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 STATEMENT Marketplace Policy Name & Number Date Effective Modifier 25-MP-PY-1363 10/01/2024-09/30/2025 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 Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 25B. Background Reimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to promote accurate coding and provide 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. CareSource may verify the use of any modifier through prepayment and post-payment edit or audit. Reimbursement modifiers are a 2-digit code 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. Modifier 25 is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional. The American Medical Association (AMA) Current Procedural Terminology (CPT) book defines modifier 25 as a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. There must be documentation that substantiates the use of modifier 25 provided in the medical record. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a medically necessary, significant, and separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service that is medically necessary is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57 for a surgical decision. For significant, separately identifiable non-E/M services, see modifier 59. 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 edit or 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. CareSource uses published guidelines from Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 CPT and the Centers for Medicare & Medicaid Services (CMS) to determine whether the modifier was used correctly.C. DefinitionsAmerican Medical Association (AMA) A professional association of physicians and medical students that maintains the Current Procedural Terminology coding system. Current Procedural Terminology (CPT) Codes that are issued, updated, and maintained by the 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 2-character code used along with a CPT or HCPCS code to provide additional information about the service or procedure rendered. D. PolicyI. 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 25 may be flagged for either a prepayment clinical validation or prepayment 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. Modifier 25 may only be used to indicate that a significant, separately identifiable evaluation and management service [was provided] by the same physician on the same day of the procedure or other service. If documentation does not support the use of modifier 25, the code may be denied. VI. Appending modifier 25 to an E/M service is considered inappropriate in the following circumstances: Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 A. The initial decision to perform a major procedure is made during an E/M service that occurs on the day before or the day of a major procedure. A major surgical procedure has a 1-day pre-operative period and a 90-day post-operative period. B. The E/M service is reported by a qualified professional provider other than the qualified professional provider who performed the procedure. C. The E/M service is performed on a different day than the procedure. D. The modifier is reported with an E/M service that is within the usual pre-operative or post-operative care associated with the procedure. E. The modifier is reported with a non-E/M service. F. The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related pre-operative and post-operative service. G. The professional provider performs ventilation management in addition to an E/M service. H. The preventative E/M service is performed at the same time as a preventative care visit (eg, a preventative E/M service and a routine gynecological exam performed on the same date of service by the same professional provider). Since both services are preventative, only one should be reported. I. The routine use of the modifier is reported without supporting clinical documentation.E. State-Specific InformationNA F. Conditions of Coverage Reimbursement 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, 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/RulesModifier 59, XE, XP, XS, XU Modifiers policy H. Review/Revision History DATE ACTION Date Issued 07/20/2022 New Policy Modifier 25-MP-PY-1363 Effective Date: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date Revised 08/02/202307/17/2024 Annual Review: updated references. Approved at Committee Review: updated references, approved at Committee Date Effective 10/01/2024 Date Archived 09/30/2025 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. I. References1. American Medical Association. Reporting CPT modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed July 8, 2024. www.ama-assn.org 2. Appropriate use of modifier 25. American College of Cardiology. Accessed July 8, 2024. www.acc.org 3. Chaplain S. Are you using Modifier 25 correctly. American Academy of Professional Coders. Published March 25, 2022. Accessed July 8, 2024. www.aapc.com 4. Chapter 1 General Correct Coding Policies for Medicare National Correct Coding Initiative Policy Manual . Centers for Medicare and Medicaid Services; 2024. Accessed July 8, 2024. www.cms.gov 5. Felger TA, Felger M. Understanding when to use modifier-25. Fam Pract Manag. 2004;11(9):21-22. Accessed July 8, 2024. www.aafp.org 6. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners . Centers for Medicare and Medicaid Services; 2024. Accessed July 8, 2024. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Durable Medical Equipment (DME) Unlisted and Miscellaneous Codes – IN MP-PY-1481 10/01/2024 Policy Type REIMBURSEMENT Reimbursement Pol icies 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 oth er 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, claim s 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 supplies that are prope r 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 significant pain an d 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 servic es 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 ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Durable Medical Equipment (DME) Unlisted and Miscellaneous Codes-IN MP-PY-1481 Effective Dat e: 10/01/2024 The 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) Unlisted and Miscellaneous Codes B. BackgroundReimbursement policies are designed to assist providers when submitting claims to CareSource. They are routinely updated to pro mote 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 item 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 members eligibility. It is the responsibility of the submitting provider to submit the most accurate andappropriate Health Care Common Procedure Coding System (HCPCS) code(s) for the item that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. The Centers for Medicare and Medicaid Services (CMS) establishes and maintains HCPCS codes. The code sets were establi shed so providers can use the most specificand appropriate code when submitting claims for reimbursement of the item rendered to members. Occasionally, a HCPCS code may not be available for a n item if it is rarely used,unusual, or new. Only then would providers use an unlisted, unclassified, not otherwise specified (NOS), not otherwise classified (NOC), miscellaneous, or generic code for any DME item or supply.C. Definitions Durable Medical Equipmen t (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Miscellaneous (Unlisted, Unclassified, Not Otherwise Specified [NOS], or Not Otherwise Classified [NOC]) Codes Submitted by a supplier for an item for which there is no existing or no specific HCPCS code that adequately describes the item being billed. D. PolicyI. All unlisted or miscellaneous codes require a prior authorization and medical necessity review. II. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the item requested .III. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis.Durable Medical Equipment (DME) Unlisted and Miscellaneous Codes-IN MP-PY-1481 Effective Dat e: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 IV. Prior authorization subm itted 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, including an invoice . B. Statement that no other more appropriate code exis ts. C. Any other information requested by CareSource . V. Unlisted/non-specific codes used for DME item (s) deemed to be experimental and investigational may be denied. VI. WarrantyCareSource may request warranty information regarding the DME item (s) or supply when an unlisted or miscellaneous code is used. If the requested DME item(s) and/or supplies are covered by the suppliers or manufacturers warranty, CareSource will deny the prior authorization. VII. The following codes are not all inclusive but provide some typical examples of DMEunlisted/miscellaneous codes that are generally used incorrectly. Code Descri ptionA4335 Incontinence supply; miscellaneous A4421 Ostomy supply; miscellaneous A9999 Miscellaneous DME supply or accessory, not otherwise specified B9998 Not otherwise classified ( NOC) for enteral supplies E1399 Durable medical equipment, miscellaneous K0108 Wheelchair component or accessory, not otherwise specified 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 E. Conditions of CoverageA. 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 i nvoice. 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/RulesNA G. Review/Revision HistoryDATE ACTIONDate Issued 06/19/2024 New policy . Approved at Committee.Date Revised Durable Medical Equipment (DME) Unlisted and Miscellaneous Codes-IN MP-PY-1481 Effective Dat e: 10/01/2024 The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 Date Effective 10/01/2024Date Archived H. References1. CPT overview and code approval. American Medical Association. Accessed June 3, 202 4. www.ama-assn.org 2. Durable medical equipment (DME). Accessed June 3, 2024 . www.healthcare.gov 3. Healthcare Common Procedure Coding System (HCPCS). American Medical Asso ciation. Accessed June 3, 2024 . www.ama-assn.org
REIMBURSEMENT POLICY STATEMENTIndiana Marketplace Policy Name & Number Date Effective Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406 07/01/2024 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-standa rd 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 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 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. Medica lly 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., Evidenc e 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 Policy at any time. According to the rules of Mental Health Parity Addiction Equity Act (MHP AEA), 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 ………………………….. ………………………….. ………………………….. ……………………… 2 D. Policy ………………………….. ………………………….. ………………………….. ………………………….. .. 2 E. Conditions of Coverage ………………………….. ………………………….. ………………………….. …… 3 F. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 G. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 H. References ………………………….. ………………………….. ………………………….. ……………………. 