………….. …………………. 2 C. Def initions ………………………….. ………………………….. ………………………….. …………………… 3 D. Policy ………………………….. ………………………….. ………………………….. …………………………. 3 E. Conditions of Coverage. 4 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …… 4 G. Review/Revision History ………………………….. ………………………….. ………………………….. … 4 H. Ref erences ………………………….. ………………………….. ………………………….. ………………….. 4 Sin g le Do se Vial Claims Mo d ifiersMarketp lacePY-PHARM-0104 Effective Date: 07-01-2023 2 A. SubjectThis policy provides guid ance for claims billing documentation and reimbursement of single dose injectable vials. B. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarif ication. These proprietary policies are not a guarantee of payment. Reimbursement f or claims may be subject to limitations and/or qualif ications. 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 f or processing. H ealth care providers and their of f ice staf f are encouraged to use self-service channels to verif y members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS /ICD-10 code(s) f or the produc t or service that is beingprovided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment.This policy describes documentation requirements and reimbursement guidelines f orbilling of the administe red and discarded portion (s) of drugs and biologicals . Providers shall bill and receive reimbursement f or both the dose administered and the unused portion of weight-based or variable dosing injectable drugs that are manuf actured and supplied only in single dose or single use f ormat. The JW modif ier is required to be reported on a claim to report the amount of drug that is discarded and eligible f or payment and should be used only f or claims that bill single-dose con tainer drugs. The discarded portion of single use or single dose vials must be identif ied with the JW Modif ier as a separate line item f rom the dose or administered portion. Providers may be reimbursed f or the discarded portions of drugs and biologicals in single-dose vials (otherwise known as drug waste) only when appropriately reported based on the policy reimbursement guidelines. As of July 1, 2023, providers and suppliers are required to report the JZ modif ier on all claims that bill f or drugs f rom sin gle-dose containers when there are no discardedamounts. The JZ modif ier is reported on a claim to attest that no amount of drug was discarded and should only be used f or claims that bill f or single-dose container drugs. Claims containing drug administered f rom multi-dose vials are not subject to this requirement. Under this policy, a ll claims for separately payable single dose format injectabledrugs must include either a JW modifier or a JZ modifier after 7-1-2023 in order to be reimbursed Sin g le Do se Vial Claims Mo d ifiersMarketp lacePY-PHARM-0104 Effective Date: 07-01-2023 3 MODIFIER SHORT DESCRIPTOR LONG DESCRIPTORJW Discard ed p o rtio n o f d rug no t ad ministered Drug amo unt d iscard ed /no t ad ministered to any p atient JZ All d rug ad ministered no ne d iscard ed Zero d rug amount d iscarded/not administered to any p atient C. Def initionsModif ie r JW ref ers to the drug amount discarded (wasted)/not administered to any patient . Modif er JZ ref ers to zero drug amount discarded/not administered to any patient. Discarded Wastage or Unused Portion is def ined as the amount of a single use/dose vial or other single use/dose package that remains af ter administering a dose/quantity of a drug or biological. Single Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that is meant f or use in a single patient f or a sing le procedure. These vials are labeled as single-dose or single-vial by the manuf acturer and typically do not contain a preservative. Multi-Dose Vial is def ined as a vial of medication intended f or administration by injection or inf usion that contains more than one dose of medication. These vials are labeled as multi-dose by the manuf acturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. D. PolicyModif ier JW should be billed on the detail line that denotes the discarded portion of the drug or biological. The amount administered to the patient should be billed on a separate detail line without modif ier JW. Both details are reimbursable. CareSource will consider reimbursement f or: I. A single-dose or single-use vial drug that is wasted, when Modif ier JW is appended. II. The wasted amount when billed with the amount of the drug that was administered to the member. III. The wasted amount billed that is not administered to another patient. CareSource will NOT consider reimburse ment f or:I. The wasted amount of a multi-dose vial drug. II. Any drug wasted that is billed when none of the drug was administered to the patient. III. Any drug wasted that is billed without using the most appropriate size vial, or combination of vials, to deliver the administered dose. NOTE: The JZ modif ier is required when there are no discarded amounts of a single – dose container drug f or which the JW modif ier would be required if there were discarded Sin g le Do se Vial Claims Mo d ifiersMarketp lacePY-PHARM-0104 Effective Date: 07-01-2023 4 amounts. The JZ modif ier is required to attest that there were no discarded amounts,and no JW modif ier amount is reported. E. Conditions of Coverage Providers must not use the JW modif ier f or medications manuf actured in a multi – dose vial f ormat. Providers must choose the most appropriate vial size(s) required to prepar e a dose to minimize waste of the discarded portion of the injectable vials. Claims considered f or reimbursement must not exceed the package size of the vial used f or preparation of the dose. Providers must not bill f or vial contents overf ill. Providers must not use the JW modif ier when the actual dose of the drug or biological administered is less than the billing unit. The JW Modif er is only applied to the amount of drug or biological that is discarded (wasted). The discarded (wasted) drug should be billed on a separate line with the JW modif ier. 1. Claim Line #1 HCPCS code f or drug administered and the amount admistered to the patien t. 2. Claim Line #2 HCPCS code f or drug discarded (wasted) with JW modif ier appended to indicate waste and the amount discarded (wasted). The JZ Modif ier is applied when zero amounts of a single-dose container drug is discarded. F. Related Policies/Rules Chapt er 17, Section 40.1 of CMS Medicare Claims Processing Manual G. Review/Revision History DATE ACTIONDate Issued 01-22-2023 Original ef f ective dateDate Revised 08-25-2023 Updated policy to include JZ modif ier. Updated policy name and ref erences. Date Effective 07-01-2023 Date Archived H. Ref erences 1. Billin g an d Co d ing : JW an d JZ Mo d ifier Billin g Guid elines Article – Billin g an d Co d in g : JW an d JZ Mo d ifier Billin g Guid elin es (A55932) (cms.g o v) 2. New JZ Claims Mo d ifer fo r Certain Med icare Part BDru gs h ttp s://www.cms.g o v/files/d ocumen t/mm13056-n ew-jz-claims-modifier-certain-med icare-part-b- d rug s.p d f 3. Discard ed Drug s an d Bio lo g icals JW Mo d ifier an d JZ Mo d ifier Po licy FAQs. jw-mo d ifier – faq s.p d f (cms.g o v) The Reimbursement Policy Statement detailed abo ve has recei ved due con sideration as defined in theReimbursement Policy Statement Policy and is app roved.