4 Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectScreening and Surveillance for Colorectal Cancer B. BackgroundIn the United States, colorectal cancer (CRC) ranks second to lung cancer as a cause of cancer mortality and is the third most commonly occurring cancer in both men and women with approximately 20% higher incidence rates among African Americans. CRC incide nce and mortality rates have declined over previous decades driven by changes in risk factors, early detection of cancer through screening, removal of precancerous polyps with colonoscopy, and advances in surgical/treatment approaches. Appropriate screening reduces colorectal cancer mortality in adults 45 years of age or older. The benefit of the early detection of and intervention for colorectal cancer declineswith age, but it is recommended by both the American College of Gastroenterol ogy and the American Society for Gastrointestinal Endoscopy that screening begin at 45 years of age . Individuals 75 years of age and older are recommended to work with a primary care physician to determine if continued screening is appropriate and/or recom mended. C. Definitions Risk Agents or situations known to increase development of a condition. Per American Cancer Society guidelines : o Low Certain f actors are not present , including a personal or family history of colorectal cancer, certain types of polyps, inflammatory bowel disease (eg, ulcerative colitis, Crohns disease), or radiation to abdomen or pelvic area to treat prior cancer, and/or a confirmed or suspected hereditary colo rectal cancer syndrome (eg, familial adenomatous polyposis (FAP), or Lynch syndrome) . o High or Increased Any of the factors seen above are present. Colorectal Cancer Screening Testing for early-stage colorectal cancer and precancerous lesions in asympto matic members with an average risk . Surveillance for Colorectal Cancer Close observation f or members who are at increased or high risk for colorectal cancer. D. PolicyI. Colorectal Cancer Screening A. Prior authorization is not required for par ticipating providers . B. Benefit coverage is for members at least 45 years of age or less than 45 years of age if a t risk for colorectal cancer . C. Screening for colorectal cancer claims must be submitted with one of the following ICD-10 codes: 1. Z12.10 Encounter for sc reening for malignant neoplasm of intestinal tract, unspecified 2. Z12.11 Encounter for screening for malignant neoplasm of colon 3. Z12.12 Encounter for screening for malignant neoplasm of rectum 4. Z12.13 Encounter for screening for malignant neoplasm of small intestine Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 D. The following are reimbursed :1. Highly sensitive fecal immunochemical test (FIT) annually 2. Highly sensitive guaiac-based fecal occult blood test (gFOBT) annually 3. Multi-targeted stool DNA test (mt-sDNA) annually 4. Colonoscopy every 10 years 5. CT colonography (virtual colonoscopy) every 5 years 6. Flexible sigmoidoscopy (FSIG) every 5 years E. A follow-up colonoscopy is reimbursed as part of the screening process when a non-colonoscopy test is positive . F. Screening with plasma or serum markers is NOT covered . II. Colonoscopy Surveillance for Colorectal CancerA. Prior authorization is not required for participating providers . B. Surveillance for colorectal cancer claim must be submitted with one of the following ICD-10 codes: 1. Z84.81 Family history of carrier of genetic diseas e 2. Z15.89 Genetic susceptibility to other disease 3. Z83.71 Family history of colonic polyps 4. Z85.038 Personal history of other malignant neoplasm of large intestine 5. Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus 6. Z80.0 Family history of malignant neoplasm of digestive organs 7. Z86.010 Pe rson al history of colonic polyps 8. Z92.3 Personal history of irradiation or radiation therapy 9. K50 through K52 category codes Noninfective enteritis and colitis E. Conditions of CoverageReimbursement is dependent on, but not limited to, submitting HCPCS an d CPT codes alo ng with appropriate modifiers. Please refer to the individual CMS fee schedule for appropriate codes. F. Related Policies/RulesN/A G. Review/Revision HistoryDATE ACTIONDate Issued 11/ 01/2017Date Revised 04/28/2020 09/17/202001/12/202202/15/2023 05/10 /2023 Added specific ICD-10 to use for screening and surveillance; added ages; added benefit limits; added definitions Removed definitions and codes ; updated ages , PT modifiers, and frequencies Annual review. Annual review . Removed PT modifier information. Appro ved at Committee. Screening and Surveillance for Colorectal Cancer-IN MP-PY-0406Effective Dat e: 07/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.4 09/ 27 /202303/27/2024Updated frequency for stool DNA testing. Approved at Committee.Annual review , references updated. Approved at Committee Date Effective 07/01/2024 Date Archived H. References1. American Cancer Society guideline for colorectal cancer screening. Revised November 17 , 2020 . Accessed February 8, 2024. www.cancer.org 2. Cancer Intervention and Surveillance Modeling Network Colorectal Cancer Working Group. Colorectal Cancer Screening: An U pdated Decision Analysis for the U.S. Preventive Services Task Force . Agency for Healthcare Research and Quality; 2021. AHRQ Publication No 20-05271-EF-2. Accessed February 14, 2024. www.ncbi.nlm.nih.gov 3. Coverage for Colorectal Cancer Screening; Exception for Grandfathered Health Plans , IND . CODE 27-8-14 .8-3 (202 3). 4. Gupta S, Lieberman D, Anderson JC, et al . Recommendations for follow-up after colonoscopy and polypectomy: a consensus update b y the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc . 2020;91(3):463-485.e5. doi :10.1053/j.gastro.2019.10.026 5. Qaseem A, Harrod CS, Crandall CJ, Wilt TJ . Screening for colorectal cancer in asymptomatic average-risk adults: a gui dance statement from the American college of physicians (version 2) . Ann Intern Med . 20 23 ;17 6(8):1017-1144 . doi:10.7326/M23-0779 6. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA . 2021;325(19):1965-1977. doi: 10.1001/jama.2021.6238 7. Wilkins T, McMechan D, Talukder A. Colorectal cancer screening and prevention. Am Fam Physician . 2018;97(10):658-665. Accessed February 12, 2024. www.aafp.org
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 Overpayment Recovery-MP-PY-1393 05/01/2024 Kentucky inactive as of 01/01/2026 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 ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 3 E. State-Specific Information ………………………………………………………………………………………. 5 F. Conditions of Coverage ………………………………………………………………………………………….. 5 G. Related Policies/Rules ……………………………………………………………………………………………. 5 H. Review/Revision History …………………………………………………………………………………………. 5 I. References …………………………………………………………………………………………………………… 5 Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectOverpayment RecoveryB. Background Reimbursement policies are designed to assist you when submitting claims to CareSource. They are routinely updated to promote accurate coding and policy clarification. These proprietary policies are not a guarantee of payment. Reimbursement for claims may be subject to limitations and/or qualifications. Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing. Health care providers and their office staff are encouraged to use self-service channels to verify members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Retrospective review of claims paid to providers assist CareSource with ensuring accuracy in the payment process. CareSource will request voluntary repayment from providers when an overpayment is identified. Fraud, waste and abuse investigations are an exception to this policy. In these investigations, the look back period may go beyond 2 years. C. Definitions Claims Adjustment Adjustment is defined as a claim that was previously adjudicated and is being updated for one of the following reasons: o denied as a zero payment o a partial payment o a reduced payment o a penalty applied o an additional payment o a supplemental payment Coordination of Benefits (COB) A payment from another carrier that is received after a payment from CareSource; and the other carrier is the primary insurance for the member. Credit Balance / Negative Balance Funds that are owed to CareSource as a result of a claim adjustment. Explanation of Payment (EOP) The EOP or contains the payment and adjustment information for claims the provider has submitted for payment to CareSource. Forwarding Balance (FB) An adjustment that occurs within an EOP to a claim with a prior paid amount. The FB amount does not indicate funds have been withheld from the providers payment for this remittance advice. It only indicates that a past Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 claim has been adjusted to a different dollar amount and that funds are owed to CareSource. Improper Payment A payment that should not have been made or an overpayment was made. Examples include, but are not limited to: o payments made for an ineligible member o ineligible service payments o payments made for a service not received o duplicate payments Overpayment Any payment made to a network provider by a Managed Care Organization (MCO) to which the network provider is not entitled to under Title XIX of 42 CFR. o A claim adjustment is only considered to result in an overpayment when a claim that previously paid is updated to a denied status as a zero payment or results in a reduced payment. Provider Level Balancing (PLB) Adjustments to the total check/remit amount occur in the PLB segment of the remit. The PLB can either decrease the payment or increase the payment. The sum of all claim payments (CLP) minus the sum of all provider level adjustments (in the PLB segment) equals the total payment (BPR, which means total payment within the EOP). Retroactive Eligibility A payment for a member who was retroactively terminated by the state. The member is not eligible for benefits.D. PolicyI. CareSource will provide all the following information when seeking recovery of an overpayment made to a provider: A. the name and patient account number of the member to whom the service(s) were provided B. the date(s) of services provided C. the amount of overpayment D. the reason for the recoupment E. that the provider has appeal rights II. Overpayment Recoveries A. Lookback period is 24 months from the claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. III. Coordination of Benefit Recoveries A. Lookback period is 12 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. C. If the recovery occurs outside of original claim timely filing limits, the corrected claim submission timeframe is 60 days from the date of the recovery. Normal Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 timely filing limits apply to corrected claims being submitted within original claim timely filing guidelines. IV. Retro Active Eligibility Recoveries A. Lookback period is 24 months from claim paid date. B. Advanced notification will occur 30 days in advance of recovery. V. Management of Claim Credit Balances. A. Regular and routine business practices, including, but not limited to, the updating and/or maintenance of a providers record, can create claim credit balances on a providers record. This may result in claim adjustments, both increases and/or decreases in claim paid amounts, and/or forward balancing may move a providers record into a negative balance in which funds would be owed to CareSource. This information will be displayed on the EOP in the PLB section. B. Negative balance status and the associated reconciliation of that balance that is the result of a claim adjustment that increased the claim paid amount is not considered to be an overpayment recovery and does not fall under the terms of this policy. 