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 01/01/2024-05/31/2025 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 C. Definitions ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. Conditions of Coverage ………………………………………………………………………………………….. 6 F. Related Policies/Rules ……………………………………………………………………………………………. 6 G. Review/Revision History …………………………………………………………………………………………. 6 H. References …………………………………………………………………………………………………………… 6 Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectNeonatal Intensive Care Unit (NICU) Level of CareB. Background This policy aligns with guidance from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) regarding NICU levels of care. This policy provides guidelines for determining the medically appropriate level of care for reimbursement based on available documentation. NICU admissions are reviewed to ensure that services are of an appropriate duration and level of care to promote optimal health outcomes in the most efficient manner. Clinical documentation of an ongoing NICU hospitalization will be reviewed concurrently to substantiate level of care with continued authorization based on the documentation submitted. Reimbursement for the NICU stay will be based on the authorized level of care and determined by the concurrent review process. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have defined and specified the capabilities for each of 4 facility levels of care (ie, a specific unit located in the hospital). These facilities range from a Level I Newborn Observation Unit to a Level IV Regional Neonatal Intensive Care Unit. Facilities offering neonatal intensive care must meet healthcare standards through federal/state licensing or certification. The Neonatal Intensive Care Unit (NICU) is a critical care area in a facility for newborn babies who need specialized care. The NICU designation requires a combination of advanced technology and a NICU team of licensed professionals. NICU levels of care are based on the complexity of care that a newborn with specified diagnoses and symptoms requires. All four levels of care are represented by a unique revenue code. Any inpatient revenue codes not billed as levels 2-4 will be recognized as a level 1. Level 1=0171 Level 2=0172 Level 3=0173 Level 4=0174 While most infants admitted to the NICU are premature, others are born at term but suffer from medical conditions, such as infections or birth defects. A newborn also could be admitted to the NICU for associated maternal risk factors or complicated deliveries. Although the list of criteria used to determine the NICU levels of care in this policy is not all inclusive, it does provide an overview of the guidelines that are used. C. Definitions Level of Care (LOC) – Care based on the complexity of care that a newborn with specified diagnoses and symptoms requires. Newborn Care Services-Services performed from birth to four weeks. Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Neonatal Intensive Care Services (NICU) – Critical care services for a newborn. Well baby care services-A basic level of care to neonates who are low risk.D. PolicyI. As per federal mandate, newborn members are covered at an inpatient facility for a 2-day stay for vaginal deliveries and a 4-day stay for cesarean sections. These stays will be covered without clinical review (notification may be required) if they are submitted with revenue codes 0170/0171 and a normal newborn DRG. II. For any newborn diagnoses/revenue codes/procedures that may be associated with care/treatment outside of routine newborn care (any revenue code 0172, 0173, 0174), preauthorization is required regardless of the length of stay and is subject to medical necessity review. The provider must be able to provide documentation establishing the criteria are met for the level of care, revenue code, and/or DRG submitted on the claim. III. When a newborn requires a NICU admission or a higher LOC service, a prior authorization is required. IV. If a complication develops with the mother or baby that necessitates additional hospital days, NICU admission, or non-well-baby service, a prior authorization should be submitted along with clinical information to support the stay. V. If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed during transitional time. VI. Clinical review will determine appropriate LOC utilizing MCG standards. CareSource will adjust LOC reimbursement if clinical documentation does not support the LOC billed. VII. Inpatient admissions may be reviewed to ensure that all services are of an appropriate duration and level of care to promote optimal health outcomes. Clinical documentation of an ongoing neonatal hospitalization will be reviewed concurrently to substantiate the level of care and length of stay. A continued authorization will be based on the documentation submitted and alignment with MCG Neonatal Facility Levels of Care and Neonatal Intensity of Care Criteria, as well as CareSource policy. VIII. In order to avoid reimbursement delay or adjustments, providers are encouraged to follow MCG guidelines along with the criteria below. NICULevel Revenue Code Description MCG NICU Intensity of Care Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 Level 1 0171: NewbornLevel I For NICU Intensity of Care Criteria 1 (See MCG Care Guidelines LOC: LOC-010 (ISC, GRG)) Level 1-Neonatal care may be indicated for a newborn or neonate with ALL of the following: Physiologically stable (eg, no apnea, bradycardia, or unstable temperature)In need of care consisting of one or more of the following: o Routine newborn care o Evaluation and care of neonates with conditions that require inpatient services available at Level Io Continued inpatient care during convalescence from condition(s) treated in Level II, Ill or IV while awaiting resolution of specific issues, (eg: Sustained weight gain, poor PO feeding) Establishment of safe discharge destination and plan o Uncomplicated jaundice treated only with phototherapy and requiring bilirubin checks while inpatient at intervals of greater than 6 hours o Absence of parenteral medications o Evaluation and management of glucose levels without IV fluids, diagnostic work – up/surveillance, on an otherwise stable neonate where no therapy is initiated Level 2 0172: Newborn Level II For NICU Intensity of Care Criteria 2 (See MCG Care Guidelines LOC: LOC-011 (ISC, GRG)) Level 2-Neonatal care may be indicated for one or more of the following: Use of oxygen via hood ( 40%), nasal cannula oxygen, ( 2L/min), with other co-morbidities stable Administration of intravenous (IV) medications IV Therapy; peripheral or PICC o IV fluids inclusive of hyperalimentation o IV heparin lock medications; or o IV medications in a physiologically/clinically stable infant; or o IV treatment of hypoglycemia Weaning from nasogastric (NG) or naso-jejunal (NJ) tube feedings while attempting to increase oral intake Apnea, bradycardia, or desaturation, but with rare episodes requiring stimulation, or only self-limited episodes; OR o apnea countdown OR o weaning caffeine Services for neonatal abstinence syndrome (NAS) requiring medication (weaning) when the Finnegan score is 8 or less or Eat Sleep Console (ESC) scores are improving Monitoring of jaundice during phototherapy with bilirubin levels at intervals of less than 6 hours Temperature control system, e.g., incubator, radiant warmer, in otherwise stable infant. Evaluation for sepsis NOT toxic appearing but on antibiotics Clinically stable infections completing course of IV medications Continued inpatient care during convalescence from condition(s) treated in Level Ill care Neonatal Intensive Care Unit (NICU) Level of Care-MP-PY-1433 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Withdrawal of Life support; end of life care; palliative careLevel 3 0173: Newborn Level III For NICU Intensity of Care Criteria 3 (See MCG Care Guidelines LOC: LOC012 (ISC, GRG)) Level 3-Neonatal care includes Level 2 requirements and one or more of the following: Respiratory support using one of the following:o HFNC with > 2 L/minute of blended oxygen, continuous positive airway pressure(CPAP), NIPPV o conventional ventilation (via endotracheal tube, nasotracheal tube or tracheostomy tube) o high-frequency ventilation long-term (> one week) Presence of chest tubes or UAC. Active apnea/bradycardic episodes requiring PPV Suspected or proven sepsis during acute phase or with toxic appearance Persistent hypoglycemia (glucose