1. Claim Adjustment Example a. A claim paid $10 previously but was updated to pay $12. The adjustment created a $10 negative balance and paid the provider the full $12 when adjusted, instead of the $2 difference. b. The $10 negative balance is not considered to be an overpayment subject to the guidelines outlined in section D.I D. IV. 2. Overpayment Example a. A claim previously paid $12 but is updated to pay $10. The claim adjustment with the $2 reduced payment is subject to the guidelines outlines in section D.I D. IV. b. The reduced payment will trigger a 30-day advanced notification with the details related to the claim and overpayment. C. Reconciliation of negative balance status will be done through claims payment withholds for otherwise payable claims until the full negative balance has been offset, unless otherwise negotiated. D. Providers are notified of negative balances through EOPs and 835s. Providers are expected to use this information to reconcile and maintain their Accounts Receivable (AR) to account for the reconciliation of negative balances.E. Notification of negative balances and reconciliation of negative balances may not occur concurrently. Providers are expected to maintain their AR to account for the reconciliation of negative balances when they occur. VI. In the event of any conflict between this policy and any written agreement between the provider and CareSource, that written agreement will be the governing document.Overpayment Recovery-MP-PY-1393 Effective Date: 05/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 E. State-Specific Information1. Georgia a. Payment, GA. C ODE 33-20A-62 (2022). 2. Indiana a. Claim Payment Errors, I ND . C ODE 27-13-36.2-8 (2022). b. Claim Overpayment Adjustment, IND . C ODE 27-13-36.2-9 (2022). 3. Kentucky a. Resolution of Payment Errors Retroactive Denial of Claims Conditions, K Y. R EV . S TAT . 304.17A-708 (2024). b. Collection of Claim Overpayments Dispute Resolution, K Y. R EV . S TAT . 304.17A-714 (2024). 4. Ohio a. Payments Considered Final Overpayment, O HIO REV . C ODE ANN . 3901.388 (2002). 5. West Virginia a. Civil Penalty Imposed by Commissioner, W. V A. C ODE R. 33-25A-23a (2022). b. Definitions, W. V A. C ODE R. 33-45-1 (2022). c. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner's Jurisdiction, W. V A. C ODE R. 33-45-2 (2022). F. Conditions of Coverage Reimbursement 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. G. Related Policies/Rules CareSource Marketplace Provider Manual CareSource Provider Agreement, Article V. Claims and Payments H. Review/Revision History DATE ACTIONDate Issued 10/26/2022 New policyDate Revised 02/14/2024 Annual review. Removed IV.C. Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived I. References1. Limitation on Recoupment (935) for Provider, Physicians and Suppliers Overpayments . Center of Medicare & Medicaid Services; 2008. Reviewed 2020. Accessed January 29, 2024. www.cms.gov
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Interest Payments-MP-PY-1391 05/01/2024 Policy Type REIMBURSEMENT Reimbursement Policies prepared by CareSource and its affiliates are intended to provide a general reference regardin g 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, Reimbur sement 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, 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 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.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. State-Specific Information ………………………………………………………………………………………. 3 F. Conditions of Coverage …………………………………………………………………………………………. 3 G. Related Policies/Rules …………………………………………………………………………………………… 3 H. Review/Revision History ………………………………………………………………………………………… 3 I. References ………………………………………………………………………………………………………….. 3Interest Payments-MP-PY-1391 Effective Date: 05/01/2024 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. SubjectInterest Payments B. Background Reimbursement 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 members 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 being provi ded. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. C. Definitions Adjusted Claim An adjusted claim is the result of a request by the provider or CareSource to change historical data or reimbursement of an original claim. Clean Claim A clean claim has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. A provider submits a clean claim by providing the required data elements on the standard claims forms that are accurate at the time of payment, along with any attachments and additional elements, or revisions to data elements, of which the provider has knowledge. Original Claim The initial complete claim for one or more benefits on an application form. Prompt Payment Prompt payment is defined by State and/or Federal regulation defining timeliness and interest requirements . D. Policy I. CareSource strictly adhere to all regulatory guidelines relating to interest. We follow the guidelines outlined in Prompt Payment regulations. (42 C .F .R . 422.520) II. Payment of interest is made when CareSource fails to pay the claim within the applicable state and federal prompt pay timeframes on clean claims. III. CareSource considers interest payment on claims that were not paid accurately on prior processing attempts. If CareSource had the information to pay the claim correctly on a previous payment but failed to do so, CareSource will pay the claim within the allotted timeframe from Prompt Pay and Interest Regulations. Interest will begin accruing when payment is not made within the Prompt Pay timeframe. IV. CareSource only pays interest on claim payments that are occurring under prompt pay regulations. A contractual adjustment of a claim is not subject to state and Interest Payments-MP-PY-1391 Effective Date: 05/01/2024 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. 