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 01/01/2024-12/31/2024 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. State-Specific Information ………………………………………………………………………………………. 4 F. Conditions of Coverage ………………………………………………………………………………………….. 4 G. Related Policies/Rules ……………………………………………………………………………………………. 4 H. Review/Revision History …………………………………………………………………………………………. 4 I. References …………………………………………………………………………………………………………… 5 Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectPre-Exposure Prophylaxis (PrEP) Preventive ServicesB. Background An estimated 1.2 million individuals in the United States are human immunodeficiency virus positive (HIV+), with an estimated 30,635 new infections in 2020. Though treatable, HIV infection is incurable and is associated with significant health complications. Effective strategies to prevent HIV infection remain a key public health priority. To prevent the spread of HIV, the Centers for Disease Control and Prevention (CDC) recommends the use of antiretroviral pre-exposure prophylaxis (PrEP) in sexually active individuals who are at high risk of HIV exposure as well as individuals who use drugs intravenously. Studies have shown that PrEP significantly reduces the transmission of HIV to persons who are currently HIV -. The Federal Patient Protection and Preventive Care Act of 2010 requires insurance plans cover preventive medicine services with a recommendation of A or Bby the U.S. Preventive Services Task Force (USPSTF). The USPSTF assigns one of five letter grades (A, B, C, D, or I) which describes the strength of a recommendation and communicates its importance to providers. Grade A The USPSTF recommends the service; there is high certainty that the net benefit is substantial. Grade BThe USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Grade CThe USPSTF recommends selectively offering or providing the service to individual patients based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small. Grade DThe USPSTF recommends against the service; there is moderate or high certainty that the service has not net benefit or that the harms outweigh the benefits. Grade I The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of the service. The USPSTF recommends clinicians prescribe PrEP with effective antiretroviral therapy to individuals who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV infection (Grade A). To achieve the benefit of PrEP, it is important for individuals to receive counseling about antiretroviral medication adherence, safer sex practices, and regular testing for HIV and other related infections. Prior to receiving a prescription for PrEP, individuals may require counseling and laboratory testing to evaluate the need for PrEP as well as establish a baseline health status. As PrEP is only effective with medication adherence, follow-up appointments with or without laboratory testing are often necessary. As of October 1, 2023, ICD-10 code Z29.81 (encounter for HIV pre-exposure prophylaxis) is available for providers to use on medical claims. Insurance plans are not required to provide coverage for these preventive services when delivered by out-of-network providers. Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 C. Definitions Pre-Exposure Prophyaxis (PrEP) Antiretroviral medication that helps prevent individuals from acquiring HIV. USPSTF An independent, volunteer panel of national experts that makes evidence-based recommendations about clinical preventive services.D. Policy I. CareSource will provide PrEP and related services to members who qualify as high risk, following USPSTF guidelines for the prevention of HIV. These services are classified as preventive, with no cost share. Please refer to the most recently published USPSTF guideline for clarification of high risk and current coverage recommendations. II. CareSource covers the following without cost-sharing when associated with PreP: A. FDA-approved PrEP antiretroviral medications B. Baseline and monitoring services, including 1. HIV testing 2. hepatitis Band Ctesting 3. creatinine testing and calculated estimated creatine clearance (eCrCI) or glomerular filtration rate (eGFR) 4. pregnancy testing (as appropriate) 5. sexually transmitted infection (STI) screening and counseling 6. adherence counseling C. office visits associated with PrEP III. The following code set has been provided for informational purposes only. These codes may be used to identify a service as part of PrEP preventive services. In order for a service in Section II to be identified as part of PrEP preventive services and cost sharing to be waived, providers need to follow the below coding steps: A. Use ICD-10 code Z29.81 on the claim, or B. Use ICD-10 code Z20.6 or Z11.4, AND at least one of the other below codes on the claim. ICD-10Code Code Description Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z11.4 Encounter for screening for human immunodeficiency virus [HIV] Z11.59 Encounter for screening for other viral diseases Z11.8 Encounter for screening for other infectious and parasitic diseases Z11.9 Encounter for screening for infectious and parasitic diseases, unspecified Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission Z20.6 Contact with and (suspected) exposure to human immunodeficiency virus [HIV] Z20.828 Contact with and (suspected) exposure to other viral communicable diseases Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 Z20.89 Contact with and (suspected) exposure to other communicable diseasesZ20.9 Contact with and (suspected) exposure to unspecified communicable disease Z29.89 Encounter for other specified prophylactic measures Z32.00 Encounter for pregnancy test, result unknown Z32.01 Encounter for pregnancy test, result positive Z32.02 Encounter for pregnancy test, result negative Z51.81 Encounter for therapeutic drug level monitoring Z70.0 Counseling related to sexual attitude Z70.1 Counseling related to patients sexual behavior and orientation Z70.3 Counseling related to combined concerns regarding sexual attitude, behavior and orientation Z71.7 Human immunodeficiency virus [HIV] counseling Z72.51 High risk heterosexual behavior Z72.52 High risk homosexual behavior Z72.53 High risk bisexual behavior Z72.89 Other problems related to lifestyle Z77.21 Contact with and (suspected) exposure to potentially hazardous body fluids Z77.9 Other contact with and (suspected) exposures hazardous to health Z79.899 Other long term (current) drug therapy W46.0XXA Contact with hypodermic needle, initial encounter W46.0XXD Contact with hypodermic needle, subsequent encounter W46.1XXA Contact with contaminated hypodermic needle, initial encounter W46.1XXD Contact with contaminated hypodermic needle, subsequent encounter IV. Exclusions Claims received from the emergency department would not generally qualify as PrEP preventive services.E. State-Specific InformationNA F. Conditions of Coverage NA G. Related Policies/Rules NA H. Review/Revision History DATE ACTION Date Issued 09/27/2023 New Policy. Approved at Committee. Date Revised Date Effective 01/01/2024 Date Archived 12/31/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI guidelines without a formal documented Policy. Pre-Exposure Prophylaxis Preventive Services-MP-PY-1450 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 I. References1. Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, 85 Fed. Reg. 71142 (Nov. 6, 2020). 