3federal regulations for interest payment. CareSource performs regular audits to correct claim payment. A. Audits on retroactive eligibility updates, authorization updates, coordination of benefits (COB) updates, and fee schedule updates. B. Audits include proactive measures to correct claim payment when it has been determined that a systemic issue has paid claims incorrectly. C. Claims are not subject to interest payment when CareSource takes proactive measures to pay claims correctly .E. State-Specific Information A. Georgia 1. Definitions; Prompt Pay Requirements; Penalties , G A. CODE ANN . 33-24-59.14 (2023). B. Indiana 1. Payment or Denial of Claims; Interest, I ND . CODE 27-13-36.2-4 (2023). 2. Required Rules, I ND . CODE 12-15-21-3 (2023). C. Kentucky 1. Payment of Interest for Failing to Pay, Denying, or Settling a Clean Claim as Required, K Y. REV . STAT . ANN . 304.17A-730 (2023) . D. Ohio 1. Computation of I nterest, O HIO REV . CODE ANN . 3901.389 (2002). E. West Virginia 1. Minimum Fair Business Standards Contract Provisions Required; Processing and Payment of Health Care Services; Provider Claims; Commissioner's Jurisdiction , W. VA. CODE 33-45-2 (2022).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 . G. Related Policies/Rules NA H. Review/Revision Histo ry DATE ACTIONDate Issued 04/12/2023 New Policy.Date Revised 01/31/2024 Updated references. Approved at Committee. Date Effective 05/01/2024 Date Archived I. References1. Interest, 41 U.S.C. 7109 (2022). 2. Interest Penalties, 31 U.S.C. 3902 (2023). Interest Payments-MP-PY-1391 Effective Date: 05/01/2024 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. 43. Interest rates. Bureau of the Fiscal Service. Updated August 15, 2023. Accessed December 21, 2023. www.fiscal.treasury.gov 4. Prompt Payment Interest Rate; Contract Disputes Act , 88 Fed. Reg. 55,501 (Aug. 15, 2023). Accessed December 21, 2023. www. govinfo.gov 5. Prompt Payment of Claims, 42 U.S.C. 1395h(c)(2)(B) (2021). 6. Prompt Payment of Claims, 42 U.S.C. 1395u(c)(2)(B) (2021). 7. Prompt Payment by MA Organization, 42 C .F .R . 422.520 (2022) .
REIMBURSEMENT POLICY STATEMENTMarketplace Policy Name & Number Date Effective Temporary Codes-MP-PY-1413 04/01/2024 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 requirement s, 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 no t 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 fun ction, 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 contr act (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 an y 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 ………………………….. ………………………….. ………………………….. …… 3 G. Related Policies/Rules ………………………….. ………………………….. ………………………….. …….. 3 H. Review/Revision History ………………………….. ………………………….. ………………………….. ….. 3 I. References ………………………….. ………………………….. ………………………….. ……………………. 3 Temporary Codes-MP-PY-1413Effective Dat e: 04/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.2 A. SubjectTemporary Codes 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 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 inc lusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. Temporary codes exist in both CPT and HCPCS manuals and are updated throughout the year. Tcodes (ie, Category III codes) are temporary CPT codes for em ergingtechnologies, services, and procedures , which support data collection to substantiate widespread use and/or provide documentation for the Food and Drug Administration (FDA) approval process. Many of these codes have not been proven medically necessa ry and are considered to be experimental or investigational based on a lack of peer-reviewed scientific literature. A variety of temporary HCPCS codes exist . Temporary HCPCS codes may be established by the Centers for Medicare and Medicaid Services (CMS) t o report drugs, biologicals, devices, and procedures , to identify services and procedures under FDA review or address miscellaneous services, procedures, and supplies . Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) may develop t emporary HCPCS codes to report supplies and other products for which a national code has not yet been developed. Temporary HCPC S codes may also be developed by commercial payers to report drugs, services, and supplies. Coverage of these services is under t he discretion of local carriers. C. DefinitionsNA D. PolicyI. CareSource con siders temporary codes medically necessary when ALL the following criteria are met: A. Documentation in the medical record supports the use of the code . B. A more specific code is not available to describe the service/procedure . C. The service provided is within the scope of the members benefit plan. II. CareSource will use current industry standard procedure codes (HCPCS CPT I and Category II codes) throughout the processing systems. HIPAA Transaction & CodeTemporary Codes-MP-PY-1413Effective Dat e: 04/01/2024The REIMBURSEMENT Policy Statement detailed above has recei ved due consideration as defined inthe REIMBURSEMENT Policy Statement Policy and is approved.3 Set Rule requires providers use the procedure code(s) that are valid at the time the service is provided.III. Providers must use industry standard code sets and must use specific HCPCS CPT I and Category II codes when available unless otherwise directed through the providers contract. IV. If specific codes are not available, unlisted codes require plan preauthorization.E. State-Specific Information NA 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. G. Related Policies/RulesNA H. Review/Revision Histo ryDATE ACTIONDate Issued 02/01/2023 New policyDate Revised 01/17/2024 Annual rev iew: updated references, approved at Committee. Date Effective 04/01/2024 Date Archived I. References1. American Academy of Professional Coders. What is HCPCS? Accessed January 2, 2024. www.aapc.com 2. CPT Professional 2024 . American Medical Association; 2024. 3. HCPCS Codes Temporary Codes for Use with Outpatient Prospective Payment System. Accesse d January 2, 2024. www.hcpcs.codes 4. Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule. American Medical Association. Accessed January 2, 2024. www.assets.ama-assn.org