2. Assistant Secretary for Public Affairs. About the Affordable Care Act. United States Dept of Health and Human Services. Reviewed March 17, 2022. Accessed July 28, 2023. www.hhs.gov 3. Billing Coding Guide for HIV Prevention. National Alliance of State & Territorial AIDS Directors; 2016. Accessed July 24, 2023. www.nastad.org 4. Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2021. Accessed July 27, 2023. www.cdc.gov 5. Centers for Medicare and Medicaid Services. FAQs about Affordable Care Act implementation part 54. July 28, 2022. Accessed July 27, 2023. www.cms.gov 6. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About HIV. Centers for Disease Control and Prevention. Reviewed June 30, 2022. Accessed July 28, 2023. www.cdc.gov 7. Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention. About PrEP. Centers for Disease Control and Prevention. Reviewed June 30, 2022. Accessed July 28, 2023. www.cdc.gov 8. Krakower D, Mayer KH. HIV pre-exposure prophylaxis. UpToDate. Updated February 24, 2023. Accessed July 20, 2023. www.uptodate.com 9. Mayer KH, Molina JM, Thompson MA, et al. Emtricitabine and tenofovir alafenamide vs emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis (DISCOVER): primary results from a randomised, double-blind, multicentre, active-controlled, phase 3, non-inferiority trial. Lancet . 2020;396(10246):239-254. doi:10.1016/S0140-6736(20)31065-5 10. Patient Protection and Affordable Care Act, 42 U.S.C. 18001-18122 (2022). 11. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: Clinical Providers Supplement. Centers for Disease Control and Prevention; 2021. Accessed July 25, 2023. www.cdc.gov 12. Pre-Exposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review for the U.S. Preventive Services Task Force. December 2022. Accessed August 7, 2023. www.uspreventiveservicestaskforce.org. 13. Task Force at a Glance. United States Preventive Services Task Force. Accessed July 28, 2023. www.uspreventiveservicestaskforce.org 14. US Preventive Services Task Force. Preexposure prophylaxis to prevent acquisition of HIV: US Preventive Services Task Force recommendation statement. JAMA. 2023;330(8):736-745. doi:10.1001/jama.2023.14461 15. U.S. Preventive Services Task Force. Grade Definitions. June 2018. Accessed July 24, 2023. www.uspreventiveservicestaskforce.org 16. US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2021 Update: A Clinical Practice Guideline. US Centers for Disease Control and Prevention; 2021. Accessed July 25, 2023. www.cdc.govPre-Exposure Prophylaxis Preventive Services-MP-PY-1450 Effective Date: 01/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 6 17. What does FDA regulate. United States Food and Drug Administration. Reviewed January 18, 2022. Accessed July 28, 2023. www.fda.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Durable Medical Equipment (DME) Modifiers-MP-PY-1368 01/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefi ts design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limited to, those health care services or suppli es 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 functi on, dysfunction of a body organ or part, or si gnificant 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 inc lude those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 4 F. State-Specific Information ………………………….. ………………………….. ………………………….. … 4 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 4 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 4 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectDurable Medical Equipment (DME) Modifiers B. BackgroundReimbursement policies are designed to assist providers 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 office staff are encouraged to use self-service channels to verify a members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Modifiers ca n be used to further describe a product or service rendered. Some modifiersare for informational purposes only, while other modifiers are used to report additional information, to the code description, of the product or service. Using a modifier inappropr iately can result in the denial of a claim or an incorrect reimbursement for a product or service. The purpose of this policy is to simplify and standardize the use of modifiers when billingfor rented, purchased, or rent to purchase DME equipment. There are many modifiers that can be used when billing DME. This policy addresses the rental modifier RR and the new equipment purchase modifier NU. CareSource expects providers to use the modifiers stated in this policy to increase efficiency and timely rei mbursement. Any other appropriate modifier per national or state billing standards can be appended to a DME item along with the modifiers addressed in this policy (LT, RT, etc.). The modifiers addressed in this policy are not an all-inclusive list , and pro viders should adhere to national and state billing guidelines for modifier usage for all other modifiers not addressed within this policy. C. Definitions Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated and maintained by the American Medical Association (AMA) that provides a standard lang uage for coding and billing of products, supplies, and services not included in the CPT codes. Modifier Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyI. This policy outlines the use of DME modifiers for the rental and/or purchase of Durable Medical Equipment (DME). II. DME items can be:A. purchased; B. rented; or C. rented on a short-term basis and then purchased at the end of the rental period. III. DME it ems must be billed with appropriate HCPCS codes along with appropriatemodifiers when applicable:A. Purchase Modifier – NU: 1. CareSource requires that Modifier NU is appended to all claims for the purchase of DME equipment.B. Rental Modifier – RR:1. CareSource requires that Modifier RR is appended to all claims for the rental period of DME equipment.a. The combined total reimbursement for rental and subsequent purchase of a DME item cannot exceed the maximum fee.b. At the end of the rent to purchase period, the DME becomes the property of the member.C. Disposable supplies do not require a modifier.IV. Modifiers that are not to be used for claims submission for DME equipment:A. LL – Lease/rentalB. NR – New when rented C. RB – Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair (use modifier NU as replacement parts are new equipment) V. CareSource considers a replacement part as a new equipment purchase , andmod ifier NU should be used instead of modifier RB.VI. DME items submitted for reimbursement without a modifier are considered apurchase. If the DME item was intended to be a rental and the modifier RR was left off the claim in error, CareSource may verify the use of any modifier through post payment audit and proper reimbursement adjustment will occur. All information regarding the use of these modifiers must be made available upon CareSources request. VII. KX ModifierA. DME items that do not require a prior authorization must have a KX modifier appended to the HCPCS.B. The KX modifier indicates that the supplier has ensured that coverage criteria for the DMEPOS billed is met and that documentation does exist to support the medical necessity of the item. Documentation must be available upon request. Durable Medical Equipment (DME) Modifiers-MP-PY-1368Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 C. Claims that do not have the KX modifier appended in accordance with the policy will be denied.E. Conditions of CoverageModifier Description KX Confirmation that services are medically necessary RR Rental (use the RR modifier when DME is to be rented) NU Purchase New Equipment (use the NU modifier when DME is to be purchased) F. State-Specific InformationNA G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 09/14/2022 New policyDate Revised 10/11/2023 Annual review. Added KX modifier language. Updated references. Approved at Committee. Date Effective 01/01/2024 Date Archived I. References1. Durable Medical Equipment (DME). Accessed October 2, 2023. www.healthcare.gov 2. HCPCS (HCPCS – Healthcare Common Procedure Coding System). Accessed October 2, 2023. www.nlm.nih.gov 3. Use of the KX modifier. Medicare Claims Processing Manual: Chapter 5-Part B Outpatient Rehabilitation and CORF/OPT Services. US Centers for Medicare and Medicaid Services; 2021. Rev 11129. Accessed October 2, 2023. www.cms.gov 4. What are medical coding modifiers? 2023. American Academy of Professional Coders . Accessed Oc tober 2, 2023 . www.aapc.com
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Chiropractic Care-IN MP-PY-1447 01/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, reg ulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services i nclude, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity , impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenien ce 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 a nd procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and apply ing this Policy to services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will n ot be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 5 F. Related Policies/R ules ………………………….. ………………………….. ………………………….. …….. 5 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 5 H. References ………………………….. ………………………….. ………………………….. ……………………. 5 Chiropractic Care-IN MP-PY-1447Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectChiropractic Care B. BackgroundReimbursement policies are designed to assist providers 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 office staff are encouraged to use self-service channels to verify member eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS/ICD-10 code(s) for the product or service that is beingprovided. The inclusion of a code in this policy does not imply any righ t to reimbursement or guarantee claims payment. C. Definitions Chiropractor A Doctor of Chiropractic who is duly licensed and qualified to provide chiropractic services. Chiropractic Therapy Therapy that focuses on the joints of the spine and the nervous system, while osteopathic therapy includes equal emphasis on the joints and surrounding muscles, tendons and ligaments. Manipulation Therapy Osteopathic/chiropractic therapy used for treating problems associated with bones, joints and the back. Medically Necessary/Medical Necessity Health care services that a provider would render to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is (i) in accordance with generally accepted standards of medical practice; and (ii) clinically appropriate in terms of type, frequency, extent, and duration. D. PolicyI A covered chiropractic service that is legally performed will not be denied when such covered service is rendered by a n in-network licensed chiropractor in the state that the covered service is performed. II. All services are subject to members share of c ost (deductible, co-insurance and/orco-pays). This varies based on the members plan enrolled at the time of service.III. When manipulation services are provided in addition to an evaluation andmanagement (E/M) office visit, modifier 25 should be appen ded to the E/M code.This distinguishes a significant , separately identifiable E/M office visit from the additional manipulation service. Chiropractic Care-IN MP-PY-1447Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. Scope of practiceChiropractors must follow their states scope of practice. Any training or certification requi red by the state must be available to CareSource, upon request . V. Chiropractic patients whose diagnosis is not within the chiropractic scope of practice, shall be referred by the chiropractor to a medical doctor or other licensed health practitioner for treatment of that condition.VI. Manipulation therapy A. Includes chiropractic manipulation therapy used for treating problems associated with bones, joints and the back. Chiropractors would be limited to subluxations of the articulations of the human spine and its adjacent tissue. B. Annual benefit limits apply. It is the providers responsibility to validate the available remaining quantity before rendering se rvice. Manipulations performed will be counted toward any maximum for manipulation therapy services as specified in the members Evidence of Coverage (EOC) or Schedule of Benefits regardless if: 1. billed as the only procedure 2. done in conjunction with an exam and billed as an office visit C. The members plan does not provide benefits for manipulation therapy services provided in the home as part of Home Health Care Services. D. Modifier AT is required to be appended to any manipulation code. E. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patients neuromusculoskeletal condition. VII. All codes contained within this policy are not all inclusive but provide a general reference of covered codes base d on what chiropractors are allowed to perform within the respective state. Codes contained within this policy that may or may not require a prior authorization should be confirmed by accessing the Provider Look-up Tool on the CareSource website (www.proce durelookup.caresource.com). VIII. The following are a list of c odes that may be covered and do not require a prior authorization: A. Evaluation and management (E/M) codes (99202-99204, 99211-99214) B. 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions C. 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions D. 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions E. 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions F. X-rays (radiol ogic examination (RE)) for diagnostic purposes: 1. 72020 RE, spine, single view, specify level 2. 72040 RE, spine, cervical; 2 or 3 views 3. 72050 RE, spine, cervical; 4 or 5 views 4. 72052 RE, spine, cervical; 6 or more views 5. 72070 RE, spine; thoracic, 2 views 6. 72072 RE, spine; thoracic, 3 views 7. 72074 RE, spine; thoracic, minimum of 4 views Chiropractic Care-IN MP-PY-1447Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 8. 72080 RE, spine; thoracolumbar junction, minimum of 2 views9. 72081 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); one view 10. 72082 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views 11. 72083 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); 4 or 5 views 12. 72084 RE, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (e.g., scoliosis evaluation); minimum of 6 views 13. 72100 RE, s pine, lumbosacral; 2 or 3 views 14. 72110 RE, spine, lumbosacral; minimum of 4 views 15. 72114 RE, spine, lumbosacral; complete, including bending views, minimum of 6 views 16. 72120 RE, spine, lumbosacral; bending views only, 2 or 3 views 17. 72170 RE, pelvis; 1 or 2 views 18. 72190 RE, pelvis; complete, minimum of 3 views 19. 72200 RE, sacroiliac joints; less than 3 views 20. 72202 RE, sacroiliac joints; 3 or more views 21. 72220 RE, sacrum and coccyx, minimum of 2 views 22. 73000 RE; clavicle, complete 23. 73010 RE; scapula, complete 24. 73020 RE, shoulder; 1 view 25. 73030 RE, shoulder; complete, minimum of 2 views 26. 73050 RE; acromioclavicular joints, bilateral, with or without weighted distraction 27. 73501 RE, hip, unilateral, with pelvis when performed; 1 view 28. 73502 RE, hip, unilateral, with pelvis when performed; 2-3 views 29. 73503 RE, hip, unilateral, with pelvis when performed; minimum of 4 views 30. 73521 RE, hips, bilateral, with pelvis when performed; 2 views 31. 73522 RE, hips, bilateral, with pelvis when pe rformed; 3-4 views 32. 73523 RE, hips, bilateral, with pelvis when performed; minimum of 5 views 33. 73551 RE, femur; 1 view 34. 73552 RE, femur; minimum 2 views IX. Codes that may be covered but require a prior authorization:A. 97 010 hot or cold packs B. 97012 traction C. 97014 electrical stimulation D. 97035 ultrasound E. 97139 unlisted therapeutic procedure F. 97140 manual therapy technique X. Exclusions/services not covered for chiropractors:A. 20560 needle insertion(s) without injection(s); 1 or 2 muscle(s) -dry needling B. 20561 needle insertion(s) without injection(s); 3 or more muscles-dry needling Chiropractic Care-IN MP-PY-1447Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.5 1. CareSource follows the Center for Medicare and Medicaid (CMS) analysis stating that acupuncture includes dry needling. 