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 STATEMENT Marketplace Policy Name & Number Date Effective Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-MP- PY-1388 04/01/2024-01/31/2026 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 ……………………………………………………………………………………………………………. 2 D. Policy ………………………………………………………………………………………………………………….. 2 E. State-Specific Information ………………………………………………………………………………………. 3 F. Conditions of Coverage ………………………………………………………………………………………….. 3 G. Related Policies/Rules …………………………………………………………………………………………… 3 H. Review/Revision History …………………………………………………………………………………………. 3 I. References ………………………………………………………………………………………………………….. 3 Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-MP-PY-1388 Effective Date: 04/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectPreventive Evaluation and Management Services and Acute Care Visit on Same Date of Service B. Background Reimbursement 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 code(s) for the product or service that is being provided. The inclusion of a code does not imply any right to reimbursement or guarantee claims payment. CareSource will reimburse participating providers for medically necessary and preventive screening tests as required by federal statue through criteria based on recommendations from the U.S. Preventive Services Task Force (USPSTF). C. Definitions Preventive Services Exams and screenings that check for health problems with the intention to prevent any problem discovered from worsening and may include, but are not limited to, physical checkups, hearing, vision, and dental checks, nutritional screenings, mental health screenings, developmental screenings, and vaccinations/immunizations. Regularly scheduled visits to a primary care provider for preventive services are encouraged at every age but are especially important for children under the age of 18 years. D. PolicyI. When any of the following preventive health service codes are billed on the same date of service as an acute care visit with the appropriate ICD-10 codes, CareSource will reimburse only the preventive service code at 100%. The acute care visit service codes will not be reimbursed unless billed with the appropriate modifier to identify separately identifiable services that were rendered by the same physician on the same date of service. A. Preventive Health Service Codes 1. 99381-99387 2.99391-99397 B. Acute Care Visit Codes 1.99202-99205 2.99211-99215Preventive Evaluation and Management Services and Acute Care Visit on Same Date of Service-MP-PY-1388 Effective Date: 04/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 II. CareSource reserves the right to request documentation to support billing both services for all claims received. If documentation is requested, it must clearly delineate the problem-oriented history, exam, and decision making from those of the preventive service. Documentation must include the following: A. Key elements that support the additional preventive health services that were rendered. B. A separate history paragraph describing the chronic/acute condition that clearly supports additional work needed on the same date of service. C. A clear list in the assessment portion of the documentation of the acute/chronic conditions being managed at the time of the encounter. If there is a portion of the physical exam that is not routinely performed at the time of the preventive service, the provider should clearly identify those exam pieces (eg, a thorough MS and neuro exam of the left hip performed as it relates to the HPI).E. State-Specific Information NA F. Conditions of Coverage Reimbursement is dependent on, but not limited to, submitting Centers for Medicare and Medicaid Services (CMS) approved HCPCS and CPT codes along with appropriate modifiers. Please refer to the CMS fee schedule for appropriate codes. G. Related Policies/Rules Modifier 25 Reimbursement policy H. Review/Revision History DATE ACTION Date Issued 09/14/2022 Date Revised 01/17/2024 Annual Review; Approved at Committee. Date Effective 04/01/2024 Date Archived 01/31/2026 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. I. References1. Coverage of Preventive Health Services, 26 C.F.R. 54.9815-2713 (2023). 2. Draak K. Successfully bill a preventive service with a sick visit. American Academy Professional Coders. March 1, 2022. Accessed December 20, 2023. www.aapc.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, 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 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 03/01/2024 Kentucky inactive as of 01/01/2026 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 ………………………………………………………………………………………….. 4 F. Related Policies/Rules ……………………………………………………………………………………………. 4 G. Review/Revision History …………………………………………………………………………………………. 4 H. References …………………………………………………………………………………………………………… 5 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 2 A. SubjectModifier 26 and TC: Professional and Technical ComponentB. Background Reimbursement 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 members eligibility. It is the responsibility of the submitting provider to submit the most accurate and appropriate CPT/HCPCS code(s) for the product or service that is being provided. The inclusion of a code in this policy does not imply any right to reimbursement or guarantee claims payment. According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. It may also provide more information about a service such as it was performed more than once, unusual events occurred, or it was performed by more than one physician and/or in more than one location. The Current Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Some