2. Acupun cture is not a covered benefit. E. Conditions of CoverageNA F. Related Policies/RulesModifier 25 Marketplace Plan Indiana Evidence of Coverage G. Review/Revision HistoryDATE ACTIONDate Issued 08/03/2022 New policyDate Revised 10/11/2023 Annual review. Policy number changed from PY – 1358. Updated references. Approved at Committee . Date Effective 01/01/2024 Date Archived H. References1. Authority to Diagnose and Treat Injuries, Conditions, and Disorders , IND . CODE 25 – 10-1-17 (2022). 2. Definitions , IND . CODE 25-10-1-1 (2022). 3. National Coverage Analysis : Acupuncture for Chronic Low Back Pain CAG-00452N. Medicare Coverage Database. January 21, 2020. Accessed August 7, 2023. www.cms.gov. 4. Use of the AT Modifier for Chiropractic Billing . US Centers for Medicare and Medicaid Services ; 2019. MLN Matters Number SE1602. Accessed August 7, 2023. www.cms.gov.
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Lactation Education-IN MP-PY-1429 01/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a gen eral reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, aut horization, 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, i llness, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage doc uments, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan contract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determi nation. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 3 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related P olicies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 3 Lactation Education-IN MP-PY-1429Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectLactation Education B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. Policies 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 office staff are encouraged to use self-service channels to verify member 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. Theinclusion 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 as required by federal statu te through criteria based onrecommendations from the U.S. Preventive Services Task Force (USPSTF) and HealthResources and Services Administration (HRSA) . Research demonstrates convincing evidence that breastfeeding prov ides substantialhealth and developmental benefits for children. It is recommended that infants are exclusively breastfed for the first six months, followed by continued breastfeeding for at least 1 year. In the United States, however, nearly half of all b reastfeeding mothers stop by six months. Breastfeeding interventions have increased breastfeeding rates at six months and one year post-delivery when implemented during a mothers pregnancy and continued after birth. The USPSTF and HRSA, through the Women s Preventive Services Initiative (WPSI), recommends comprehensive lactation support services provided by trained counselors during pregnancy and after delivery . These services include, but are not limited to (1) counseling, (2) education, (3) breastfeeding equipment and supplies, and (4) psychosocial support for the mother and family. Occasionally, a mother may face breastfeeding complications outside of the global maternity package timeframe and require continued lactation education. Lactation consultatio ns are covered as part of an inpatient stay or in the outpatientsetting (eg, clinic or physician’s office). The service is typically rendered by a certified lactation consultant employed by a clinic, physician office, or homecare agency.Claims for lactat ion consults are reimbursed only when submitted by a facility, physician , or home care agency. Lactation Education-IN MP-PY-1429Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 C. Definitions Global Maternity Package Routine maternity services dividing the pregnancy into three stages: prenatal, delivery, and postpartum. Lactation Educat ion Interventions provided to women during pregnancy and after birth to support the preparation, initiation, and continuation of breastfeeding for their child. D. PolicyI. CareSource provides access to lactation education and counseling in the global maternity package for mothers who plan to breastfeed or are currently breastfeeding. This service is covered as a preventative service for wome n to support better health outcomes . II. Lactation counseling performed outside of the global maternity package may be separately reimbursable with HCPCS code S9443 when ALL the following apply: A. Lactation education and counseling during this period promote the continuation of breastfeeding. B. Lactation education and counseling is completed by an approved non-physician provider. An approved non-physician provider includes ANY of the following: a. Certified Lactation Counselor (CLC) b. Certified Breastfeeding Counselor (CBC) c. International Board Certified Lactati on Counselor (IBCLC) E. Conditions of CoverageNA F. Related Policies/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 10/11/2023 New Policy; approved at Committee.Date Revised Date Effective 01/01/2024 Date Archived H. References1. Breastfeeding services and supplies. Womens Preventive Services Initiative. Accessed October 10, 2023. www.womenspreventivehealth.org 2. IND . CODE 27-8-24-2 (2022). 3. IND . CODE 27-8-24-3 (2022). 4. Minimum Maternity Benefits, IND . CODE 27-8-24-1 (2022). 5. Preventive care benefits for women. US Centers for Medicare and Medicaid Services. Accessed October 10 , 2023. www.healthcare.gov Lactation Education-IN MP-PY-1429Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 6. US Preventive Services Task Force. Primary care interventions to support breastfeeding: US Preventive Services Task Force recommendation statement. JAMA . 2016;316(16):1688-1693. doi:10.1001/jama.2016.14697
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifiers-MP-PY-1392 01/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billin g, coding and documentation guidelines. Coding methodology, regulatory requirements, ind ustry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, m edical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are no t limit ed to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illnes s, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of functi on, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provi der. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contract (often referred to as the Evidence of Coverage) for the service(s) referenced herein. If there is a conflict between this Policy and the plan con tract (i.e., Evidence of Coverage), then the plan contract (i.e., Evidence of Coverage) will be the controlling document used to ma ke the determination. CareSource and its affiliates may use reasonable discretion in interpreting and applying this Policy t o services provided in a particular case and may modify this Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of ContentsA. Subject ………………………….. ………………………….. ………………………….. …………………………. 2 B. Background ………………………….. ………………………….. ………………………….. …………………… 2 C. Definitions ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 3 E. State-Specific Information ………………………….. ………………………….. ………………………….. … 3 F. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 4 Modifiers-MP-PY-1392Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectModifiers B. BackgroundReimbursement policies are designed to assist providers 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 wi ll 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 a members eligibility. Reimbursement modifiers are a two-digit code that provide a way for physicians andother qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Modifiers can be found in the appendices of both Current Procedural Terminology (CPT) and Healthcare Common Pro cedure Coding System (HCPCS) manuals. Use of a modifier does not change the code or the codes definition. Examples of modifiers use includes: To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same procedure; To indi cate that a procedure was performed on the left side, right side, or bilaterally; To report multiple procedures performed during the same session by the same health care provider; To indicate multiple health care professionals participated in the procedure ; To indicate a subsequent procedure is due to a complication of the initial procedure. Although CareSource accepts the use of modifiers, use does not guaranteereimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. C. Definitions Current Procedural Terminology (CPT) – Codes that are issued, updated and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) – Codes that are issued, updated and maintained by the Ame rican Medical Association (AMA) that provide a standard language for coding and billing of products, supplies, and services not included in the CPT codes. Modifier – Two-character codes used along with a CPT or HCPCS code to provide additional information about the service or supply rendered. Modifiers-MP-PY-1392Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. PolicyI. It is the responsibility of the submitting provider to submit accurate documentation of services performed. Providers are expected to use the most accurate and appropriate CPT/HCPCS code(s) for the product or s ervice that is being provided according to the following industry standard guidelines (may not be all-inclusive): A. National Correct Coding Initiative (NCCI) editing guidelines B. American Medical Association (AMA) guidelines C. American Hospital Association (A HA) billing rules D. Current Procedural Terminology (CPT) E. Healthcare Common Procedure Coding System (HCPCS) F. ICD-10 CM and PCS G. National Drug Codes (NDC) H. Diagnosis Related Group (DRG) guidelines I. CCI table edits II. The inclusion of a code in a policy does no t imply any right to reimbursement or guarantee claims payment. III. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.E. State-Specific InformationNA F. Conditions of CoverageI. Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved CPT/HCPCS codes along with appropriate modifiers, if applicable. Please refer to the individual CMS fee schedule for appropriate codes. II. Providers must follow proper billing, industry standards, and state compliant codes on all claim submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, CareSourcepolicies apply to both participating and nonparticipating providers and facilities.G. Related Policies/RulesNA H. Review/Revision HistoryDATE ACTIONDate Issued 10/12/2022 New policyDate Revised 09/27/2023 Updated references. Approved at Committee. Date Effective 01/01/2024 Date Archived Modifiers-MP-PY-1392Effective Dat e: 01/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 I. References 1. Billing 340B Modifiers Under the Hospital Outpatient Prospective Payment System (OPPS) . US Centers for Medicare and Medicaid Services. March 3, 2023. Accessed September 11, 2023. www.cms.gov 2. CPT overview and code approval. American Medical Association. Accessed September 11, 2023. www.ama-assn.org 3. Medicare Claims Processing Manual, XII: Ph ysicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 2003. Revised February 9, 2023. Accessed September 11, 2023. www.cms.gov 4. Medicare Claims Processing Manual, XIV: Ambulatory Surgical Centers . US Centers for Medicare and Me dicaid Services; 2003. Revised March 24, 2023. Accessed September 11, 2023. www.cms.gov 5. Optum Encoder Pro. 2023. Accessed September 11, 2023 . www.encoderprofp.com
Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regarding billing, coding and documentation guidelines. Coding methodology, regulatory requirements, industry-standard claims editing logic, benefits design and other factors are considered in developing Reimbursement Policies. In addition to this Policy, Reimbursement of services is subject to member benefits and eligibility on the date of service, medical necessity, adherence to plan policies and procedures, claims editing logic, provider contractual agreement, and applicable referral, authorization, notification and utilization management guidelines. Medically necessary services include, but are not limited to, those health care services or supplies that are proper and necessary for the diagnosis or treatment of disease, illne ss, or injury and without which the patient can be expected to suffer prolonged, increased or new morbidity, impairment of function, dysfunction of a body organ or part, or significant pain and discomfort. These services meet the standards of good medical practice in the local area, are the lowest cost alternative, and are not provided mainly for the convenience of the member or provider. Medically necessary services also include those services defined in any federal or state coverage mandate, Evidence of Coverage documents, Medical Policy Statements, Provider Manuals, Member Handbooks, and/or other policies and procedures. This Policy does not ensure an authorization or Reimbursement of services. Please refer to the plan contr act (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 control ling document used to make the determination. CareSource 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. According to the rules of Mental Health Parity Addiction Equity Act (MHPAEA), coverage for the diagnosis and treatment of a behavioral health disorder will not be subject to any limitations that are less favorable than the limitations that apply to medical conditions as covered under this policy.REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Modifier 59, XE, XP, XS, XU-MP-PY-1367 11/01/2023-09/30/2024 Policy Type REIMBURSEMENT This policy applies to the following Marketplace(s): Georgia Indiana Kentucky Ohio West Virginia Table of Contents A. Subject ………………………………………………………………………………………………………………… 2 B. Background ………………………………………………………………………………………………………….. 2 C. Definitions ……………………………………………………………………………………………………………. 3 D. Policy ………………………………………………………………………………………………………………….. 3 E. State-Specific Information ………………………………………………………………………………………. 4 F. Conditions of Coverage ………………………………………………………………………………………….. 5 G. Related Policies/Rules ……………………………………………………………………………………………. 5 H. Review/Revision History …………………………………………………………………………………………. 5 I. References …………………………………………………………………………………………………………… 5 Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 59, XE, XP, XS, XUB. Background Reimbursement policies are designed to assist physicians when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide policy clarification. These proprietary policies are no t 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. Reimbursement modifiers are two-digit codes that provide a way for physicians and other qualified health care professionals to indicate that a service or procedure has been altered by some specific circumstance. Although CareSource accepts the use of modifiers, their use does not guarantee reimbursement. Some modifiers increase or decrease the reimbursement rate, while others do not affect the reimbursement rate. CareSource may verify the use of any modifier through prepayment and post-payment audit. Using a modifier inappropriately can result in the denial of a claim or an incorrect reimbursement for a product or service. All information regarding the use of these modifiers must be made available upon CareSources request. The Medicare National Correct Coding Initiative (NCCI) includes Procedure-to-Procedure edits that def ine when two Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes should not be reported together either in all situations or in most situations. Modifier 59 is used to identify procedures/services, other than evaluation and management (E/M) services, that are not usually reported together, but are appropriate under the patients specific circumstance. NCCI guidelines state that providers should not use modifier 59 solely because two different procedures/surgeries are performed or because the CPT codes are different procedures. Modifier 59 should only be used if the two procedures/surgeries are performed at separate anatomic sites, at separate patient encounters, or by different practitioners on the same date of servic e. Contiguous anatomic sites are not considered separate in this circumstance. The Centers for Medicare and Medicaid Services (CMS) established four HCPCS modifiers to define specific subsets of modifier 59 XE Separate Encounter, a service that is distinct because it occurred during a separate encounter XP Separate Practitioner, a service that is distinct because it was performed by a different practitioner XS Separate Structure, a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service, a service that is distinct because it does not overlap usual components of the main service. Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT instructions state that modifier 59 should only be used if no more descriptive modifier is available, and its use best explains the coding circumstances. Providers should use the more specific X {EPSU} modifier when appropriate CMS guidelines note that the Xmodifiers are more selective versions of modifier 59.C. DefinitionsCurrent Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the American Medical Association (AMA) that provide a standard language for coding and billing medical services and procedures. Healthcare Common Procedure Coding System (HCPCS) Codes that are issued, updated, and maintained by the AMA that provides a standard language for coding and billing products, supplies, and services not included in the CPT codes. Modifier Two-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. Policy I. CareSource reserves the right to review any submission at any time to ensure correct coding standards and guidelines are met. II. Provider claims billed with modifier 59 or X {EPSU} may be flagged for either a prepayment clinical validation or post-payment medical record coding review. A. For prepayment review, once the claim has been clinically validated , it is either released for payment or denied for incorrect use of the modifier. B. For post-payment review, once the review has been completed, a decision is made based on the submitted documentation. If the claim is not supported by the documentation, CareSource will recover the payment, when applicable. III. It is the responsibility of the submitting provider to submit accurate documentation to substantiate the coding of their claim. Failure to submit accurate and complete documentation may result in a denial. If the documentation does not support the claims submission, this will also result in a claims denial. IV. Standard appeal rights apply for both pre-and post-payment findings and outcome of the review. V. Modifiers X {EPSU} should be used prior to using modifier 59. VI. Modifier X {EPSU} (or 59, when applicable) may only be used to indicate that a distinct procedural service was performed independent from other non-E/M services performed on the same day when no other more appropriate modifier is available. Documentation should support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separ ate injury not ordinarily encountered or performed on the same day by the same provider, provider group, and/or provider specialty. Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 A. Modifier XS (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that 1. Are performed at different anatomic sites, and 2. Are not ordinarily performed or encountered on the same day, and 3. Cannot be described by one of the more specific anatomic NCCI Procedure to Procedure (PTP)-associated modifiers (ie, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI). B. Modifier XE (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that 1. Are performed during different patient encounters, and 2. Cannot be d escribed by one of the more specific NCCI PTP-associated modifiers (ie, 24, 25, 27, 57, 58, 78, 79, 91). C. Modifier XE (or 59, when applicable) may also be used when two timed procedures are performed during the same encounter but occur one after another (the first service must be completed before the next service begins). D. Modifier XU (or 59, when applicable) is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that 1. Are performed at separate anatomic sites, or 2. Are performed at separate patient encounters on the same date of service. E. Modifier XU (or 59, when applicable) may be used when a diagnostic procedure is performed before a therapeutic procedure only when 1. The diagnostic procedure is the basis for performing the therapeutic procedure, and 2. It occurs before the therapeutic procedure and is not mingled with services the therapeutic intervention requires, and 3. Provides clearly the information needed to decide whether to proceed with the therapeutic procedure, and4. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical procedure, it cannot be reported separately. F. Modifiers XU (or 59, when applicable) may be used when a diagnostic procedure is performed after a therap eutic procedure only when 1. The diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure, and 2. It occurs after the completion of the therapeutic procedure and is not mingled with or otherwise mixed with services that the therapeutic intervention requires, and 3. Does not constitute a service that would have otherwise been required during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component or otherwise included (eg, not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it cannot be reported separately.E. State-Specific Information NA Modifier 59, XE, XP, XS, XU-MP-PY-1367 Effective Date: 11/01/2023 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 F. Conditions of CoverageReimbursement is dependent upon, but not limited to, submitting approved HCPCS and CPT codes along with appropriate modifiers, if applicable. In the absence of state specific instructions, the CMS guidelines will apply. Please refer to the individual fee schedule for appropriate codes. Providers must follow proper billing, industry standards, and state compliant codes on all claims submissions. The use of modifiers must be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, this policy applies to both participating and nonparticipating providers and facilities. In the event of any conflict between this policy and a providers contract with CareSource, the providers contract will be the governing document.G. Related Policies/Rules Modifier 25 Modifiers H. Review/Revision History DATE ACTION Date Issued 08/17/2022 Date Revised 08/02/2023 Annual review: updated references. Approved at Committee. Date Effective 11/01/2023 Date Archived 09/30/2024 This Policy is no longer active and has been archived. Please note that there could be other Policies that may have some of the same rules incorporated and CareSource reserves the right to follow CMS/State/NCCI gui delines without a formal documented Policy. I. References1. General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. US Centers for Medicare and Medicaid Services; 2023. 2. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . US Centers for Medicare and Medicaid Services; 2022. Updated February 9, 2023. 3. MLN1783722-Proper Use of Modifiers 59 & – X{EPSU}. US Centers for Medicare & Medicaid Services; 2023. 4. Medicare National Correct Coding Initiative (NCCI) Edits. US Centers for Medicare and Medicaid Services. Updated July 18, 2023. 5. Transmittal R1422OTN-Publication 100-20-MM8863-Specific Modifiers for Distinct Procedural Services. US Centers for Medicare and Medicaid Services; 2014.
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