procedure coding, described by a single CPT code, is comprised of two distinct portions: a professional component (26) and a technical component (TC). When the professional component of one such procedure is performed separately, the specific service performed by the physician may be identified by adding CPT modifier 26. In this scenario, the facility provides the technical component of a service/procedure, billing the same procedure code with modifier TC. In this way the components of the service can be separately billed by the provider and facility. C. Definitions Global Procedure/Service-Represents both the professional and technical component as a complete procedure or service, identified by reporting the procedure without modifier 26 or TC. Modifier 26 (Professional Component) – Used to indicate when a physician or other qualified health care professional renders the supervision and interpretation portion of a service or procedure and the preparation of a written report. Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 3 Modifier TC (Technical Component) Used to indicate the technical personnel, equipment, supplies, and institutional charges of a service or procedure.D. PolicyI. CareSource expects providers and facilities to adhere to national coding guidelines and standards when utilizing modifiers. II. Modifier 26 A. The professional component is outlined as a physicians service, which may include technician supervision, interpretation of results, and a written and signed report. B. To claim only the professional portion of a service, CPT instructs professionals (or providers) to append modifier 26 to the appropriate CPT code. C. Modifier 26 is also be used to bill for the professional component portion of a test when the provider utilizes equipment owned by a hospital/facility. III. Modifier TC A. The technical component includes the provision of all equipment, supplies, personnel, and costs related to the performance of the procedure. B. The payment for the technical component portion also includes the practice expense and the malpractice expense. C. To claim only the technical portion of a service, append modifier TC Technical component to the appropriate CPT code. D. Fees for the technical component are generally reimbursed to the facility or practice that provides or pays for the supplies, equipment, and/or clinical staff (technicians). E. Hospitals are typically exempt from appending modifier TC because it is assumed that the hospital is billing for the technical component portion of any onsite service. IV. Global procedure/service A. The global procedure is when the same physician or other qualified health care professional performed both the professional component and technical component of that service. This may be the case if an X-ray of a broken bone is taken in the orthopedic surgeons office. B. A global service is identified by reporting the eligible code without modifier 26 or TC. In such cases, the provider is reimbursed for the equipment, supplies, and technical support, as well as the interpretation of the results and the report. C. When reporting a global service, no modifiers are necessary to receive payment for both components of the service. V. Exclusions A. Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (eg, 93010 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 4 electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). B. Do not append modifier TC if there is a dedicated code to describe the technical component, for example, 93005 electrocardiogram: tracing only, without interpretation and report. C. CareSource does not allow reimbursement for use of modifier 26 or modifier TC when: 1. It is reported with an Evaluation and Management (E&M) code. 2. There is a separate standalone code that describes the professional component only, technical component only or global test only of a selected diagnostic test. VI. Duplicate billing A. When one provider reports a global procedure and a different provider reports the same procedure with a professional (26) or technical (TC) component modifier for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. B. When one provider reports a procedure with a professional (26) and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. C. When one provider reports a procedure with a technical (TC) component modifier and a different provider reports a global procedure for the same patient on the same date of service, the first charge approved by CareSource will be eligible for reimbursement and subsequent charges processed will be considered duplicate services and will not be eligible for separate reimbursement. VII. CareSource may request documentation for post-payment review of claims submitted with modifier 26 or modifier TC. If documentation is not provided, CareSource may recoup previously paid claim.E. Conditions of CoverageNA F. Related Policies/Rules Electrocardiogram (EKG/ECG) Interpretation and Imaging Interpretation G. Review/Revision History DATE ACTIONDate Issued 11/29/2023 New policy. Approved at Committee.Date Revised Date Effective 03/01/2024 Modifier 26 and TC: Professional and Technical Component-MP-PY-1475 Effective Date: 03/01/2024 The REIMBURSEMENT Policy Statement detailed above has received due consideration as defined in the REIMBURSEMENT Policy Statement Policy and is approved. 5 Date ArchivedH.References1. CPT overview and code approval. American Medical Association. Accessed November 6, 2023. www.ama-assn.org 2. Medicare Claims Processing Manual Chapter 23-Fee Schedule Administration and Coding Requirements . Centers for Medicare and Medicaid Services. Revised June 2, 2023. Accessed November 6, 2023. www.cms.gov
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
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